attributes of critical thinking essential to nurses

The Value of Critical Thinking in Nursing

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

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

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

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

How Do Nurses Use Critical Thinking?

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

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

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

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

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

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

Top 5 Ways Nurses Can Improve Critical Thinking Skills

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

Case-Based Approach

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

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

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

Practice Self-Reflection

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

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

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

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

Develop a Questioning Mind

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

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

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

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

Practice Self-Awareness in the Moment

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

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

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

Use a Process

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

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

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

Common Critical Thinking Pitfalls in Nursing

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

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

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

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

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

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

An Essential Skill for All Nurses

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

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

Frequently Asked Questions About Critical Thinking in Nursing

How are critical thinking skills utilized in nursing practice.

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

How does nursing school develop critical thinking skills?

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

Do only nurse managers use critical thinking?

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

Meet Our Contributors

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

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

Jenna Liphart Rhoads, Ph.D., RN

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

Nicholas McGowan, BSN, RN, CCRN

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

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

Successful nursing requires learning several skills used to communicate with patients, families, and healthcare teams. One of the most essential skills nurses must develop is the ability to demonstrate critical thinking. If you are a nurse, perhaps you have asked if there is a way to know how to improve critical thinking in nursing? As you read this article, you will learn what critical thinking in nursing is and why it is important. You will also find 18 simple tips to improve critical thinking in nursing and sample scenarios about how to apply critical thinking in your nursing career.

What Is Critical Thinking In Nursing?

4 reasons why critical thinking is so important in nursing, 1. critical thinking skills will help you anticipate and understand changes in your patient’s condition., 2. with strong critical thinking skills, you can make decisions about patient care that is most favorable for the patient and intended outcomes., 3. strong critical thinking skills in nursing can contribute to innovative improvements and professional development., 4. critical thinking skills in nursing contribute to rational decision-making, which improves patient outcomes., what are the 8 important attributes of excellent critical thinking in nursing, 1. the ability to interpret information:, 2. independent thought:, 3. impartiality:, 4. intuition:, 5. problem solving:, 6. flexibility:, 7. perseverance:, 8. integrity:, examples of poor critical thinking vs excellent critical thinking in nursing, 1. scenario: patient/caregiver interactions, poor critical thinking:, excellent critical thinking:, 2. scenario: improving patient care quality, 3. scenario: interdisciplinary collaboration, 4. scenario: precepting nursing students and other nurses, how to improve critical thinking in nursing, 1. demonstrate open-mindedness., 2. practice self-awareness., 3. avoid judgment., 4. eliminate personal biases., 5. do not be afraid to ask questions., 6. find an experienced mentor., 7. join professional nursing organizations., 8. establish a routine of self-reflection., 9. utilize the chain of command., 10. determine the significance of data and decide if it is sufficient for decision-making., 11. volunteer for leadership positions or opportunities., 12. use previous facts and experiences to help develop stronger critical thinking skills in nursing., 13. establish priorities., 14. trust your knowledge and be confident in your abilities., 15. be curious about everything., 16. practice fair-mindedness., 17. learn the value of intellectual humility., 18. never stop learning., 4 consequences of poor critical thinking in nursing, 1. the most significant risk associated with poor critical thinking in nursing is inadequate patient care., 2. failure to recognize changes in patient status:, 3. lack of effective critical thinking in nursing can impact the cost of healthcare., 4. lack of critical thinking skills in nursing can cause a breakdown in communication within the interdisciplinary team., useful resources to improve critical thinking in nursing, youtube videos, my final thoughts, frequently asked questions answered by our expert, 1. will lack of critical thinking impact my nursing career, 2. usually, how long does it take for a nurse to improve their critical thinking skills, 3. do all types of nurses require excellent critical thinking skills, 4. how can i assess my critical thinking skills in nursing.

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

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

Brain, Decision Making and Mental Health pp 179–189 Cite as

Critical Thinking in Nursing

• Şefika Dilek Güven 3  
• First Online: 02 January 2023

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

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

Graphical Abstract/Art Performance

Critical thinking in nursing.

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

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

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

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Why Critical Thinking Is Important in Nursing

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

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

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

Why Are Critical Thinking Skills in Nursing Important?

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

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

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

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

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

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

How can you develop your critical thinking skills?

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

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

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

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

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

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

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

Reasons Critical Thinking In Nursing Is Important

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

Following are the reasons:

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

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

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

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

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

Skills that Critical Thinkers Need

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

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

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

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

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

The decisions need to be based on sound reasoning:

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

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

Critical Thinking Pitfalls

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

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

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

Conclusion:

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

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

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• Critical Thinking

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)

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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15 Attitudes of Critical Thinking in Nursing (Explained W/ Examples)

Last updated on August 19th, 2023

Critical thinking is a powerful tool that nurses use to make informed decisions, provide top-notch care, and untangle complex problems.

Think of it as a toolbox filled with skills that let nurses dig deeper, understand better, and think smarter.

In this article, we’re going to explore the 15 super-important attitudes of critical thinking in nursing .

Each attitude is like a special key that helps nurses unlock the best care for their patients. Let’s dive in and learn about each attitude.

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

15 Attitudes of Critical Thinking in Nursing

1. Independence

Independence is like thinking for yourself and making your own choices. Imagine you’re deciding what book to read, and you pick one that interests you, not just what others like – that’s being independent.

In nursing, independence means using your own judgment to provide the best care.

For, example, consider Rachel, a nurse, who considers various options to treat a patient’s pain, not just following what others do. Rachel’s independence helps her find solutions tailored to each patient’s needs.

 Just like choosing your own book, independent nurses think critically and make decisions based on what’s best for their patients.

2. Confidence

Confidence is like believing in yourself and your abilities, even when faced with challenges. Imagine you’re trying a new activity, and you trust that you can learn and do well – that’s having confidence.

In nursing, confidence means having faith in your skills and judgment to provide excellent care. Example: For instance, think of Ava, a nurse, who remains composed when a patient’s condition suddenly worsens.

She knows she can handle the situation because of her training and experience. Ava’s confidence allows her to make quick and effective decisions during critical moments.

Just like trusting yourself in a new activity, confident nurses trust their expertise to deliver top-notch care to their patients.

3. Fair-Mindedness

Fair-mindedness is like treating everyone equally and making judgments based on facts, not personal feelings. Imagine you’re playing a game, and you give every player the same chance to win – that’s being fair-minded.

In nursing, fair-mindedness means being impartial and considering all viewpoints without bias.

For example, picture Liam, a nurse, who listens to both the patient and the family when making a decision about treatment.

He doesn’t let his own opinions influence his judgment. Liam’s fair-mindedness ensures that he provides balanced and patient-focused care.

Just like being fair in a game, fair-minded nurses make decisions that are just and unbiased, promoting the best outcomes for their patients.

4. Insight into Personal Biases

Insight into personal biases is like looking at yourself from the outside to see if your own feelings might affect your decisions. Imagine you have a favorite color, and you realize you tend to choose things in that color even if other options might be better – that’s being aware of your bias.

In nursing, insight into personal biases means being mindful of your own preferences and not letting them cloud your judgment.

For instance, think of Maya, a nurse, who knows she might prefer a particular treatment because it worked for her family member.

However, she steps back and considers what’s truly best for her patient’s situation. Maya’s insight helps her provide care that’s unbiased and patient-centered.

Just like being aware of your color preference, insight into personal biases helps nurses make decisions that are based on what’s right for their patients, not influenced by their own feelings.

5. Intellectual Humility

Intellectual humility is like knowing that you don’t have all the answers and being open to learning from others. Imagine you’re playing a video game, and you ask a friend for tips because they’re better at it – that’s being humble about your skills.

In nursing, intellectual humility means recognizing that you can always learn more and considering others’ expertise.

Picture James, a nurse, who seeks advice from experienced colleagues when faced with a complex case.

He knows that learning from others can lead to better patient care. James’s intellectual humility helps him grow as a nurse and keeps him open to new perspectives.

Just like seeking gaming tips, intellectual humility encourages nurses to value knowledge from various sources and continuously improve their practice.

6. Intellectual Courage to Challenge the Norms

Intellectual courage to challenge the norms is like having the bravery to question things that everyone believes are true. Imagine you’re playing a game with your friends, and everyone agrees on the rules – but you speak up and suggest a new way to play.

In nursing, intellectual courage means daring to question established practices and seeking innovative solutions.

For instance, think of Sarah, a nurse, who notices that a routine procedure might be improved for patient comfort.

Instead of staying silent, she speaks up and proposes a change, backed by research and careful thought. Sarah’s intellectual courage drives her to challenge the status quo for the sake of better patient care.

Just like suggesting a new game rule, nurses with this attitude challenge norms to advance healthcare practices and outcomes.

7. Integrity

Integrity is like being honest and doing the right thing, even when nobody’s watching. Imagine finding a lost wallet on the street – instead of keeping it, you return it to its owner because it’s the right thing to do.

In nursing, integrity means always acting ethically and responsibly, even in challenging situations.

Picture Emma, a nurse, who follows protocols and makes decisions based on what’s best for her patients, not personal gain.

 Emma’s integrity shines when she prioritizes honesty, fairness, and patient well-being in every action she takes.

Just like returning that wallet, integrity is a nurse’s commitment to uphold high moral standards and maintain the trust placed in them by patients and their families.

8. Perseverance

Perseverance is like having a never-give-up attitude, even when things get tough. Imagine you’re trying to solve a challenging puzzle – even if it takes time and effort, you keep going until you find the solution.

In nursing, perseverance means facing obstacles and difficulties head-on without giving up.

For example, consider Mark, a nurse, who’s dealing with a complex patient case. Despite encountering roadblocks and uncertainties, Mark doesn’t lose hope.

He keeps researching, consulting colleagues, and trying different approaches until he finds the right solution for his patient.

Just like working through a tough puzzle, perseverance empowers nurses to keep pushing forward and find the answers that lead to the best care outcomes.

9. Curiosity

Curiosity is like having a hunger for knowledge that never goes away. Imagine you’re exploring a new place, and every corner seems to hide something interesting – you want to know what’s around the next bend.

In nursing, curiosity means having a strong desire to learn and discover.

Picture Anna, a nurse, who’s always asking questions like “Why?” and “How?” She’s not content with just knowing the basics; she wants to dive deeper and understand the “whys” behind patient conditions and treatments.

Anna’s curiosity drives her to stay updated with the latest research and innovative methods. Just like an explorer seeking new horizons, curious nurses seek new ways to provide better care for their patients.

10. Open-Mindedness

Open-mindedness is like having a door in your mind that’s always ready to welcome new ideas. Imagine you’re reading a book, and suddenly you come across a different way of thinking – instead of dismissing it, you consider it with interest.

In nursing, open-mindedness means being willing to listen to various viewpoints and explore different approaches.

For instance, think of Rachel, a nurse, who’s used to a specific way of treating wounds. But when a colleague suggests a new method, Rachel doesn’t shut the idea down.

Instead, she’s open to trying it out and seeing if it might work better for her patients. Just like being curious about new stories, open-minded nurses are curious about new ways to improve patient care.

11. Skepticism

Skepticism is like being a curious investigator who asks questions to make sure things are true. Imagine you hear about a magical potion that promises to make you fly – you might be skeptical and ask, “Is that really possible?”

In nursing, skepticism means not accepting things blindly but investigating to find the truth.

Picture Sarah, a nurse, who reads about a new treatment for pain relief. Instead of immediately believing it, she looks for evidence and checks if other experts agree.

Sarah’s skepticism helps her make sure that the treatments she uses are safe and effective for her patients.

Just like asking questions about that magical potion, nurses use skepticism to make informed decisions based on facts.

12. Reflective Thinking

Reflective thinking is like looking back at your day and thinking about what went well and what you could improve. Imagine you finished playing a game and you think about how you did – that’s reflective thinking!

In nursing, it’s when nurses take a moment to think about their actions, decisions, and interactions with patients.

For example, let’s say Jessica, a nurse, had a challenging day where she had to juggle multiple tasks. At the end of her shift, she takes a few minutes to reflect.

She thinks about what she did right, like comforting a worried patient, and what she could do better, like managing her time more efficiently.

This reflection helps Jessica learn from her experiences and become an even better nurse.

Just like looking in a mirror to see yourself, reflective thinking helps nurses see their actions and grow from them.

13. Logical Reasoning

Logical reasoning is like putting together the pieces of a puzzle to see the bigger picture. It’s about thinking step by step to reach a smart conclusion.

Imagine you have a math problem to solve. You start with the information you know and use logical steps to find the answer.

Similarly, nurses use logical reasoning to understand their patients’ situations

Let’s say Emily, a nurse, has a patient with a high fever and a sore throat. She gathers information about the symptoms, asks questions, and puts all the clues together.

By using logical steps, Emily figures out that the patient might have a throat infection and can recommend the right treatment.

Just like solving a puzzle, logical reasoning helps nurses connect the dots and make decisions that make sense for their patient’s health.

14. Evidence-Based Decision Making

Evidence-based decision-making is like being a detective who gathers clues before solving a mystery.

For instance, imagine Alex, a nurse, who wants to find the best way to help patients with diabetes manage their blood sugar levels.

Instead of guessing, he reads research studies and talks to experts in the field. Alex uses the facts he collects to choose treatments that are proven to work.

Just like a detective uses evidence to solve a case, Alex uses evidence to make informed decisions that lead to better patient outcomes.

15. Problem-Solving

Problem-solving is like being a detective on a mission. Think of it like when you have to figure out how to fix a broken toy.

For instance, Linda, a nurse, faces a challenge when a patient’s pain medication isn’t working well. Instead of giving up, she gathers information, talks to the patient, and works with the medical team to find a better solution.

Linda’s problem-solving skills help her piece together the right treatment plan, just like solving a tricky puzzle.

• What is Critical Thinking in Nursing? (Explained W/ Examples)
• What is the “5 Whys” Technique?
• What Are Socratic Questions?
• Clinical Reasoning In Nursing (Explained W/ Example)
• 8 Stages Of The Clinical Reasoning Cycle

Critical thinking is a powerful tool that nurses use every day. These 15 attitudes are like a treasure map that guides nurses through the world of healthcare.

From being independent thinkers to having the courage to challenge norms, these attitudes help nurses provide the best care possible.

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21. Becoming a critical thinker

CHAPTER 21. Becoming a critical thinker Steve Parker LEARNING OBJECTIVES At the completion of this chapter, the student will be able to: • describe the essential nature of critical thinking • describe the main characteristics of a critical thinker • explain the basic structure of an argument • apply the basic structure of an argument to various areas of nursing practice, and • identify resources for further reading and the study of critical thinking. KEY WORDS Thinking reflection action evaluation argument induction premise nursing process decision making WHAT IS CRITICAL THINKING? There are a variety of definitions of critical thinking and no consensus on any one of them ( Riddell 2007 ). This situation means we need to be careful about relying on any one definition. In essence, however, critical thinking refers to the activity of questioning what is usually taken for granted . Whether we are aware of it or not, all behaviour is based on certain values, assumptions and beliefs. These form the basis for our decisions to act in certain ways. In a professional context such as nursing practice, everything that we think, say or do is the result of a complex web of beliefs, values and assumptions that have formed as a result of our life experiences. As we grow up in our family, attend school, participate in religious communities, associate with friends, watch television, read newspapers, and work for various employers, we develop a ‘pair of spectacles’ through which we understand and interpret the world and all that happens in it. Just as a person who wears glasses eventually becomes unaware that they are even wearing them, so too each of us adjusts to our worldview ‘spectacles’ until, often, we are completely unaware what values, beliefs and assumptions are influencing us in a specific situation. Critical thinking means stopping and reflecting on the reasons for doing things the way they are done or for experiencing things the way they are—focusing on what is frequently taken for granted and evaluating the values, beliefs and assumptions that are held, and asking whether or not what is done and thought is justifiable or not. These characteristics of critical thinking imply a self-consciousness of what, how and why we are thinking, with the intention of improving thinking. In short, ‘critical thinking is thinking about your thinking while you’re thinking in order to make your thinking better’ ( Paul 2008 ). Improving thinking is essential because it is intimately related to the many decisions that need to be made each day. The quality of our lives is determined by the quality of our decisions, and the quality of our decisions is determined by the quality of our reasoning ( Schick & Vaughn 1995 ). In particular, ‘[i]f nurses are to deal effectively with complex change, increased demands and greater accountability, they must become skilled in higher level thinking and reasoning abilities’ ( Simpson & Courtney 2002 :89). An important aspect of critical thinking is healthy scepticism. This scepticism is necessary because there are many attempts to persuade people to accept various claims. These attempts to persuade also occur in professional contexts. For example, research reports suggest changes to practice; peers argue that their way of acting is the right one; therapists promote various interventions; administrators argue that certain changes need to be made to the workplace; and so on. Often these claims are contradictory, so they cannot all be acceptable. Practitioners need to sort through all these, often competing, claims. To accept them all without question will, at best, be highly confusing and, at worst, may endanger the lives of others if actions are based on wrong information or conclusions. To adopt an attitude of healthy scepticism means to cautiously listen to or read the claims that others make, carefully evaluating their legitimacy, and not rushing to accept a conclusion without careful thought. The same rigorous thinking needs to be done about our own nursing practice. We make decisions every moment, which we assume are of benefit to our patients. Asking questions about the practices we engage in, including what evidence is available to support their efficacy, is essential if our nursing practice is to produce positive outcomes for those for whom we care. It is possible, of course, to become too pedantic, resulting in inaction because we are not prepared to accept anything unless it is 100% proven. This is why the scepticism needs to be healthy. There is a limit to what can be known for certain. And part of critical thinking is knowing these limits and making the best evaluation under the circumstances. THE RELATIONSHIP BETWEEN CRITICAL AND CREATIVE THINKING Critical thinking is not the same as creative thinking. According to Miller and Babcock (1996 :117), creative thinking is, among other things, more divergent, messy, unpredictable, provocative, spontaneous and playful than critical thinking. They describe critical thinking as selective, orderly, predictable, analytical, judgmental and evaluative. Creative thinking, although different from critical thinking, is an essential, complementary process to critical thinking. As a practitioner, there are many situations that arise that do not fit with the ideal or that are not predictable. No individual person for whom nurses care ever fits the ‘average’ because each person and situation is unique. In order to solve problems for these unique situations and individuals, the practitioner needs to be able to develop new approaches and solutions so that all parties have their needs met. Miller and Babcock suggest that: Creative thinking is very useful when what we know and what we know how to do are not working, including the rules of reason, common sense, gravity, and routine. The creative thinker is willing to think wildly, without having any idea where her or his path of thinking may lead. Deliberative cognition is temporarily held in abeyance ( Miller & Babcock 1996 :120). Because creative thinking is so ‘chaotic’ it means that it needs to be evaluated to ensure that any conclusions that are reached are appropriate. In this regard, Ruggiero understands the mind to have two phases: It both produces ideas and judges them. These phases are intertwined; that is, we move back and forth between them many times in the course of dealing with a problem, sometimes several times in the span of a few seconds ( Ruggiero 1998 :81). In the past, critical thinking has often been presented apart from creative thinking. However, in practice, creative and critical thinking go hand-in-hand. Without creative thinking, critical thinking would be dry and mechanical. Without critical thinking, creative thinking would be chaotic and inefficient. As Ruggiero (1998 :81) asserts, ‘[t]o study the art of thinking in its most dynamic form [where creative and critical thinking are intertwined] would be difficult at best’. Consequently, in practice, we need to consider them separately. However, although critical thinking and creative thinking are distinct from each other, they should never be separated. THE CHARACTERISTICS OF CRITICAL THINKING So what are the characteristics that a critical thinker will demonstrate? Jacobs et al (1997) have developed a set of observable skills that indicate the presence of critical thinking. These are grouped into categories, as described below. First, a critical thinker needs the ability to integrate information from all relevant sources by being able to distinguish between relevant and irrelevant data, validate data that are obtained, recognise when data are missing, predict multiple outcomes, and recognise the consequences of actions. Second, to think critically means to be able to examine assumptions by recognising them when they are present, detect bias, identify assumptions that are not stated, recognise the relationships of action or inaction, and transfer thoughts and concepts to diverse contexts, or develop alternative courses of action. Third, it is important for the critical thinker to be able to identify relationships and patterns. This includes recognising inconsistencies or fallacies of logic, working out generalisations, developing a plan of action consistent with a model, and, where appropriate, seeking out alternative models. Jacobs et al offer a definition of critical thinking that incorporates all these characteristics: Critical thinking is the repeated examination of problems, questions, issues, and situations by comparing, simplifying, synthesizing information in an analytical, deliberative, evaluative, decisive way ( Jacobs et al 1997 :20). Many more examples of various ways of describing the characteristics of critical thinking could be offered. One way of summarising these is to focus on critical thinking as reasoning. The heart of reasoning is the argument. In what follows, the nature of argument will be described, followed by a survey of the ways in which arguments ‘appear’ in nursing. Suggestions will then be offered regarding the way in which the principles of critical thinking might be applied in these areas. By doing so, the way in which this approach synthesises the skills of critical thinking will become obvious. WHAT IS AN ARGUMENT? In colloquial language the word ‘argument’ is often used for a shouting match between two people who are having a disagreement where the participants are very angry, abusive or physically aggressive. There may be shouting, pointing of fingers, threats, crying, name-calling, and so on. However, in critical thinking, the term ‘argument’ does not apply to these situations. In fact, these situations are the very opposite of critical thinking. In critical thinking, an argument consists of a conclusion and one or more reasons that are intended to support the conclusion. Figure 21.1 shows the relationship between these parts of an argument. Each reason may or may not have evidence that is intended to support the reason or reasons. Figure 21.1 Components of an argument Here is an example of an argument: Every person has the right to choose how they live their lives. Therefore, a person has the right to choose to practise life-threatening behaviours if they wish. This is an argument because it has a conclusion (‘A person has the right to choose to practise life-threatening behaviours if they wish’) and a reason intended to support that conclusion (‘Every person has the right to choose how they live their lives’). At this stage, we are not concerned whether this is a good argument or not, only with what makes something an argument. If it were desirable, a person presenting this argument could provide some evidence for the first statement by drawing attention, for example, to various statements of human rights, the constitutions of countries, or discussions about ethics. So an argument needs to have the following: • a conclusion, and • one or more reasons intended to support the conclusion. WHAT MAKES A SOUND ARGUMENT? For an argument to be sound, three criteria need to be met. First, the reasons need to be acceptable to the person evaluating the argument. Second, the reasons need to be relevant. And, third, the reasons need to provide adequate grounds for accepting the conclusion. Govier (1992) offers a useful way to remember these three criteria, which she calls the conditions of argument. If the first three letters of the word argument (ARG) are taken on their own, each letter stands for one of the conditions of argument. That is: A Acceptability R Relevance G Grounds Govier’s definitions of each of these conditions are also useful: • Acceptability : The premises [reasons] are acceptable when it is reasonable for those to whom the argument is addressed to believe these premises. There is good reason to accept the premises—even if they are not known for certain to be true. And there is no good evidence known to those to whom the argument is addressed that would indicate either that the premises are false or that they are doubtful. • Relevance : [Premises are relevant to the conclusion] when they give at least some evidence in favor of the conclusion’s being true. They specify factors, evidence, or reasons that do count toward establishing the conclusion. They do not merely describe distracting aspects that lead you away from the real topic with which the argument is supposed to be dealing or that do not tend to support the conclusion. • Grounds : The premises provide sufficient or good grounds for the conclusion. In other words, considered together, the premises give sufficient reason to make it rational to accept the conclusion. This statement means more than that the premises are relevant. Not only do they count as evidence for the conclusion, they provide enough evidence, or enough reasons, taken together, to make it reasonable to accept the conclusion ( Govier 1992 :68–69). The following example illustrates these criteria: Nurses must have a practising certificate to be employed as a nurse. Sue does not have a practising certificate. Therefore, Sue is not permitted to be employed as a nurse. Statements 1 and 2 are both reasons, which are intended to support the conclusion in Statement 3. If this is a sound argument, then the reasons must be relevant and acceptable, and they must provide adequate grounds for accepting the conclusion. Statement 1 is certainly acceptable. Most countries have a requirement that nurses need to be licensed to practise. Statement 2 is hypothetical, so we will assume that it is true for the sake of the discussion. All the reasons, then, are acceptable. The two reasons are also relevant to the issue under consideration. The next question is whether these reasons provide adequate grounds for accepting the conclusion. We can test this by asking: Is it possible to reject the conclusion and still believe the reasons to be true? Or, in other words, even though the reasons are true, is there a legitimate way that we can escape accepting the conclusion? In other words, could one believe that Sue could practise and still believe that the two reasons offered are true? In this case, the answer is no. If it is true that a nurse must have a practising certificate to practise, and Sue does not have one, we are ‘compelled’ to accept the conclusion that Sue cannot practise. This argument, then, is a sound one.

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Reflective and critical thinking in nursing curriculum

O pensamento crítico-reflexivo nos currículos de enfermagem, el pensamiento reflexivo y crítico en los currículos de enfermería, maría antonia jiménez-gómez.

1 Universidad Nacional de Colombia, Facultad de Enfermería, Bogotá, Colombia.

Lucila Cárdenas-Becerril

2 Universidad Autónoma del Estado de México, Facultad de Enfermería, Toluca, México.

Margarita Betzabé Velásquez-Oyola

3 Universidad Nacional José Faustino Sánchez Carrión, Facultad de Medicina Humana, Huacho, Lima, Peru.

Marcela Carrillo-Pineda

4 Universidad de Antioquia, Facultad de Enfermería, Medellín, Colombia.

Leyvi Yamile Barón-Díaz

5 Universidad Nacional de Colombia, Facultad de Medicina, Bogotá, Colombia.

to evaluate the teaching of transversal competence of the Reflective and Critical Thinking that is fundamental in the decision-making and solution of nursing problems, in degree programs of public and private institutions in the Andean region.

multi-center, cross-sectional, exploratory-descriptive study, with mixed approach in 5 countries.

76 nursing programs participated in the study. The Reflective and Critical Thinking was found as a subject, subject content and didactic strategies. Of the 562 subjects reviewed, this type of thinking is found in 46% of the humanities area and 42% in the area of research and professional discipline. It is important to train teachers to achieve coherence between the pedagogical model approach, teaching strategies and evaluations.

Conclusion:

nursing programs in the Andean region contemplate the critical thinking as cognitive and personals skills of communication. They also use real situations analysis, supervised practice, simulation labs and specifically learning based in problems to develop the capacity to solve them, decision-making and develop communication skills, including analysis, synthesis and evaluation.

avaliar o ensino da competência transversal do pensamento crítico-reflexivo, fundamental na tomada de decisões e solução de problemas de enfermagem, nos programas de graduação de instituições públicas e privadas da região Andina.

Método:

estudo multicêntrico, transversal, exploratório-descritivo, com abordagem mista em cinco países.

Resultados:

76 programas de Enfermagem participaram do estudo. O pensamento crítico-reflexivo foi constatado como disciplina, conteúdo de disciplina e estratégias didáticas. Das 562 disciplinas revisadas, este tipo de pensamento se encontra em 46% da área de humanidades e 42% na área de pesquisa e profissional-disciplinar. Existe a necessidade de capacitar os docentes para obter coerência entre a proposta do modelo pedagógico, as estratégias didáticas e a avaliação.

Conclusão:

os programas de enfermagem da região Andina contemplam o pensamento crítico como habilidades cognitivas, de comunicação e pessoais. Da mesma forma, utilizam a análise de situações reais, estágio supervisionado, laboratórios de simulação e, principalmente, a aprendizagem baseada em problemas, com a finalidade de desenvolver a capacidade para solucionar problemas, tomar decisões e desenvolver habilidades comunicativas, incluindo análise, síntese e avaliação.

evaluar la enseñanza de la competencia transversal del Pensamiento Reflexivo y Crítico, fundamental en la toma de decisiones y en la solución de problemas de enfermería, en los programas de grado de instituciones públicas y privadas de la región Andina.

estudio multicéntrico, transversal, exploratorio-descriptivo, con abordaje mixto en 5 países.

76 programas de Enfermería participaron en el estudio. El Pensamiento Reflexivo y Crítico se encontró como asignatura, contenido de asignatura y estrategias didácticas. De las 562 asignaturas que han sido revisadas, este tipo de pensamiento se encuentra en el 46% del área de humanidades y el 42% en el área de investigación y profesional disciplinar. Está la necesidad de capacitar a los docentes para lograr coherencia entre el planteamiento del modelo pedagógico, las estrategias didácticas y la evaluación.

Conclusión:

los programas de enfermería de la región Andina contemplan el pensamiento crítico como habilidades cognitivas, de comunicación y personales. Asimismo, utilizan el análisis de situaciones reales, la práctica supervisada, los laboratorios de simulación y, principalmente, el aprendizaje basado en problemas, con la finalidad de desarrollar la capacidad para solucionar los problemas, tomar decisiones y desarrollar habilidades comunicativas, incluyendo el análisis, la síntesis y la evaluación.

Introduction

Globalization brought with it changes in all aspects of life: social, political, economic and cultural. Moreover, the nursing profession is evolving, so that it is increasingly moving away from the biomedical model of care, focused on the instrumental, to focus on people’s health care, with primacy of dialogue and agreements between the professional and the person under care. As part of a multiprofessional team, this requires changes in the curricular proposal and, in turn, a qualifying teacher for a new profile of graduate, whereby reflection, self-criticism and professional responsibility are developed ( 1 ) .

Therefore, it is necessary to work intensely to reduce the dichotomies that are present in nursing programs, namely: between theory-practice; training and the reality of professional practice; and the student as a passive part of the teaching-learning process and the professional who is required, active, proactive, creative, analytical, with contextual perspective, flexible, with logical thinking, able to carry out a permanent and continuous search for information, able to contribute with his profession to the solution of health problems.

The General Conference of the United Nations Educational, Scientific and Cultural Organization (UNESCO), at its 38th session, held in Paris from 3 to 18 November 2015, “Recommendation about Adult Learning and Education” states in one of its objectives the need to develop people’s capacity to think critically and to act with autonomy and a sense of responsibility ( 2 ) .

Critical thinking (CT) is a process and a learning outcome ( 3 - 4 ) and the clinical judgment is the result of this process. The development of the clinical judgment (clinical reasoning skills) is one of the most important and challenging tasks of being a nurse. Clinical reasoning precedes clinical judgment and the decision-making that is important in professional and personal life.

In order to achieve professionals with reflective and critical thinking (RACT), it is necessary to make deep changes in the educational dynamics, in the teaching and student roles, in the use of pedagogy and didactics to transmit knowledge, the curricular structure, the strategies of teaching-learning. These changes are expected to be centered on the student, who must actively participate in the learning process in order to achieve greater development of his or her capacities for reasoning, self-learning, self-evaluation, self-management and self-regulation. Likewise, it is expected that teachers to be critical and creative, attending to individual ways of learning, encouraging the development of good thinking in the student ( 3 ) .

Literature points out that critical thinking is the “essential foundation for education, since it is the basis for adaptation to the individual, social and professional demands of daily life in the 21st century and beyond” ( 4 ) . The world changes fast and new realities arise, so there is a fundamental need of people to develop capabilities that allow them to respond and adapt themselves to these changes.

Critical thinking is “the process of seeking, obtaining, evaluating, analyzing, synthesizing and conceptualizing information as a guide, to develop self-conscious thinking and the ability to use this information by adding creativity and taking risks” ( 4 ) .

Authors pointed out one of the first definitions of critical thinking: “knowledge, skills and attitudes” ( 5 ) and, since the end of 1980, various strategies for its teaching have been discussed at all school levels ( 4 ) . On the other hand, authors point out the importance of generating opportunities to develop RACT in students. Therefore, some authors emphasize the importance of developing it in all health situations in favor of the patient ( 4 , 6 - 7 ) . The nursing professional developing RACT will know where, when and how to use their knowledge, skills, values and attitudes.

The motivation for nurse training in the Andean region became evident in the 1960s. In particular, Colombia generated the first degree program in 1958, which was approved in 1961. In the same period, Venezuela, Ecuador, and Peru initiated undergraduate programs; in the case of Bolivia, it happened only until 1970 ( 8 ) .

The 1980s were marked by the rise of postgraduate programs, increased development of research and the generation of knowledge. The 1990s saw a boom in graduate, specialization, masters, and doctoral programs, the latter especially in education. However, there were also more options for the qualification of nursing professionals for the teaching role. On the other hand, the Higher Education Quality Assurance System ( Sistema de Aseguramiento de la Calidad de la Educación Superior ) was implemented, as well as the Accreditation of the programs and the own regulations or nursing law emerged in each country of the region.

The first decade of the 21st century brought the development of the highest level of nursing education, the doctorate, and, with it, the generation of nursing knowledge in the region and its progress towards consolidation as a discipline ( 8 ) .

Throughout this journey, there was a permanent motivation for balance and congruence between the graduation profiles and the reality of the job, based on the permanent motivation for the adaptation of the curriculum, the teaching-learning strategies, the evaluation processes, and the teacher qualification to respond to this constantly changing context.

The literature ( 9 - 11 ) shows the need to expand the research in the area of education, to achieve greater development of research and to work in education and nursing policies and practices. On the other hand, the latter shows the need to implement and evaluate pedagogical and didactic strategies that help the student to develop a critical judgment, justified decision making, comprehensive memory and communicative competence ( 11 ) .

For its part, the Ibero-American Network for Research in Nursing Education ( Red Iberoamericana de Investigación en Educación en Enfermería - RIIEE), in 2011, identified as a research priority, “The development of RACT in nursing students”, within the tree of the problems detected in its research line Higher Education and Nursing. For the development of this research purpose, the Network suggested a multicenter macroproject with the theme “Strategies to develop the RACT in nursing students: situation in Latin America”. In fact, the conceptual paradigm refers to “critical theory and constructivism, since RACT is an analytical, cyclical, broad and systematic process, but not rigid; its analysis and interpretation allows to have elements for decision-making, as well as to make informed choices” ( 8 - 12 ) .

The project involves five of the six regions that make up the RIIEE: the Andean region (Bolivia, Colombia, Ecuador, Peru and Venezuela), Brazil, the Southern Cone, Europe, and Mexico and the Caribbean. The investigation is planned in three stages: 1. Diagnose; 2. Planning and implementation of interventions; and 3. Evaluation. The diagnostic stage includes: 1. The state of the art on scientific production in RACT and teaching strategies for its development; 2. Characterization of educational strategies for teaching the RACT collected in nursing literature; 3. To determine the development of the RACT competence in the different nursing curriculum; 4. To identify the educational strategies used by teachers to develop the competence of reflective critical thinking in nursing students; 5. To identify levels of critical thinking in nursing students according to the classification of Paul and Elder (unreflective thinker - master thinker). Objectives 4 and 5 are currently being developed.

The analysis of the “Scientific Production in RACT in Nursing in 1990-2012 in Ibero-America” produced among others the following conclusion: the formation of a critical reader and the investigative process are strategies that help university students to be critical and autonomous and to access more critically to the knowledge of the disciplinary area. For this, teachers are required to make of each moment and situation in the teaching-learning relationship an open forum for reflection, debate, questioning and contrasting of the different perspectives around the area of professional training and society’s problems ( 8 ) .

After reviewing the literature on the web of science by using the descriptors critical thinking and nursing, education and curriculum, it was not possible to find studies that analyzed the presence of RACT in the curriculum of nursing degree programs. However, it is very striking the motivation to analyze the importance of its development and studies that demonstrate its value, as well as the use of different and combined teaching-learning strategies to achieve the formation of RACT in nursing students.

This study was done with the purpose of to evaluate the teaching of transversal competence of the Reflective and Critical Thinking that is fundamental in the decision-making and solution of nursing problems, in degree programs of public and private institutions in the Andean region.

The coordinating group of RIIEE developed the research project from which the research groups of each country and region of the Network were made up, integrated by members of the Network and researchers in education and nursing, who are also teachers in Higher Education Institutions (HEI), and mostly with PhD academic level. The HEI in Nursing (HEIN) were identified through the Ministries of Education, the Associations of Schools and Universities of Nursing of each country and the Latin American Association of Schools and Universities of Nursing ( Asociación Latinoamericana de Escuelas y Facultades de Enfermería - ALADEFE).

The project was benefited from the Declaration of Helsinki (Ethical principles for medical research on human subjects) and the current ethics legislation in each country, was approved by the Ethics Committee of the University of Antioquia, Colombia, by Act No. CEI-FE 2015-25 on July 31, 2015. The respect for privacy and confidentiality were ensured to each Program Director, with the informed consent signed by each participant. The project was also sent to them and their understanding was guaranteed. In turn, we conceded the right to choose what information they wanted to share. Confidentiality was maintained by institutional coding. Finally, was given a deadline of 15 days to obtain the response of acceptance to participate.

The target population of this research were 187 undergraduate nursing programs in the Andean region: Bolivia (47), Colombia (47), Ecuador (21), Peru (62) and Venezuela (10). We considered only the nursing curriculum of the HEI, recognized by the Associations of Schools and Colleges of Nursing of each country or its counterpart, regardless of whether they were public or private. Resulting in the nursing curriculum of 76 Institutions that correspond to the 40.64% HEIN that teach undergraduate nursing in the Andean region: Bolivia (7), Colombia (38), Ecuador (11), Peru (14), and Venezuela (6). Due to the difficulty in obtaining the information, we checked web pages, contacted HEIN members, made contacts by telephone, in some cases, we made personal visits and, finally, the complete program was requested in PDF format for the complete the instrument of the research group. In addition, the HEIN did not refused to participate, but some institutions did not respond to the invitation. The result of this process: 30 institutions accepted to participate and provided the complete information, and out of 46 partial results were obtained. An HEIN database of the names, telephone numbers and e-mail addresses of the authorities in charge of managing the programs was created in order to follow up on their responses.

After identifying, during 2011 and 2012, the theoretical and conceptual framework of RACT from different authors and different perspectives (education, pedagogy, psychology and nursing), despite the abundance of literature about the subject, we concluded that the concept is very unclear from a nursing point of view ( 13 - 14 ) .

However, it was necessary to establish a concept that was accepted by the research group of the Network, that allowed to determine a starting point or consensus to carry out this work and, without detriment to seek some level of fidelity to the multiple approaches of the scholars of this research object, that was understandable for the group and reflected what was intended to be done in its research phases and stages.

The Network took as a theoretical framework the approaches made by Paul ( 15 ) and Paul; Elder ( 16 ) , the elements of the CT and the attitudes of the Critical Thinker proposed by these authors. With the material analyzed, RIIEE constructed the following concept: “Reflective and critical thinking is a complex, systematic and deliberate process of reasoning, self-directed and action-oriented. It is primary purpose to choose, based on intellectual and affective processes (cognitive, experiential and intuitive), the best response options that favor the solution of nursing problems, in well-defined contexts and in accordance with the ethical postulates of the profession that allow it to act with rationality and professional autonomy” ( 8 ) .

The research process included the conceptual and theoretical analysis of the curriculum, the updating of the context of research development in nursing education in each country of the region, the characterization of the HEIN and, finally, the results of the state of the art on teaching strategies for the development of the RACT 1990-2012, Andean region.

Once the exhaustive bibliographic review was carried out, the instrument was designed based on the concept of Stenhouse ( 17 ) , the curriculum as a macro concept that encompasses the socializing function of the school is at the same time pedagogical ideas, structure of contents in a particular form, precision of them, reflection of educational aspirations more difficult to translate in concrete terms and skills to promote in the students ( 16 ) . In Posner ( 18 ) , who raised the great number of phenomena involved in the curriculum; Gimeno-Sacristán; Pérez-Gómez ( 19 ) , there is five categories in which the definitions of curriculum can be articulated: as an organized knowledge structure, production technology system, instructional plan, set of learning experiences and problems solution.

Based on the aforementioned, the specific instrument for this investigation was constructed with three parts. The first with 10 items, with general information from the HEI or University. Each University is subdivided into Centers that are parted into Colleges and these are divided into programs: name, geographic location, type of institution, accreditation data, mission, vision, objectives, curricular guidelines for degree programs, web page, and data about who completed the instrument. The second, 28 items, for the College, School, Department or Nursing Program (typology to identify HEIN in the region), with the following subsections: general aspects of the nursing program, character within the institution, number of sites where the program is offered, accreditation data (date, resolution, and time of accreditation), program justification, mission, vision and objectives of the program, evaluation process, graduation profile, pedagogical model, number of hours and credits, curricular structure (nursing program subjects that correspond to each area or component). Finally, the general characteristics of the teachers: kind of affiliation with the institution, time worked, and maximum educational level achieved. The third, 9 items, for specific information about each of the subjects: name, component or area to which it belongs, number of hours and credits, type of subject (theoretical, practical and theoretical-practical), contents, teaching-learning methodologies and evaluation process.

The members of the research group carried out an analysis of the validity of the content of the instrument. Afterwards, the pilot test was conducted, starting with its implementation in each of the HEI in which the researchers worked; the results were analyzed and the corresponding adjustments were made in its structure. Subsequently, the adjusted instrument was tested with five members from the region, one from each country, but different from the research group. Because of this test, we decided to design a guide to facilitate the completion of the instrument and ensure objectivity in the collection of information, because of the language differences. It is possible to obtain the final version of the instrument from the authors of the project.

Each participant received the letter of invitation, the project, the informed consent, the instrument to collect the information and the corresponding guide for its completion in hands and by e-mail.

The information obtained was reviewed and, in some cases, it was necessary to request the complementation of some aspects of the instrument. Then we proceeded to codify the HEI or Universities and the HEIN. The information was included in Excel tables designed with the predetermined categories and subcategories, which were later incorporated into the SPSS statistical analysis program, version 19. The information was processed using descriptive statistics, with frequency distributions and average analysis, and analyzed by institution, by country and as an Andean region, according to the categories and subcategories determined, allowing comparisons between countries and conclusions to be drawn as a region.

The analysis of the information was carried out using the deductive-inductive method, considering the objectives of the project and the revised conceptual theoretical framework, with the aim of determining the presence of the RACT, explicit and implicit, in each categories, the coherence of the approaches between University-College-Program, the coherence between the objectives, contents, teaching-learning strategies and the evaluation process in each subject. In this sense, we analyzed the linearity or coherence with respect to what was proposed, developed and evaluated in relation to the RACT and, finally, the contradictions and inconsistencies found in the aforementioned approaches were pointed out. We considered national and international studies about the subject for the analysis and discussion of the results obtained, in addition to the documents mentioned above.

According to the information obtained by the research group, the Andean region has 2,552 HEI; 410 with character of universities and 160 are public, 220 are private and 14 are in special regime. There are 167 universities with nursing programs, 146 affiliated and recognized by the respective Associations of Schools and Colleges of Nursing in each country. The number of accredited nursing programs in the Andean region is 43: Colombia (20), Peru (20) and Bolivia (3). Precisely, of the 20 accredited institutions in Colombia, 11 already have their certifications renewed, which are of 8, 6 and 4 years; 5 and 6 years for Ecuador and 3 years for Peru. Bolivia is just beginning the process and Venezuela has no information about it.

The total population of HEIN by country was Bolivia 47, Colombia 42, Ecuador 21, Peru 62 and Venezuela 10. A total of 76 HEIN answered: Bolivia 7; Colombia 38; Ecuador 11; Peru 14 and Venezuela, 6. These institutions constituted the sample of the study.

Twenty-one of these institutions are certified: in Colombia 20 and in Bolivia 1; 12 did not include this information and 41 were not yet certificated. Of the total number of institutions that provided the information, 47 are public, 26 private and three do not know the information. Administratively, 36 are programs; 22 Colleges; 21 Schools and one Department.

The number of hours and credits of the programs showed considerable heterogeneity: the average number of hours was 5,552.3, corresponding on average to 232.11 credits. Regarding the number of hours per credit, the lowest is in Peru, which has 13 hours per credit, and the highest is in Colombia, with 48 hours corresponding to one credit. There are institutions that do not work with credits, especially in Bolivia; others did not included this information, among them Ecuador and Venezuela.

The main characteristics of the 912 teachers developing nursing programs in the Andean region are: 501 (54.9%) with a Specialist degree; 634 (69.51%) with a Master’s degree and 58 (6.35%) with a PhD; 249 (27.3%) with a postgraduate degree in Education.

From a general perspective, it should be noted that of the five countries in the region only Venezuela and Peru explicitly present the RACT in their Organic Law (OL) or Higher Education Law in terms of integral and permanent formation of reflective critical citizens (LOE, 2009, or Organic Law of Education, in Venezuela) ( 20 ) and (Law 30220, 2014, or University Law, in Peru) ( 21 ) .

The results of RACT’s presence are presented below: Universities or HEI; in Colleges, Programs, Schools and Departments, that is, in HEIN; and in the subjects.

When analyzing the information of the Universities or HEI, we found the RACT as direct mention, indirect mention and evidence of traditional positions was found. Directly, it was found as a training purpose in Bolivia, Colombia and Peru: receptor and analytical constructor, with critical conscience; as methodology to achieve it, in Colombia and Peru: “ promoting reasoning, the CT and creative”; as a result of learning in Ecuador and Venezuela: capable of solving problems, CT promoter.

The indirect mention was found as result in the five countries of the Region, as a strategy in Bolivia, Ecuador, Peru and Venezuela: integral formation, relation practical theory; and as objective in Colombia: future graduates with ethical conscience, autonomy, democratic spirit and highly qualified.

There are still traditional postures: teaching, evaluation as a final product, training in instrumental action, the educational process as providing knowledge.

By going a little deeper into the HEI, we found that 88% (38) consider the RACT: 63% (27) in the mission; 7% (3) in the vision; 51% (22) in the objectives and 30% (13) in the curricular guidelines. Among these, three defining categories were identified. The first, as a training purpose: prepare professionals and leaders with CT and social conscience . The second, as a methodological strategy to achieve its development: to develop and implement pedagogical methods that encourage reasoning, CT and creativity, and that encourage habits of discipline and productive work . And the third, as a result of the formation process that includes the subject: Training of critical, self-managed, creative and proactive men and women; and, moreover, refers to the projection and utility: with the promotion of CT and the generation of knowledge, thanks to the strengthening of critical analysis, anticipation and vision of the future and development of viable alternatives to the problems.

At HEIN, RACT is expressed in the graduation profile, objectives, curricular guidelines and mission. Table 1 shows the data summarized in relation to the number and percentage in which the RACT is presented in the subcategories and with regard to the total. The information recovered allows us to identify that the RACT ranks first with 38.3% in the graduation profile, followed by 35% both in the curricular guidelines and in the objectives; thirdly, is in the mission, 26.7%, and finally, with 11.7% it is in the vision. Bolivia has the highest percentage of presence in its curricular guidelines, followed by Colombia in its graduation profile, objectives, and mission, while Venezuela is in one before the last place with a 28% of presence in its mission and is not present in the profile or in the curricular guidelines. Peru has the last place and presents it only in the objectives of the programs.

In a cross-sectional view of what is proposed by curricular programs, three categories were identified to be highlighted. The first, the development of cognitive and personal skills, expressed as the training of professionals with scientific, technical, critical, analytical and reflective knowledge, as well as communication, oral and written expression skills; and referred to a critical, creative, participative, supportive, innovative and sensitive attitude towards social change.

The second, the way in which its development could be achieved, among which the research stands out: promote and develop research, generating knowledge in the different areas of nursing that contribute to universal science and the solution of health problems; and the use of technologies: learns permanently developing the capacity of abstraction, analysis, synthesis and using information technologies . The third, its finality, related to the ability of individuals, families and community groups to interfere and make decisions in the solution of health problems, to provide comprehensive care with the capacity to solve health problems in changing and emerging environments.

Concerning the pedagogical models expressed in the HEIN, a variety was found in the denomination. First of all, the constructivist approaches are highlighted in eight (8) Institutions, with some connotations as the model social-critical-constructivist and second, the cognitive - humanistic in four (4). Other models or approaches were also identified, among them: dialectic, technological, psychological, the problematic schools, the Active, Reflective, Dialectic, Innovative and Critical . Finally one institution works with the model based on the pillars of education , in which learning to know, learning to do, learning to be and learning to live together, which includes, educating for life, educating for life, educating for work, educating in society and for society ( 22 ) .

The RACT in the subjects of the programs of Nursing in the Andean region

Only 29 of the 76 HEIN participants in the study were able to obtain information on subjects (38.15%), and 22 (75.86%) of these in nursing programs, RACT was present in different elements of the subjects. 562 subjects were reviewed, 159 (29%) of which have no information about teaching strategies or evaluation. Moreover, some programs record the same teaching and assessment strategies for all subjects in the program, 45 (8%).

Table 2 presents the results by subcategory and the total presence of RACT in the different groups of subjects, basic area or foundation subjects (which introduce and contextualize the student in the field of knowledge), Research, Humanities (the study of the behavior, conditions and performance of the human being), disciplinary professional area (gives the basic grammar of the profession and discipline) and those of the flexible area (the student chooses them according to personal interests, allow to the learner to approach, contextualize and study in depth aspects of the profession and discipline, allowing to learn tools and other kinds of knowledge, leading to develop interdisciplinarity, flexibility and diversity).

The information provided makes it possible to indicate RACT as a subject: Workshop of Critical Thinking and Introduction to CT ; second, as a subject content: CT in Nursing, and, third, RACT is evidenced in teaching-learning strategies.

The highest percentage of subjects in which RACT is evident correspond to the area of humanities, with 46% (55), in which analysis of real situations, group work, concept maps, role playing and seminars are predominant.

In second place, it is in the professional-disciplinary area with 42% (307) subjects with the predominance of the following strategies: supervised clinical practice, clinical case, problem-based learning, simulation laboratories, and the nursing process. The research is in the same place, 42% (41) subjects. The most commonly used strategies are: critical discussions of research reports and articles, project development, workshops, and problem-based learning.

In the last place, subjects from the basic or foundation area 144 (24%). Including discussion workshops, concept maps and case studies.

A great variety of strategies have been identified, among them are: presentation and discussion of clinical case, group work, clinical practice, flipchart, observation guides, debates, discussion about specific topics, resolution of case studies, support of the nursing care plan, investigative reports , workshop development.

What is evaluated: the development of competencies, the acquisition of skills, the development of superior cognitive processes, the professional spirit and the development of processes and independence.

Finally, in some of the subjects, the intentionality of the evaluation of the RACT is explicitly presented: written works about the topics of each seminar in which the proper handling of the bibliography is evidenced, the capacity for criticism, analysis and synthesis, evidence of problem solving, case analysis and Nursing Based in Evidences , didactic relationship analysis and fundamental elements of the RACT, conceptual knowledge, written and oral reflections, group work, practical reflections and group discussions.

It is evident that traditional evaluation techniques still exist: evaluating procedural aspects, dexterity, motivation and initiative in the procedures, memory evaluation, participation in class, oral and written interventions and, finally, the replication of the topics studied in classes.

Therefore, the analyzed programs show interest in including as an important element in their future graduates the development of the RACT. This aspect is vanishing in the development of the subjects. It is evident in the pedagogical strategies, but it is lost until disappearing in most of the evaluative processes.

The analysis results of the plans and programs of the HEI and HEIN allow to conclude that the proposes of the Law of Higher Education to develop the RACT in the students does not guarantee that it is included in the subjects and evaluations.

What is stated in HEI and HEIN allows us to infer that epistemological and theoretical contradictions are present in the Institutions and among them. It makes necessary an epistemological, theoretical and methodological consideration in order to achieve alignment and coherence between the purposes in the curricular guidelines and what is programmed in the curricular plans for the concrete work with the students. This matter goes against comprehensive training, since it is demonstrated that critical and reflective skills contribute to train professionals with greater ability to care for patients ( 23 ) .

It should be noted that it is the University or HEI that determines the philosophical bases that will guide the academic units that compose it, so that they, in turn, incorporate these principles into their academic programs. The results show that there is no linearity between the proposals of the university with respect to its mission, vision, objectives, graduation profile, curricular guidelines, and what is proposed in the nursing degree programs. There is more linearity in Institutions with a longer trajectory and development, private and public ones.

The analysis of the areas in which the subjects are grouped made it possible to identify that the subjects of the humanities area have the highest percentage of presence of the RACT. This result can be explained by the strategies used, but even more by the subjects under study, since it has been demonstrated that the teaching-learning strategies based on the humanities have a significant impact on the development of skills such as clinical reasoning ( 24 ) . The subjects in the professional area use strategies such as case study, supervised clinical practice and other relatively new ones as problem-based learning and simulation laboratories. Strategies that, by involving simulation or potential practical actions, contribute to enhance critical skills and make decisions that lead to the future professional committing fewer errors during the care of patients ( 25 - 26 ) .

By contrast, it is not the same with the subjects of the foundation or basic area in which it is necessary to return to some knowledge aspects that already exists, such as anatomy, physiology, anthropology, psychology, statistics, among many others. For some students these topics are very difficult and involve, on several occasions, an excellent dose of memory. However, the teaching strategies that develop the RACT are not so frequent. It is important doing more research on this point to sustain if it is true.

On the other hand, for the majority of HEIN, training is conceived as qualification and progress achieved by people and as a principle of theories, concepts, methods, models, strategies and courses of pedagogical action that aim to understand and qualify the teaching. In some cases, the transfer of knowledge is approached, but it still underlies the concept of learning as acquisition of knowledge built and finished; the teacher is the one who has the knowledge and the student is who learns what teacher knows.

The curricula of the Andean region include explicit elements that contribute to the development of the RACT, such as reading, writing and reasoning, allowing to the future professional to know how to learn, reason, think creatively, generate and evaluate ideas, make decisions and solve problems ( 24 ) . It includes as proposals the development of social skills, with emphasis on oral and written communication, cognitive skills including problem solving, establish different alternatives, understand the consequences of actions, make decisions and critical thinking ( 16 ) . Also, intend to achieve in the student some characteristics of the critical thinker like to be creative, innovative, proactive, analytical, participatory, entrepreneurial, self-critical, supportive, humanistic, ethical and scientific ( 27 ) .

Regarding the pedagogical models proposed by the HEIN, inconsistencies between the approach of constructivist approach and meaningful learning are evident. The axis is the student and the repetitive approach in the subjects with master class methodology, reading guides and analysis made by teacher, but not by the student. It shows a traditional model centered on the teacher, with an emphasis on memory, comprehension and the application of concepts. Some subjects focus learning on the acquisition of concepts, despite using the integrating project as a teaching-learning strategy, workshops and practice as evaluation. The pretense for the development of the RACT is not in line with the evaluation, with the examination, in the application of contents, since it is centralized in aspects of memory and knowledge, in an asymmetric theory-practice relationship.

Although significant learning is intended and the importance of integrating it into the formation of learning approaches with the intention of promoting critical thinking, added with successful learning experiences ( 28 ) , it is not really concrete how it could be achieved. Strategies such as simple repetition and teaching for the acquisition of concepts show the persistence of the traditional educational models.

This study found there is no a clear structure to operationalize the theories of the proposed pedagogical models, even though there are expressions that point to RACT. Thus, the elements important for its development are presented in the teaching and learning strategies in a more remarkable way.

The curricular guidelines express the intention to transcend technical rationality and behavioral objectives ( 29 ) , from the positivist, rationalist or empirical analyst paradigm, to the humanist and critical curriculum ( 30 ) to the socio-critical paradigm and critical thinking based on hermeneutic processes ( 31 ) . The social and contextual (political, economic and cultural) aspects that influence and determine the health behaviors of the people are still incipient in the curricula ( 32 ) .

According to what has been demonstrated, it is possible to state that there is no predominance of a pedagogical model, but a mixture of several models in the same program with varied influences. The presence of the following models was identified: Traditional Pedagogical, Behavioral, Cognitive, and Social Pedagogical, the latter being very tenuous ( 33 ) .

There are four fundamental elements to forming critical thinkers: first, the question; second, the creation of continuous opportunities to participate in dialogue, debate, research, and critique; third, self-evaluation and hetero-evaluation; and fourth, teachers as models of critical thinkers ( 32 ) . Considering these elements, we can assure that the creation of opportunities is present with more intensity in some curricula, and self-evaluation and hetero-evaluation have begun to be implemented especially in public institutions.

Mentioning the subjects, it is not evident that the thought is motivated by complex kind of questions that encourage exploration, generate evaluation, create concepts and knowledge ( 33 ) .

The literature points out that the Socratic questions stimulate the student to use existing knowledge, since they promote a greater understanding and integration of new knowledge, they foment the habit of thinking critically ( 8 , 34 ) . Other authors suggest, for the reports, questions about the purpose, information, concepts, assumptions, implications, points of view and the questions, as elements that favor analysis, the evaluation of ideas and reasoning ( 24 , 35 ) .

Like other researches, this study found that the most used strategies in the progress of the professional area that promote the development of RACT are the case study ( 24 , 36 ) , problem-based learning ( 24 ) , supervised clinical practice ( 37 ) , the nursing process ( 4 , 38 ) and simulation laboratories ( 34 , 37 - 38 ) . In this article, we only refer to two of these strategies, which were selected because of the great advance of information and communications technologies. The growing need to access this kind of infrastructure as a fundamental part in the training of future professionals and as an example of a single teaching and learning strategy is not sufficient to achieve the RACT, rather, the use of different techniques enhance its development, as we will see below.

We agree with the conclusion of authors who suggest that Problem-Based Learning and simulation labs are active strategies that develop RACT in nursing students ( 37 ) .

The case study, moreover, promotes active learning, helps to solve clinical problems, promotes the development of critical thinking skills ( 34 - 35 ) , in addition, it allows to integrate knowledge, to think as a professional, to analyze individual situations in specific contexts from different angles, to use theoretical concepts in the delimitation of a concrete problem ( 36 ) . It also stimulates collaborative and team work, the work with different points of view. The question-problem is the motivator in the search for alternative solutions, is useful in simple and complex situations, allows to apply theory in practice, promotes the exchange of ideas, teaches students to learn to control their own thinking and promote the exchange of ideas and intellect ( 37 ) . In addition, it helps to incorporate time management and take responsibility. It also facilitates the integration of the four elements of the Nursing metaparadigm: the person receiving the care, health as purpose, the nature of the nursing and the context or environment.

The case study allows the simultaneous implementation of other strategies that further enhance the development of RACT, such as concept maps, the analysis and selection of scientific evidence, the nursing process, nursing history, role-playing, argued discussion and debate.

In contradiction to all the positive aspects of the case study in the development of RACT, the dichotomy between theory and practice in a large number of the curricula reviewed is an obstacle to achieving all the benefits pointed out. Since some teachers are in charge of the development of the theoretical subject in the classroom, others are in charge of their practical part in other spaces that require this care.

Regarding the practice based on simulation models, a study ( 38 ) shows how the promotion of RACT is relevant. In this connection, it highlights the importance of including simulation as a key element in curricula, because it ensures skills in this kind of thinking ( 38 ) and gives students the opportunity to show their ability in decision-making, critical thinking and other skills ( 39 ) . Other authors emphasize its importance when students reflect it on their thinking process and show how it guided their actions ( 34 ) .

There is efficiency of simulation laboratories when accompanied by active strategies, such as the conceptual map before each laboratory session, a visual aid that allows the concepts, objectives, justification, expected results and possible complications to be described in a logical manner if the procedure is not carried out in the appropriate manner ( 34 ) . The same author suggests the use of high-level questions to stimulate reason more than memory. He also suggests assigning an observer, who will ensure analysis and reflection on patient safety, communication, teamwork and leadership, among others ( 34 ) . The reflection of the group around the whole process carried out will be the end of the laboratory ( 15 , 34 ) .

Another study concluded that simulation as a pedagogical method allows students to recognize, interpret and integrate new information with previous knowledge in order to make decisions about the best direction to follow. The authors state that simulation, as an educational method, provides an opportunity to systematically structure learning to help students acquire deep content knowledge and to facilitate the development of thought processes; that simulation experiences stimulate students’ RACT skills and help them become more competent in caring for patients in complex conditions ( 37 ) .

We agree with what has been found in other studies emphasizing that simulation laboratories by themselves do not guarantee the development of RACT skills, but if combined with other strategies and implemented with adequate pedagogy, the results will be much more effective in terms of CT skills ( 34 , 37 - 38 ) .

It is also possible to find correspondence with that was discovered in the State of the Art of scientific production in RACT in the Andean region. The students perceive that “Clinical simulation is a valuable strategy for the acquisition, complementation and integration of the theoretical part with the practical part, because it seeks to make decisions according to the CT” ( 38 ) .

The evaluation of the subjects is cumulative and formative. In some cases, a diagnosis of the level of the student’s participation in the subject is made; it is evaluated in the intermediate and at the end with the objective of promotion to another level. In other cases, a teaching-learning balance is done to verify the fulfillment of the objectives and competences. Self-evaluation and heteroevaluation are increasingly used, implying a process of reflection, analysis and self-criticism.

Precisely, evaluation appears as one of the weakest points when analyzing the presence of RACT in curricula. Therefore, we agree that the “best teaching practice begins by establishing learning outcomes and continues with a focus on helping the student to achieve satisfactory results”. If the proposal is to achieve a higher order thinking, the evaluation will be oriented towards the synthesis, analysis and evaluation of knowledge ( 40 ) .

Overall, the strong approaches to RACT training formulated at HEI, HEIN, as evidenced by some of the teaching and learning strategies presented in the subjects, become much weaker in the evaluation process, with predominance of traditional evaluation models, and in some cases, the intention to evaluate RACT is outlined.

The curricula of Colleges and Schools of Nursing in the Andean region explicitly contemplate reflective and critical thinking in their mission, vision, objectives, graduation profile and didactic strategies, and implicitly as integral formation. However, there is a tension between what is proposed by the HEI and HEIN and what is implemented and evaluated in the subjects. The presence of RACT in the proposed didactic strategies is much more evident, but it is not sufficiently objective or explicit in the evaluation processes.

Despite the great diversity of pedagogical models, there is a clear intention to facilitate the development of RACT. In addition, although a constructivist model is proposed centered on the student, dialogical, active, reflexive, innovative and critical, this model is more centered on the teacher than on the student; on knowledge over a relationship between equals; more on results than on the learning process. Likewise, knowledge is considered as something finished, fixed and the ultimate truth.

In order to be able to teach the RACT to the nursing student it is necessary to include it in the nursing curriculum, teachers who are professionals in the areas of Education and Nursing and with RACT in their training. Teachers should create spaces for the development of RACT, know and implement the different and complementary didactic strategies that facilitate its learning and that analyze the students in relation to the level of RACT achieved.

The authors of this article suggest that the projects currently developed with teachers and students in Ibero-America should be finalized and retaken with the implementation and evaluation of strategies that value the development of RACT.

RACT is considered an indispensable element in personal and professional development, in order to have autonomy, confidence, the ability to make decisions, reach clinical judgment and, the most important, provide individualized, comprehensive and human nursing care. In summary, graduates should be able to work as members of the health team with sufficient clarity of the role and identity they should have, because they have to integrate and experience the four paradigms of the Nursing.

The limitations of the study are

The complexity of the project due to the number of participating countries and the different research groups;

The large number of public and private nursing schools and colleges in the Andean region;

The limitation in accessibility to the complete information of the curricula of each institution;

The minimal presence of information on the official web pages of each institution, school or nursing college;

No response and lack of interest from different schools and nursing colleges, public and private, to participate of this project;

Limited access of current and recent updates of the curricula of nursing colleges to develop this project.

The research group made efforts to reduce these limitations and devised multiple options that were proposed to the institutions, in order to facilitate the provision of information and its complementation when necessary.

Applications for practice

The innovation and contributions expected with this research are based fundamentally on documenting and analyzing of the diverse existing evidences about if RACT is contemplated in the nursing curricula or not, the strategies used by teachers to create and promote it in nursing students and the evaluation processes employed. It provides insights about how RACT’s competence in nursing is addressed in the context of the Andean region and other regions of Ibero-America, its weaknesses and strengths, as well as the improvements that can be made. The final intention of the research is to offer, as a network and collegial body, proposals for teaching, learning and evaluation that will enable the empowerment of new generations of nurses, using RACT as a center of innovation and development.

Critical thinking definition

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

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

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

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

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• Seeking out more diversity of thought
• Opening up their curiosity in an intellectual way etc.

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

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

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• Open access
• Published: 26 March 2024

The effect of “typical case discussion and scenario simulation” on the critical thinking of midwifery students: Evidence from China

• Yuji Wang 1   na1 ,
• Yijuan Peng 1   na1 &
• Yan Huang 1  

BMC Medical Education volume  24 , Article number:  340 ( 2024 ) Cite this article

Metrics details

Assessment ability lies at the core of midwives’ capacity to judge and treat clinical problems effectively. Influenced by the traditional teaching method of “teacher-led and content-based”, that teachers involve imparting a large amount of knowledge to students and students lack active thinking and active practice, the clinical assessment ability of midwifery students in China is mostly at a medium or low level. Improving clinical assessment ability of midwifery students, especially critical thinking, is highly important in practical midwifery education. Therefore, we implemented a new teaching program, “typical case discussion and scenario simulation”, in the Midwifery Health Assessment course. Guided by typical cases, students were organized to actively participate in typical case discussions and to promote active thinking and were encouraged to practice actively through scenario simulation. In this study, we aimed to evaluate the effect of this strategy on the critical thinking ability of midwifery students.

A total of 104 midwifery students in grades 16–19 at the West China School of Nursing, Sichuan University, were included as participants through convenience sampling. All the students completed the Midwifery Health Assessment course in the third year of university. Students in grades 16 and 17 were assigned to the control group, which received routine teaching in the Midwifery Health Assessment, while students in grades 18 and 19 were assigned to the experimental group, for which the “typical case discussion and scenario simulation” teaching mode was employed. The Critical Thinking Disposition Inventory-Chinese Version (CTDI-CV) and Midwifery Health Assessment Course Satisfaction Questionnaire were administered after the intervention.

After the intervention, the critical thinking ability of the experimental group was greater than that of the control group (284.81 ± 27.98 and 300.94 ± 31.67, p  = 0.008). Furthermore, the experimental group exhibited higher scores on the four dimensions of Open-Mindedness (40.56 ± 5.60 and 43.59 ± 4.90, p  = 0.005), Analyticity (42.83 ± 5.17 and 45.42 ± 5.72, p  = 0.020), Systematicity (38.79 ± 4.70 and 41.88 ± 6.11, p  = 0.006), and Critical Thinking Self-Confidence (41.35 ± 5.92 and 43.83 ± 5.89, p  = 0.039) than did the control group. The course satisfaction exhibited by the experimental group was greater than that exhibited by the control group (84.81 ± 8.49 and 90.19 ± 8.41, p  = 0.002).

The “typical case discussion and scenario simulation” class mode can improve the critical thinking ability of midwifery students and enhance their curriculum satisfaction. This approach carries a certain degree of promotional significance in medical education.

Typical case discussion and scenario simulation can improve midwifery students’ critical thinking ability.

Typical case discussion and scenario simulation can enhance students’ learning interest and guide students to learn independently.

Midwifery students were satisfied with the new teaching mode.

Peer Review reports

Maternal and neonatal health are important indicators to measure of the level of development of a country’s economy, culture and health care. The positive impact of quality midwifery education on maternal and newborn health is acknowledged in the publication framework for action strengthening quality midwifery education issued by the World Health Organization (WHO) [ 1 ]. Extensive evidence has shown that skilled midwifery care is crucial for reducing preventable maternal and neonatal mortality [ 2 , 3 , 4 ]. Clinical practice features high requirements for the clinical thinking ability of midwives, which refers to the process by which medical personnel analyze and integrate data with professional medical knowledge in the context of diagnosis and treatment as well as discover and solve problems through logical reasoning [ 5 ]. Critical thinking is a thoughtful process that is purposeful, disciplined, and self-directed and that aims to improve decisions and subsequent actions [ 6 ]. In 1986, the American Association of Colleges of Nursing formulated the “Higher Education Standards for Nursing Specialty”, which emphasize the fact that critical thinking is the primary core competence that nursing graduates should possess [ 7 ]. Many studies have shown that critical thinking can help nurses detect, analyze and solve problems creatively in clinical work and is a key factor in their ability to make correct clinical decisions [ 8 , 9 , 10 ].

However, the traditional teaching method used for midwifery students in China is “teacher-led and content-based”, and it involves efficiently and conveniently imparting a large amount of knowledge to students over a short period. Students have long failed to engage in active thinking and active practice, and the cultivation of critical thinking has long been ignored [ 5 ]. As a result, the critical thinking ability of midwifery students in China is mostly at a medium or low level [ 5 ]. Therefore, it is necessary to develop a new teaching mode to improve the critical thinking ability of midwifery students.

In 2014, Professor Xuexin Zhang of Fudan University, Shanghai, China, proposed a novel teaching method: the divided class mode. The basic idea of this approach is to divide the class time into two parts. The teachers explain the theoretical knowledge in the first lesson, and the students discuss that knowledge in the second lesson. This approach emphasizes the guiding role of teachers and encourages and empowers students to take responsibility for their studies [ 11 ]. Research has shown that the divided class mode can improve students’ enthusiasm and initiative as well as teaching effectiveness [ 12 ].

The problem-originated clinical medical curriculum mode of teaching was first established at McMaster University in Canada in 1965. This model is based on typical clinical cases and a problem-oriented heuristic teaching model [ 13 ]. The process of teaching used in this approach is guided by typical cases with the goal of helping students combine theoretical knowledge and practical skills. This approach can enhance the enthusiasm and initiative of students by establishing an active learning atmosphere. Students are encouraged to discuss and analyze typical cases to promote their ability to digest and absorb theoretical knowledge. Research has shown that the problem-originated clinical medical curriculum teaching mode can enhance students’ confidence and improve their autonomous learning and exploration ability. Scenario simulation teaching can provide students with real scenarios, allowing them to practice and apply their knowledge in a safe environment [ 14 ], which can effectively improve their knowledge and clinical skills and enhance their self-confidence [ 15 , 16 ].

Based on the teaching concept of divided classes, our research team established a new teaching model of “typical case discussion and scenario simulation”. Half of the class time is allocated for students to discuss typical cases and carry out scenario simulations to promote their active thinking and active practice. The Midwifery Health Assessment is the final professional core course that midwifery students must take in our school before clinical practice. All students must complete the course in Grade 3. Teaching this course is important for cultivating the critical thinking and clinical assessment ability of midwifery students. Therefore, our team adopted the new teaching mode of "typical case discussion and scenario simulation" in the teaching of this course. This study explored the teaching mode’s ability to improve the critical thinking ability of midwifery students.

Study design

The study employed a semiexperimental design.

Participants

A convenience sample of 104 third-year midwifery students who were enrolled in the Midwifery Health Assessment course volunteered to participate in this research at a large public university in Sichuan Province from February 2019 to June 2022 (grades 16 to 19). All the students completed the course in the third year of university. Students in grades 16 and 17 were assigned to the control group, which received the traditional teaching mode. Students in grades 18 and 19 were assigned to the experimental group, in which context the “typical case discussion and scenario simulation” class mode was used. The exclusion criteria for midwifery students were as follows: (1) dropped out of school during the study, (2) took continuous leave from school for more than two weeks, or (3) were unable to complete the questionnaire. The elimination criterion for midwifery students was that all the items were answered in the same way. No significant differences in students’ scores in their previous professional courses (Midwifery) were observed between the two groups. Textbooks, teachers, and teaching hours were the same for both groups.

Development of the “typical case discussion and scenario simulation” class mode

This study is based on the implementation of the new century higher education teaching reform project at Sichuan University. With the support of Sichuan University, we first established a “typical case discussion and scenario simulation” class mode team. The author of this paper was the head of the teaching reform project and served as a consultant, and the first author is responsible for supervising the implementation of the project. Second, the teaching team discussed and developed a standard process for the “typical case discussion and scenario simulation” class mode. Third, the entire team received intensive training in the standard process for the “typical case discussion and scenario simulation” class mode.

Implementation of the “typical case discussion and scenario simulation” class mode

Phase i (before class).

Before class, in accordance with the requirements for evaluating different periods of pregnancy, the teacher conceptualized typical cases and then discussed those cases with the teaching team and made any necessary modifications. After the completion of the discussion, the modified cases were released to the students through the class group. To ensure students’ interest, they were guided through the task of discovering and solving relevant problems using an autonomous learning approach.

Phase II (the first week)

Typical case discussion period. The Midwifery Health Assessment course was taught by 5 teachers and covered 5 health assessment periods, namely, the pregnancy preparation, pregnancy, delivery, puerperium and neonatal periods. The health assessment course focused on each period over 2 consecutive teaching weeks, and 2 lessons were taught per week. The first week focused on the discussion of typical cases. In the first lesson, teachers introduced typical cases, taught key knowledge or difficult evaluation content pertaining to the different periods, and explored the relevant knowledge framework. In the second lesson, teachers organized group discussions, case analyses and intergroup communications for the typical cases. They were also responsible for coordinating and encouraging students to participate actively in the discussion. After the discussion, teachers and students reviewed the definitions, treatments and evaluation points associated with the typical cases. The teachers also encouraged students to internalize knowledge by engaging in a process of summary and reflection to achieve the purpose of combining theory with practice.

Phase III (the second week)

Scenario simulation practice period. The second week focused on the scenario simulation practice period. In the first lesson, teachers reviewed the focus of assessment during the different periods and answered students’ questions. In the second lesson, students performed typical case assessment simulations in subgroups. After the simulation, the teachers commented on and summarized the students’ simulation evaluation and reviewed the evaluation points of typical cases to improve the students’ evaluation ability.

The organizational structure and implementation of the “typical case discussion and scenario simulation” class mode showed in Fig.  1 .

“Typical case discussion and scenario simulation” teaching mode diagram

A demographic questionnaire designed for this purpose was used to collect relevant information from participants, including age, gender, single-child status, family location, experience with typical case discussion or scenario simulation and scores in previous professional courses (Midwifery).

The Critical Thinking Disposition Inventory-Chinese Version (CTDI-CV) was developed by Peng et al. to evaluate the critical thinking ability of midwifery students [ 17 ]. The scale contains 70 items across a total of seven dimensions, namely, open-mindedness, truth-seeking, analytical ability, systematic ability, self-confidence in critical thinking, thirst for knowledge, and cognitive maturity. Each dimension is associated with 10 items, and each item is scored on a 6-point Likert scale, with 1 indicating “extremely agree” and 6 representing “extremely disagree”. The scale includes 30 positive items, which receive scores ranging from “extremely agree” to “extremely disagree” on a scale of 6 to 1, and 40 negative items, which receive scores ranging from “extremely agree” to “extremely disagree” on a scale of 1 to 6. A total score less than 210 indicates negative critical thinking ability, scores between 211 and 279 indicate an unclear meaning, scores of 280 or higher indicate positive critical thinking ability, and scores of 350 or higher indicate strong performance. The score range of each trait is 10–60 points; a score of 30 points or fewer indicates negative trait performance, scores between 31 and 39 points indicate that the trait meaning is incorrect, scores of 40 points or higher indicate positive trait performance, and scores of 50 points or higher indicate extremely positive trait performance. The Cronbach’s α coefficient of the scale was 0.90, thus indicating good content validity and structure. The higher an individual’s score on this measure is, the better that individual’s critical thinking ability.

The evaluation of teaching results was based on a questionnaire used to assess undergraduate course satisfaction, and the researchers deleted and modified items in the questionnaire to suit the context of the “typical case discussion and scenario simulation” teaching mode. Two rounds of discussion were held within the study group to form the final version of the Midwifery Health Assessment satisfaction questionnaire. The questionnaire evaluates the effect of teaching in terms of three dimensions, namely, curriculum content, curriculum teaching and curriculum evaluation. The questionnaire contains 21 items, each of which is scored on a 5-point Likert scale, with 1 indicating “extremely disagree” and 5 representing “extremely agree”. The higher the score is, the better the teaching effect.

Data collection and statistical analysis

We input the survey data into the “Wenjuanxing” platform ( https://www.wjx.cn/ ), which specializes in questionnaire services. At the beginning of the study, an electronic questionnaire was distributed to the students in the control group via student WeChat and QQ groups for data collection. After the intervention, an electronic questionnaire was distributed to the students in the experimental group for data collection in the final class of the Midwifery Health Assessment course. All the data were collected by the first author (Yuji Wang). When students had questions about the survey items, the first author (Yuji Wang) immediately explained the items in detail. To ensure the integrity of the questionnaire, the platform required all the items to be answered before submission.

Statistical Package for Social Sciences Version 26.0 (SPSS 26.0) software was used for data analysis. The Shapiro‒Wilk test was used to test the normality of the data. The measurement data are expressed as the mean ± standard deviation (X ± S), and an independent sample t test was used for comparisons among groups with a normal distribution. The data presented as the number of cases (%), and the chi-square test was performed. A P value < 0.05 indicated that a difference was statistically significant.

Ethical considerations

The study was funded by the New Century Teaching Reform Project of Sichuan University and passed the relevant ethical review. Oral informed consent was obtained from all individual participants in the study.

Characteristics of the participants

A total of 104 third-year midwifery students were enrolled from February 2019 to June 2022, and 98.1% (102/144) of these students completed the survey. Two invalid questionnaires that featured the same answers for each item were eliminated. A total of 100 participants were ultimately included in the analysis. Among the participants, 48 students were assigned to the control group, and 52 students were assigned to the experimental group. The age of the students ranged from 19 to 22 years, and the mean age of the control group was 20.50 years (SD = 0.61). The mean age of the experimental group was 20.63 years (SD = 0.65). Of the 100 students who participated in the study, the majority (96.0%) were women. No significant differences were observed between the intervention and control groups in terms of students’ demographic information (i.e., age, gender, status as an only child, or family location), experience with scenario simulation or typical case discussion and scores in previous Midwifery courses (Table  1 ).

Examining the differences in critical thinking ability between the two groups

The aim of this study was to evaluate the effect of the new teaching mode of “typical case discussion and scenario simulation” on improving the critical thinking ability of midwifery students. Independent sample t tests were used to examine the differences in critical thinking ability between the two groups (Table  2 ). The results showed that the total critical thinking scores obtained by the experimental group were greater than those obtained by the control group (284.81 ± 27.98 and 300.94 ± 31.67, p  = 0.008). The differences in four dimensions (Open-Mindedness (40.56 ± 5.60 and 43.59 ± 4.90, p  = 0.005), Analyticity (42.83 ± 5.17 and 45.42 ± 5.72, p  = 0.020), Systematicity (38.79 ± 4.70 and 41.88 ± 6.11, p  = 0.006), and Critical Thinking Self-Confidence (41.35 ± 5.92 and 43.83 ± 5.89, p  = 0.039)) were statistically significant.

Examining the differences in curriculum satisfaction between the two groups

To evaluate the effect of the new teaching mode of “the typical case discussion and scenario simulation” on the course satisfaction of midwifery students. Independent sample t tests were used to examine the differences in course satisfaction between the two groups (Table  3 ). The results showed that the curriculum satisfaction of the experimental group was greater than that of the control group (84.81 ± 8.49 and 90.19 ± 8.41, p  = 0.002). Independent sample t tests were used to examine the differences in the three dimensions of curriculum satisfaction between the two groups (Table  3 ). The results showed that the average scores of the intervention group on the three dimensions were significantly greater than those of the control group (curricular content: 20.83 ± 1.96 and 22.17 ± 2.23, p  = 0.002; curriculum teaching: 34.16 ± 3.89 and 36.59 ± 3.66, p  = 0.002; curriculum evaluation: 29.81 ± 3.27 and 31.42 ± 3.19, p  = 0.015).

Midwifery is practical and intensive work. To ensure maternal and child safety, midwives must make decisions and take action quickly. Therefore, midwives should have both critical thinking ability and clinical decision-making ability [ 18 ]. In addition, the Australian Nursing and Midwifery Accreditation Council (ANMAC) regulates the educational requirements for the programs required for registration as a midwife. According to these standards, education providers must incorporate learning activities into curricula to encourage the development and application of critical thinking and reflective practice [ 19 ]. Therefore, the challenge of cultivating the critical thinking ability of midwifery students is an urgent problem that must be solved. However, influenced by the traditional teaching method of “teacher-led and content-based”, the critical thinking ability of midwifery students in China is mostly at a medium or low level. In order to improve the critical thinking ability of midwifery students. Our research team has established a new teaching model, the “typical case discussion and scenario simulation” class model. And applied to the midwifery core curriculum Midwifery Health Assessment. This study aimed to investigate the implementation of a novel systematic and structured teaching model for midwifery students and to provide evidence regarding how to improve the critical thinking ability of midwives.

The results showed that the total CTDI-CV score obtained for the experimental group was greater than that obtained for the control group. These findings indicate that the “typical case discussion and scenario simulation” class mode had a positive effect on the cultivation of students’ critical thinking ability, a conclusion which is similar to the findings of Holdsworth et al. [ 20 ], Lapkin et al. [ 21 ] and Demirören M et al. [ 22 ]. We indicate the following reasons that may explain these results.The core aim of the typical case discussion teaching mode is to raise questions based on typical clinical cases and to provide heuristic teaching to students [ 23 ]. This approach emphasizes asking questions based on specific clinical cases, which enables students to engage in targeted learning. Moreover, scenario simulation allows students to attain certain inner experiences and emotions and actively participate in curriculum practice, which can enhance their ability to remember and understand knowledge [ 24 ]. Through the divided class mode, half of the class time was divided into the students. This method emphasizes the guiding role of teachers and encourages and empowers students to assume learning responsibilities. In addition, students can think, communicate and discuss actively [ 22 , 23 ]. Furthermore, this approach created opportunities for students to analyze and consider problems independently and give students sufficient time to internalize and absorb knowledge and deepen their understanding of relevant knowledge, which can increase their confidence in their ability to address such problems and improve their critical thinking ability [ 12 , 25 , 26 ].

In addition, the results showed that except for Truth-Seeking and Systematicity, the other five dimensions were all positive. These findings are similar to the results reported by Atakro et al.. and Sun et al. [ 27 , 28 ]. Through the intervention, the Systematicity scores became positive, suggesting that the new teaching mode can help students deal with problems in an organized and purposeful way. However, Truth-Seeking still did not become positive; this notion focuses on intellectual honesty, i.e., the disposition to be courageous when asking questions and to be honest and objective in the pursuit of knowledge even when the topics under investigation do not support one’s self-interest [ 29 ]. Studies have shown that this factor is related to the traditional teaching mode used [ 30 ]. The traditional teaching mode focuses on knowledge infusion, helps students remember the greatest possible amount of knowledge in a short time, and does not focus on guiding students to seek knowledge with sincerity and objectivity. Therefore, in future educational practice, we should focus on cultivating students’ ability to seek truth and engage in systematization.

Student evaluative feedback is an important way to test the effectiveness teaching mode. Therefore, understanding students’ evaluations of the effects of classroom teaching is key to promoting teaching reform and improving teaching quality. Therefore, we distributed a satisfaction questionnaire pertaining to the midwifery health assessment curriculum, which was based on the “typical case discussion and scenario simulation” class mode, with the goal of investigating curriculum satisfaction in terms of three dimensions (curriculum content, curriculum teaching and curriculum evaluation). The results showed that the satisfaction scores for each dimension increased significantly. This finding suggests that the new teaching method can enrich the teaching content, diversify the teaching mode and improve students’ curriculum evaluations.

In summary, the “typical case discussion and scenario simulation” class mode focuses on typical cases as its main content. Students’ understanding of this content is deepened through group discussion and scenario simulation. The subjectivity of students in curriculum learning should be accounted for. Students can be encouraged to detect, analyze and solve problems with the goal of improving their critical thinking ability. Moreover, this approach can also enhance curriculum satisfaction. It is recommended that these tools should be used continuously in future curriculum teaching.

This study has several limitations. First, the representativeness of the sample may be limited since the participants were recruited from specific universities in China. Second, we used historical controls, which are less effective than simultaneous controlled trials. Third, online self-report surveys are susceptible to response biases, although we included quality control measurements in the process of data collection. Fourth, we did not use the same critical thinking instrument, CTDI-CV, to investigate the critical thinking of the students in the experimental group or the control group before intervention but used professional course grades from the Midwifery for substitution comparison. This may not be a sufficient substitute. However, these comparisons could be helpful since those grades included some sort of evaluation of critical thinking. In light of these limitations, future multicenter simultaneous controlled studies should be conducted. Nonetheless, this study also has several strengths. First, no adjustment of teachers or change in learning materials occurred since the start of the midwifery health assessment, thus ensuring that the experimental and control groups featured the same teaching materials, teachers and teaching hours. In addition, to ensure the quality of the research, the first author of this paper participated in the entirety of the course teaching.

The “typical case discussion and scenario simulation” class mode can improve the critical thinking of midwifery students, which is helpful for ensuring maternal and child safety. Students are highly satisfied with the new teaching mode, and this approach has a certain degree of promotional significance. However, this approach also entails higher requirements for both teachers and students.

Availability of data and materials

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

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The study was supported by Sichuan University’s New Century Education and Teaching Reform Project (SCU9316).

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Department of Nursing, West China Second University Hospital, Sichuan University/West China School of Nursing, Sichuan University/Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), No. 20 Third Section, Renmin South Road, Chengdu, Sichuan Province, 610041, China

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All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Yuji Wang, Yijuan Peng and Yan Huang. The first draft of the manuscript were written by Yuji Wang and Yijuan Peng, and all authors commented on previous versions of the manuscript.

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This study was supported by Sichuan University. And it was approved by the Ethics Review Committee of West China School of Nursing, Sichuan University. As it is a teaching research with no harm to samples, we only obtained oral informed consents from the participants including teachers and midwifery students and it was approved by the Ethics Review Committee of West China School of Nursing, Sichuan University(approval number 2021220). We comfirm that all methods were performed in accordance with the relevant guidelines and regulations in Ethics Approval and Consent to participate in Declarations.

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Wang, Y., Peng, Y. & Huang, Y. The effect of “typical case discussion and scenario simulation” on the critical thinking of midwifery students: Evidence from China. BMC Med Educ 24 , 340 (2024). https://doi.org/10.1186/s12909-024-05127-5

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Received : 19 November 2022

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DOI : https://doi.org/10.1186/s12909-024-05127-5

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