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Critical Thinking in Nursing: Tips to Develop the Skill

4 min read • February, 09 2024

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

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

What Is Critical Thinking in Nursing?

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

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

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

How Is Critical Thinking Important for Nurses? 

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

Elements of Critical Thinking in Nursing

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

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

How to Develop and Apply Critical-Thinking Skills in Nursing

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

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

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

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

Images sourced from Getty Images

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What is Critical Thinking in Nursing? (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?

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

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

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Developing Critical-Thinking Skills in Student Nurses

April 8, 2020

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

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

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

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

Characteristics of Critical Thinkers

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

Interpretation

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

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

Critical thinkers consider relevant information from evidence to draw conclusions.

Explanation

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

Self-regulation

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

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

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

“Therefore, education must begin at the undergraduate level to develop students’ critical thinking and clinical reasoning skills,” McCartney said. “Clinical reasoning is a learnt skill requiring determination and active engagement in deliberate practice design to improve performance. In order to acquire such skills, students need to develop critical thinking ability, as well as an understanding of how judgments and decisions are reached in complex healthcare environments.”

Teaching Critical Thinking to Nurses

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

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

Promoting interactions

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

Asking open-ended questions

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

Providing time for students to reflect on questions

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

Teaching for skills to transfer

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

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

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

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

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

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

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

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

For more information, contact Duquesne University today.

Critical Thinking: A Vital Trait for Nurses: Minority Nurse

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

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

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

Turning New Nurses Into Critical Thinkers: Wolters Kluwer

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.

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

Last updated on August 19th, 2023

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

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

24 Strategies to improve critical thinking skills in nursing

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

1. Reflective Journaling: Delving into Deeper Understanding

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

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

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

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

2. Meeting with Colleagues: Collaborative Learning for Critical Thinking

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

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

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

3. Concept Mapping: Visualizing Complexity

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

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

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

4. Socratic Questioning: Digging Deeper into Situations

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

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

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

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

5. Inductive and Deductive Reasoning: From Specifics to Generalizations

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

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

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

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

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

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

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

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

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

7. Clarifying Assumptions: Promoting Effective Communication

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

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

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

8. Clinical Simulations: Learning through Virtual Scenarios

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

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

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

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

9. Case Studies and Grand Rounds: Analyzing Complex Cases

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

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

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

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

10. Continuing Education and Lifelong Learning: Expanding Knowledge

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

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

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

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

11. Debates and Discussions: Encouraging Thoughtful Dialogue

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

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

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

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

12. Multidisciplinary Collaboration: Gaining Insights from Various Disciplines

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

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

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

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

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

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

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

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

14. Root Cause Analysis: Investigating Adverse Events

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

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

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

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

15. Creative Thinking Exercises: Expanding Solution Repertoire

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

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

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

16. Journal Clubs: Fostering Evidence-Based Discussion

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

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

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

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

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

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

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

17. Critical Reflection Groups: Collaborative Learning and Analysis

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

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

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

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

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

18. Mindfulness and Reflection Practices: Enhancing Self-Awareness

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

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

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

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

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

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

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

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

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

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

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

21. Cultural Competence Training: Navigating Diverse Perspectives

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

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

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

22. Active Listening and Empathetic Communication: Gathering Insights

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

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

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

23. Mentorship and Preceptorship: Learning from Experienced Professionals

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

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

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

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

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

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

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

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

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

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

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

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

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28.1 Clinical Judgment Measurement Model

Historically, nursing was often viewed as a task-oriented career, but in recent years, the profession has grown in terms of autonomy and clinical judgment. Some of this growth was due to the development of the CJMM, a tool designed to measure critical thinking and clinical judgment in nursing students. This tool allows educators to assess the development of nursing student’s critical thinking skills to help ensure they are ready to practice as a nurse after graduation. This tool involves several steps that have expanded upon the traditional nursing process model, making it an excellent framework to guide new nurses in making clinical judgment calls in practice.

28.2 Developing Critical Thinking Skills

Nursing involves several types of thinking, of which one of the most important is critical thinking. Critical thinking involves applying knowledge to make care decisions that reflect evidence-based practice and consider patient preferences. Thinking is a subconscious process, but there are several models that have been developed to focus upon developing more improved thinking skills. Specifically, the 4-Circle CT model demonstrates characteristics that are vital to develop critical thinking skills. The development of critical thinking skills is especially important within nursing because nurses are constantly making clinical judgment calls when caring for sick patients.

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Developing clinical judgment skills in nursing students

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Critical thinking + clinical reasoning = strong clinical judgment

Critical thinking

To develop critical thinking skills, students must engage in activities encouraging analyzing, discriminating, information-seeking, and open-mindedness. Critical thinking requires students to think precisely and accurately and act on what they know and understand; critical thinking precedes clinical reasoning (Manetti, 2018; Potter & Perry, 2012; Alfaro-LeFevre, 2017).

Clinical reasoning

Clinical reasoning involves a student's ability to apply knowledge, think in action, and reason as a situation changes over time (Benner, et al., 2010). the analysis of data is done through four steps:

• noticing relevant clinical data
• interpreting the clinical significance of data
• responding appropriately by prioritizing responses and actions
• reflecting on the effectiveness of the response (Tanner, 2006).

Clinical judgment

Clinical judgment results in a student's conclusions after making a holistic assessment that correctly interprets clinical data to determine the best response. It is an outcome that depends on critical thinking, clinical reasoning, and intuition (Rischer, 2021). 

In nursing, for example, strong clinical judgment involves choosing the best response among alternative actions in light of expected outcomes, using ongoing evaluative reflection to monitor a patient's response, and modifying interventions accordingly. Reflecting on clinical decisions afterward improves judgment when caring for future patients (Alfaro-LeFevre, 2017; Tanner, 2006; Manetti, 2019).

Clinical judgment models for nursing instruction

Nursing process (american nurses association).

• Assessment — the nurse assesses patients on an in-depth physiological, economic, social, and lifestyle basis.
• Diagnosis and analysis — the nurse considers the physical symptoms and patient behavior and forms a diagnosis or analysis of cues to determine the current nursing priority.
• Outcomes and planning — the nurse uses their expertise to set realistic goals for the patient's recovery and monitors those objectives closely.
• Implementation — the nurse implements the care plan and documents the patient's progress.
• Evaluation — the nurse analyzes the effectiveness of the care plan, studies the patient response, and alters the plan of care to achieve the best patient outcomes. (ANA Standards of Critical Nursing Practice, 1988).

Tanner's Clinical Judgment Model

• Noticing — What clinical data does the nurse recognize as important and/or significant?
• Interpreting — What is the meaning or clinical significance of relevant clinical data that was noticed?
• Responding — How will the nurse respond with a nursing priority and care plan based on the clinical data that was noticed and interpreted?
• Reflecting — After responding, what is the evaluation, reflecting on clinical data noticed by the nurse? (Tanner, 2006)

Revised Clinical Judgment Model

Based on Tanner's Clinical Judgment Model and Neilsen, Stragnell, and Jester's article Guide for Reflection using the Clinical Judgment Model, instructors from the UW-Madison School of Nursing have developed a revised model that also addresses issues of diversity, equity, social justice, and health equity into the equation. This added element of Personalizing asks the nurse to consider the emotions, reactions, beliefs, and biases they bring to the care of a patient and develop a self-care plan that manages these feelings to ensure fair and equitable patient care.

• Alfaro-LeFevre, R. (2017). Critical thinking, clinical reasoning, and clinical judgment: A practical approach. (6th ed.). St. Louise, MO: Elsevier-Saudners.
• Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation . San Francisco, CA: Jossey-Bass.
• Manetti, W. (2019). Sound clinical judgment in nursing: A concept analysis: MANETTI. Nursing Forum, 54)1, 102-110.
• Nielsen, A., Stragnell, S., & Jester, P. (2007) Guide for reflection using the clinical judgment model.  The Journal of Nursing Education , 46(11), 513-516.
• Rischer, K. (2021). Faculty guide to develop clinical judgment: Transforming nursing education through the use of clinical reasoning case studies.
• Tanner, C.A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. The Journal of Nursing Education, 45(6) , 204-211).

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

By Hannah Meinke on 07/05/2021

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

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

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

Why are critical thinking skills in nursing important?

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

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

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

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

How are critical thinking skills acquired in nursing school?

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

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

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

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

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

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

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

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

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

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

How are critical thinking skills applied in nursing?

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

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

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

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

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

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

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

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

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

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

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

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

Beyond thinking

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

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

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

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Using unfolding case studies to develop critical thinking skills in baccalaureate nursing students: A pilot study

Affiliation.

• 1 University of Wisconsin Oshkosh, College of Nursing, 800 Algoma Blvd, Oshkosh, WI, United States of America. Electronic address: [email protected].
• PMID: 32717696
• DOI: 10.1016/j.nedt.2020.104542

Background: Research has consistently demonstrated that new graduate nurses do not possess sufficient critical thinking skills when they transition to clinical practice. Unfolding case studies encourage students to participate in a number of critical thinking skills including information-seeking, logical reasoning, and analyzing of clinical data.

Objective: The aim of this study was to determine how the use of unfolding case studies as a learning modality affected baccalaureate students' critical thinking skills in their Adult Health Theory course. The researcher compared course examination scores earned by nursing students who were taught using traditional case studies to scores obtained by nursing students who completed unfolding case studies.

Setting: The pilot study took place at a moderate-sized comprehensive university in Wisconsin.

Design: A non-experimental correlational design using course examination scores data was employed to examine how the use of unfolding case studies as a learning modality affected baccalaureate students' critical thinking skills in their Adult Health Theory course.

Participants: A total of 160 students comprised the intervention group while an additional 142 students represented the control group in the study.

Methods: An independent-samples t-test was performed to explore differences in mean scores between the intervention and control groups.

Results: Results of the t-test indicate that mean examination scores were significantly higher for the intervention group (M = 234.9, SD = 13.1) than for the control group (M = 228.2, SD = 13.3); t(299) =, p < .001.

Conclusions: Results of this study suggest that unfolding case studies more effectively develop students' critical thinking skills than do a more traditional, static case study.

Keywords: Baccalaureate education; Critical thinking; Nursing students; Unfolding case study.

Copyright © 2020 Elsevier Ltd. All rights reserved.

PubMed Disclaimer

Conflict of interest statement

Declaration of competing interest The author declares no conflicts of interest.

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Effectiveness of Problem-Based Learning on Development of Nursing Students’ Critical Thinking Skills

A systematic review and meta-analysis.

Wei, Baojian MD; Wang, Haoyu BS; Li, Feng MSc; Long, Yan MSc; Zhang, Qi MSc; Liu, Hang MSc; Tang, Xiujun MSc; Rao, Mingjun MD

Author Affiliations: Adjunct Professor (Dr Wei), School of Nursing, Shandong First Medical University & Shandong Academy of Medical Sciences, Taian, Shandong, China; and Instructor (Messrs Wang, Li, Zhang, Liu, and Tang and Ms Long), Professor (Mr Tang), and Adjunct Professor (Dr Rao), Department of Plastic Surgery, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China.

Correspondence: Dr Rao ( [email protected] ) and Mr Tang ( [email protected] ) , Department of Plastic Surgery, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China.

This work was supported by the Research Program of Taishan Medical College Education and Teaching Research Project (No. XY2018051).

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website ( www.nurseeducatoronline.com ).

Accepted for publication: September 17, 2023

Early Access: November 16, 2023

Cite this article as: Wei B, Wang H, Li F, Long Y, Zhang Q, Liu H, Tang X, Rao M. Effectiveness of problem-based learning on development of nursing students’ critical thinking skills: a systematic review and meta-analysis. Nurse Educ . 2024;49(3):E115-E119. doi:10.1097/NNE.0000000000001548

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Background: 

Problem-based learning (PBL) is a student-centered approach to teaching that has been applied in medical and nursing education. The effectiveness of PBL in promoting critical thinking in nursing students has been studied extensively with mixed results.

Purpose: 

The meta-analysis aimed to investigate the impact of PBL interventions on critical thinking skills of nursing students.

Methods: 

PubMed, Embase, Cochrane, and CINAHL databases were electronically searched. Methodological quality was examined using the Newcastle-Ottawa Scale and version 2 of the Cochrane risk-of-bias tool. Data were analyzed with 95% confidence intervals based on random-effect models.

Results: 

Nineteen studies involving 1996 nursing students were included in the analysis. The results of the analysis demonstrated greater improvement in critical thinking skills compared with the control group (overall critical thinking scores: standardized mean difference [SMD] = 0.47, 95% CI = 0.33-0.61, P < .01).

Conclusions: 

The meta-analysis indicates that PBL can help nursing students to improve their critical thinking.

Nursing occupies a critical role in health care. The profession entails a myriad of responsibilities, including recognizing patients’ symptoms, taking measures to administer medications, providing other measures to help relieve symptoms, and collaborating with other health care workers to optimize patients’ comfort and families’ understanding and adaptation. 1 To effectively fulfill these responsibilities, nurses require professional knowledge across various aspects of health care. 2 , 3 Critical thinking, an essential cognitive capacity, plays a pivotal role in enabling nurses to make informed decisions and fulfill their diverse roles. 4 It involves a combination of cognitive skills and affective dispositions, as defined by the American Philosophical Association, and positively influences clinical practice, patient health, student education, and the growth of nursing science. 5 , 6

Problem-based learning (PBL) is an innovative teaching method that has gained widespread application among institutions worldwide, particularly in the fields of medical and nursing education. 6 , 7 As described by Zakaria et al, 8 PBL is a student-centered, outcome-based approach that has been proven to enhance the quality of learning across various disciplines and academic levels. PBL is described as a process-focused teaching strategy that employs small groups centered on solving well-integrated clinical problems. Unlike traditional instruction, which relies heavily on lectures and limited self-directed learning, PBL encourages active problem-solving and collaboration among students. 9 PBL has been hailed as the “most significant innovation in education for professions in many years,” a testament to its transformative impact on the field of education. 10-12 Indeed, PBL has emerged as a game-changer in medical education, and its effects on nursing education have also been studied extensively. 13

Numerous studies have shown that PBL significantly enhances critical thinking skills (CT skills) among medical students. 14 As Hajrezayi et al note, critical thinking involves purposeful, self-regulatory judgment that results in interpretation, analysis, evaluation, and inference, skills that are invaluable in the clinical setting. 15 PBL, as a teaching strategy, focuses on engaging students in group discussions to address complex and ambiguous clinical problems. This process involves analyzing problems, setting objectives, gathering information, summarizing ideas, and reflecting on problem-solving experiences. 16 Research has demonstrated that this teaching strategy effectively develops critical thinking abilities in medical students. 17

However, the efficacy of PBL as a teaching method for enhancing critical thinking in nursing students remains a topic of debate among researchers. Previous systematic reviews evaluating critical thinking in PBL have produced mixed results, with some studies supporting a positive relationship between PBL and critical thinking and others disputing it. 18-20

To address these inconsistencies and provide a more comprehensive understanding of the effectiveness of PBL in promoting critical thinking in nursing students, we synthesized the data of previous studies published and conducted a more comprehensive meta-analysis.

Methodology for Meta-analysis

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to ensure a systematic and transparent process. The PRISMA statement comprises a 27-item checklist and a 4-phase flow diagram, which guide the analysis. 21 We carefully applied each item on the checklist to guarantee transparent reporting of our systematic review, while the flow diagram helped us visualize and track the different stages of our analysis. The review protocol was registered on PROSPERO (PROSPERO ID: CRD42023406592).

Search Strategy

We conducted a comprehensive search of the literature using electronic databases (PubMed via National Library of Medicine, Embase via Elsevier, Cochrane via Cochrane library, and CINAHL via EBSCO) from inception to September 9, 2023, supplemented by a manual search of reference lists of relevant articles. There was no limit to search date, language, and publication period. We used a combination of keywords and MeSH terms related to the topic to optimize the search results, detailed in the supplementary material (see Supplemental Digital Content 1, available at: https://links.lww.com/NE/B450 ).

Study Selection

Two reviewers (R.M. and W.B.) independently screened the titles and abstracts for eligibility. Articles that did not meet the inclusion criteria were excluded. The same 2 reviewers then independently reviewed full texts of remaining articles for inclusion in the meta-analysis. Discrepancies were resolved through discussion and consensus with a third reviewer (T.X.).

Included studies satisfied the following criteria: (1) participants were nursing students including graduate and undergraduate nursing students, (2) the intervention group used PBL, (3) the control group used traditional lectures, (4) trials evaluated critical thinking, (5) reported sample size, mean difference, and standard deviation of critical thinking scores. Excluded studies included nonnursing subjects, interventions other than PBL, no critical thinking evaluation, and incomplete/duplicate articles. Both randomized and nonrandomized controlled trials were included.

Data Extraction

Two reviewers independently extracted data from the included studies using a standardized data extraction form. The data extracted included study characteristics (author, year of publication, and country), participant characteristics (sample size and grade), description of PBL, teaching methods combined with PBL, research of design, and critical thinking tools (the mean difference from baseline to post-test, as well as standard deviation). Any discrepancies were resolved through discussion and consensus with a third reviewer.

Quality Assessment

Two reviewers independently assessed the quality of the included studies using a Newcastle-Ottawa Scale (NOS) for cohort studies, and version 2 of the Cochrane risk-of-bias tool for randomized trials. A study was considered as high quality if the NOS score was 7 or more, moderate quality if the NOS score between 4 and 7, and low quality if the NOS score less than 4. As for version 2 of the Cochrane risk-of-bias tool, when there are “some concerns” (or high risk of bias ratings) in some domains, the overall risk of bias is rated as “some concerns” (or high), respectively. Any discrepancies were resolved through discussion and consensus with a third expert.

Data Analysis

We used a random-effects model to pool the effect sizes across studies. To determine the significance of our findings, we set a threshold of a 2-sided P value less than .05 for all analyses. We assessed heterogeneity using the I 2 statistic and P value of Cochran's Q statistic, P value < .10 and I 2 > 50% were considered as heterogeneity. The I 2 statistic, which indicates the percentage of variation attributed to heterogeneity, was an easily interpretable way to assess the degree of heterogeneity. We considered an I 2 statistic of 25% to 50% to indicate low heterogeneity, 50% to 75% to indicate moderate heterogeneity, and more than 75% to indicate high heterogeneity. If there is heterogeneity, we explored potential sources of heterogeneity using subgroup analyses based on the duration of PBL intervention (hours or weeks), the grade of nursing students, and the assessment tools of CT skills. We conducted sensitivity analyses to examine the robustness of the findings and assessed publication bias using funnel plots and Egger's test. All analyses are conducted using R software.

Ethics Approval

As this study is a meta-analysis of previously published studies, no ethical approval was required.

We conducted a thorough review of available literature on PBL interventions for nursing students and ultimately obtained 19 studies (see Supplemental Digital Content 2, available at: https://links.lww.com/NE/B451 ).

Study Characteristics

All included studies were published between 2004 and 2021 and involved 1996 nursing students from Iran (n = 3), South Korea (n = 8), China (n = 6), the United States (n = 1), and Turkey (n = 1). The participants included first-year, second-year, third-year, fourth-year, and graduates with a work experience ranging from 1 to 21 years; 1876 participants were undergraduate nursing students while 120 participants were graduate nursing students with a work experience ranging from 1 to 21 years. The length of the PBL intervention period varied, with 7 articles lasting less than 12 weeks and 9 articles lasting 12 weeks or more. PBL interventions were integrated with various teaching methods, including simulation, case-based learning, teamwork, concept mapping, clinical practice, internet, and tutors as guides (tutors help clarify concepts and answer questions).

To assess the critical thinking, 18 included studies adopted different assessment tools including the California Critical Thinking Skills Test (CCTST, n = 6), California Critical Thinking Dispositions Inventory (CCTDI, n = 5), Assessment Technologies Institute Critical Thinking Test (n = 1), Watson-Glaser Critical Thinking Scale (n = 1), and critical thinking tools developed by Yoon (n = 2), Kwon (n = 2), Park (n = 1), McMaster University (n = 1). Among these assessment tools, the CCTST and CCTDI stand out as the primary tools utilized in the studies. The detailed characteristics were presented in Supplemental Digital Content 3, available at: https://links.lww.com/NE/B452 .

Risk of Bias

Nine of the 12 cohort studies had a low risk of bias (see Supplemental Digital Content 4, available at https://links.lww.com/NE/B453 ). However, all 7 randomized controlled studies had a high risk of bias (see Supplemental Digital Content 5, available at: https://links.lww.com/NE/B454 ). None of the randomized controlled studies specified whether the allocation sequence was concealed until participants were enrolled and assigned to interventions, nor were they able to conceal their allocation from the participants, the teachers, and the outcome assessors during the trial.

Meta-analysis Results

Nineteen studies involving 1996 participants (PBL group = 941, lecture group = 1055) reported overall critical thinking scores. The pooled effect size showed significant difference (standardized mean difference [SMD] = 0.47, 95% CI = 0.33-0.61, P < .001) in favor of PBL, compared with traditional lectures (see Supplemental Digital Content 6, available at: https://links.lww.com/NE/B455 ). There was moderate heterogeneity ( I 2 = 52%, P < .01).

Subgroup Analysis and Publication Bias

We conducted further subgroup analyses to explore the underlying sources of heterogeneity. Regarding nursing students of different grades, compared with second-year students, the critical thinking scores of the first- and third-year improved more, but there was no clear pattern of higher or lower critical thinking scores among higher grades (see Supplemental Digital Content 7, available at: https://links.lww.com/NE/B456 ). Additionally, we conducted subgroup analysis based on the different assessment tools used in the studies and discovered that nursing students who took the CCTST had higher scores compared with the CCTDI. Furthermore, the subgroup analysis based on intervention time showed that an intervention duration with fewer weeks and more hours had a greater improvement in critical thinking scores (see Supplemental Digital Content 7, available at: https://links.lww.com/NE/B456 ). This may suggest that nursing students who receive more intensive PBL course arrangements exhibited a higher improvement in critical thinking scores.

Furthermore, during the PBL process, nursing students who visualize the ideas, concepts, and terms using concept mapping show better improvement in critical thinking abilities (see Supplemental Digital Content 7, available at: https://links.lww.com/NE/B456 ). Additionally, students who receive help from teachers to clarify concepts and solve problems also demonstrate better improvement in critical thinking abilities. It is worth noting that among the 9 studies where teachers played a significant role in guiding students (clarifying concepts and answering questions rather than simply directing the slow of the PBL), all were published in 2008 or later. In contrast, among the 9 clinical studies where teachers only assisted in implementing PBL, 4 were published before 2008. This suggests that teachers play a more important role during the development of the PBL teaching strategy.

We conducted a funnel plot analysis to determine the degree of symmetry in our results and conducted Egger's regression test to determine publication bias (see Supplemental Digital Content 8, available at: https://links.lww.com/NE/B457 ). The results showed no publication bias, with bias = 0.7445 ( t = 0.6, df = 7, P = .5580).

In this meta-analysis, we found that PBL has a greater impact on CT skills of nursing students compared with traditional lectures. In the past 2 decades, there have been several meta-analyses published on this topic, but the earlier meta-analysis did not support our current conclusion, that the PBL teaching strategy can improve nursing students’ critical thinking ability compared with traditional lectures. 18 After incorporating more studies, our meta-analyses has new findings that differ from previous meta-analysis.

The discrepancy between our conclusions and those of earlier meta-analyses can be attributed to the continuous improvement of the PBL teaching strategy itself. 22 , 23 Our meta-analysis supported that teachers played a more important role in the development of the PBL teaching strategy. Teachers in the earlier studies mainly helped implement the PBL teaching strategy, teachers in the more recent studies encouraged students to think critically and gave timely feedback. Originally introduced as a novel teaching strategy in medical education, teachers primarily act as a procedural guide, our meta-analysis suggests that increased teacher engagement in the PBL teaching process can enhance nursing students’ critical thinking abilities. Although exhaustively providing students with answers to their questions as a directive lecturer is not conducive to fostering students’ critical thinking abilities, students might be dismayed when their teachers rarely directly answer a question, but instead ask questions back and let the student find the answer independently. 24

Throughout the ongoing improvement of the PBL teaching strategy, case-based learning has been integrated. Cases present clinical problems to nursing students in a fragmented manner, fostering their autonomy in constructing a knowledge framework to investigate the problems and address the presented challenges. 25 Furthermore, the assistance of concept mapping and teamwork during the PBL teaching process further improved the PBL teaching strategy. 26 , 27

Despite various advantages demonstrated by the PBL teaching strategy over the past few decades, it is imperative that we carefully evaluate both the benefits and drawbacks of adopting this teaching strategy over traditional lecture-based learning methods. One of the most celebrated aspects of the PBL teaching strategy is its ability to situate information within the context of real-life clinical problem-solving, bridging the gap between textbook knowledge and practical application. 23 On the other hand, PBL necessitates teachers to invest substantial effort in guiding students’ self-directed learning, while medical institutions should acknowledge adequate resources to support the PBL teaching strategy. 28 Nevertheless, it is worth noting that implementing the PBL teaching strategy effectively may pose challenges for teachers who are accustomed to traditional lecture-based strategy, necessitating additional training to ensure competence in the PBL teaching strategy.

Furthermore, we must acknowledge that clinical problem-solving through the PBL teaching strategy is a complex cognitive task that involves hypothesis generation from ambiguous clues. It requires reasoning based partly on fuzzy categorical knowledge, partly on probabilities, and partly on understanding the urgency and risk-benefit relationship of potential treatments. 29 In essence, for clinical problem-solving to become a meaningful experience, nursing students must possess knowledge and experience directly tied to the clinical problems. Traditional lecture-based learning methods afford teachers the opportunity to assist students in constructing knowledge frameworks based on their own expertise experience. 30 However, in the realm of PBL teaching, students, due to their limited foundational knowledge, may pose numerous seemingly inconsequential questions, potentially appearing chaotic, time-consuming, and misguided in the eyes of teachers. 31 To mitigate this challenge, some studies have leveraged concept mapping and the internet to facilitate rapid access to relevant knowledge, aiding nursing students in comprehending clinical problems. 32 , 33 Moreover, experienced PBL teachers play a pivotal role in helping nursing students build a robust knowledge base by promptly answering their questions. 34

Moreover, the current trend in PBL teaching involves employing cases as guides for learning in specific content areas. In this situation, nursing students typically only learn the definition of possible treatments when the clinical problems are presented. This approach often simplifies the complexities and exceptional aspects of clinical cases, which may serve as illustrative examples of important concepts, which may lack practicality in the actual practice of clinical problem-solving. 31 , 35 However, as nursing students engage in independent collection of background information, teachers help guide them in applying and refining their critical thinking skills to attempt to understand the reading materials, not limiting themselves to textbooks or the small world of their peers and teachers. They are quickly guided into a broader world, namely the current cutting-edge medical issues, by the latest medical articles as well as expert teachers. 25

Our meta-analysis indicates that the PBL teaching strategy can enhance critical thinking skills in nursing students.

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• Published: 28 June 2024

Perceived efficacy of case analysis as an assessment method for clinical competencies in nursing education: a mixed methods study

• Basma Mohammed Al Yazeedi   ORCID: orcid.org/0000-0003-2327-6918 1 ,
• Lina Mohamed Wali Shakman 1 ,
• Sheeba Elizabeth John Sunderraj   ORCID: orcid.org/0000-0002-9171-7239 1 ,
• Harshita Prabhakaran   ORCID: orcid.org/0000-0002-5470-7066 1 ,
• Judie Arulappan 1 ,
• Erna Judith Roach   ORCID: orcid.org/0000-0002-5817-8886 1 ,
• Aysha Al Hashmi 1 , 2 &
• Zeinab Al Azri   ORCID: orcid.org/0000-0002-3376-9380 1  

BMC Nursing volume  23 , Article number:  441 ( 2024 ) Cite this article

Metrics details

Case analysis is a dynamic and interactive teaching and learning strategy that improves critical thinking and problem-solving skills. However, there is limited evidence about its efficacy as an assessment strategy in nursing education.

This study aimed to explore nursing students’ perceived efficacy of case analysis as an assessment method for clinical competencies in nursing education.

This study used a mixed methods design. Students filled out a 13-item study-advised questionnaire, and qualitative data from the four focus groups was collected. The setting of the study was the College of Nursing at Sultan Qaboos University, Oman. Descriptive and independent t-test analysis was used for the quantitative data, and the framework analysis method was used for the qualitative data.

The descriptive analysis of 67 participants showed that the mean value of the perceived efficacy of case analysis as an assessment method was 3.20 (SD = 0.53), demonstrating an 80% agreement rate. Further analysis indicated that 78.5% of the students concurred with the acceptability of case analysis as an assessment method (mean = 3.14, SD = 0.58), and 80.3% assented its association with clinical competencies as reflected by knowledge and cognitive skills (m = 3.21, SD = 0.60). No significant difference in the perceived efficacy between students with lower and higher GPAs (t [61] = 0.05, p  > 0.05) was identified Three qualitative findings were discerned: case analysis is a preferred assessment method for students when compared to MCQs, case analysis assesses students’ knowledge, and case analysis assesses students’ cognitive skills.

Conclusions

This study adds a potential for the case analysis to be acceptable and relevant to the clinical competencies when used as an assessment method. Future research is needed to validate the effectiveness of case analysis exams in other nursing clinical courses and examine their effects on academic and clinical performance.

Peer Review reports

Introduction

Nurses play a critical role in preserving human health by upholding core competencies [ 1 ]. Clinical competence in nursing involves a constant process of acquiring knowledge, values, attitudes, and abilities to deliver safe and high-quality care [ 2 , 3 ]. Nurses possessing such competencies can analyze and judge complicated problems, including those involving crucial patient care, ethical decision-making, and nurse-patient disputes, meeting the constantly altering health needs [ 4 , 5 ]. To optimize the readiness of the new graduates for the challenging clinical work environment needs, nurse leaders call for integrating clinical competencies into the nursing curriculum [ 6 , 7 ] In 2021, the American Association of Colleges of Nursing (AACN) released updated core competencies for professional nursing education [ 8 ]. These competencies were classified into ten fundamental essentials, including knowledge of nursing practice and person-centered care (e.g. integrate assessment skills in practice, diagnose actual or potential health problems and needs, develop a plan of care), representing clinical core competencies.

Nursing programs emphasize clinical competencies through innovative and effective teaching strategies, including case-based teaching (CBT) [ 9 ]. CBT is a dynamic teaching method that enhances the focus on learning goals and increases the chances of the instructor and students actively participating in teaching and learning [ 10 , 11 ]. Additionally, it improves the students’ critical thinking and problem-solving skills and enriches their capacity for independent study, cooperation capacity, and communication skills [ 12 , 13 , 14 , 15 ]. It also broadens students’ perspectives and helps develop greater creativity in fusing theory and practice [ 16 , 17 , 18 , 19 , 20 ]. As the learning environment significantly impacts the students’ satisfaction, case analysis fosters a supportive learning atmosphere and encourages active participation in learning, ultimately improving their satisfaction [ 21 , 22 ].

In addition to proper teaching strategies for clinical competencies, programs are anticipated to evaluate the students’ attainment of such competencies through effective evaluation strategies [ 23 ]. However, deploying objective assessment methods for the competencies remains challenging for most educators [ 24 ]. The standard assessment methods used in clinical nursing courses, for instance, include clinical evaluations (direct observation), skills checklists, Objective Structured Clinical Examination (OSCE), and multiple-choice questions (MCQs) written exams [ 25 ]. MCQs tend to test the recall of factual information rather than the application of knowledge and cognitive skills, potentially leading to assessment inaccuracies [ 26 ].

Given the aforementioned outcomes of CBT, the deployment of case analysis as a clinical written exam is more closely aligned with the course’s expected competencies. A mixed methods study was conducted among forty nursing students at the University of Southern Taiwan study concluded that the unfolding case studies create a safe setting where nursing students can learn and apply their knowledge to safe patient care [ 6 ]. In a case analysis, the patient’s sickness emerges in stages including the signs and symptoms of the disease, urgent care to stabilize the patient, and bedside care to enhance recovery. Thus, unfolding the case with several scenarios helps educators track students’ attained competencies [ 27 ]. However, case analysis as an assessment method is sparsely researched [ 28 ]. A literature review over the past five years yielded no studies investigating case analysis as an assessment method, necessitating new evidence. There remains uncertainty regarding its efficacy as an assessment method, particularly from the students’ perspectives [ 29 ]. In this study, we explored the undergraduate nursing students’ perceived efficacy of case analysis as an assessment method for clinical competencies. Results from this study will elucidate the position of case analysis as an assessment method in nursing education. The potential benefits are improved standardization of clinical assessment and the ability to efficiently evaluate a broad range of competencies.

Research design

Mixed-method research with a convergent parallel design was adopted in the study. This approach intends to converge two data types (quantitative and qualitative) at the interpretation stage to ensure an inclusive research problem analysis [ 30 ]. The quantitative aspect of the study was implemented through a cross-sectional survey. The survey captured the perceived efficacy of using case analysis as an assessment method in clinical nursing education. The qualitative part of the study was carried out through a descriptive qualitative method using focus groups to provide an in-depth understanding of the perceived strengths experienced by the students.

Study setting

Data were collected in the College of Nursing at Sultan Qaboos University (SQU), Oman, during the Spring and Fall semesters of 2023. At the end of each clinical course, the students have a clinical written exam and a clinical practical exam, which constitute their final exam. Most clinical courses use multiple-choice questions (MCQs) in their written exam. However, the child health clinical course team initiated the case analysis as an assessment method in the clinical written exam, replacing the MCQs format.

Participants

For this study, the investigators invited undergraduate students enrolled in the child health nursing clinical course in the Spring and Fall semesters of 2023. Currently, the only course that uses case analysis is child health. Other courses use MCQs. A total enumeration sampling technique was adopted. All the students enrolled in child health nursing clinical courses in the Spring and Fall 2023 semesters were invited to participate in the study. In the Spring, 36 students registered for the course, while 55 students were enrolled in the Fall. We included students who completed the case analysis as a final clinical written exam on the scheduled exam time. Students who did not show up for the exam during the scheduled time and students not enrolled in the course during the Spring and Fall of 2023 were excluded. Although different cases were used each semester, both had the same structure and level of complexity. Further, both cases were peer-reviewed.

Case analysis format

The format presents open-ended questions related to a clinical case scenario. It comprises three main sections: Knowledge, Emergency Room, and Ward. The questions in the sections varied in difficulty based on Bloom’s cognitive taxonomy levels, as presented in Table  1 . An answer key was generated to ensure consistency among course team members when correcting the exam. Three experts in child health nursing peer-reviewed both the case analysis exam paper and the answer key paper. The students were allocated two hours to complete the exam.

Study instruments

Quantitative stage.

The researchers developed a study questionnaire to meet the study objectives. It included two parts. The first was about the demographic data, including age, gender, type of residence, year in the program, and cumulative grade point average (GPA). The second part comprised a 13-item questionnaire assessing the perceived efficacy of case analysis as an assessment method. The perceived efficacy was represented by the acceptability of case analysis as an assessment method (Items 1–5 and 13) and the association with clinical competencies (Items 6 to 12). Acceptability involved format organization and clarity, time adequacy, alignment with course objectives, appropriateness to students’ level, and recommendation for implementation in other clinical nursing courses. Clinical competencies-related items were relevant to knowledge (motivation to prepare well for the exam, active learning, interest in topics, collaboration while studying) and cognitive skills (critical thinking, decision-making, and problem-solving skills) (The questionnaire is attached as a supplementary document).

The questionnaire is answered on a 4-point Likert scale: 1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree. Higher scores indicated better perceived efficacy and vice versa. The tool underwent content validity testing with five experts in nursing clinical education, resulting in an item-content validity index ranging from 0.7 to 1. The Cronbach alpha was 0.83 for acceptability and 0.90 for clinical competencies.

Qualitative stage

For the focus group interviews, the investigators created a semi-structured interview guide to obtain an in-depth understanding of the students’ perceived strengths of case analysis as an assessment method. See Table  2 .

Data collection

Data was collected from the students after they gave their written informed consent. Students were invited to fill out the study questionnaire after they completed the case analysis as a clinical written exam.

All students in the child health course were invited to participate in focus group discussions. Students who approached the PI to participate in the focus group discussion were offered to participate in four different time slots. So, the students chose their time preferences. Four focus groups were conducted in private rooms at the College of Nursing. Two trained and bilingual interviewers attended the focus groups, one as a moderator while the other took notes on the group dynamics and non-verbal communication. The discussion duration ranged between 30 and 60 min. After each discussion, the moderator transcribed the audio recording. The transcriptions were rechecked against the audio recording for accuracy. Later, the transcriptions were translated into English by bilingual researchers fluent in Arabic and English for the analysis.

Rigor and trustworthiness

The rigor and trustworthiness of the qualitative method were enhanced using multiple techniques. Firstly, quantitative data, literature reviews, and focus groups were triangulated. Participants validated the summary after each discussion using member checking to ensure the moderator’s understanding was accurate. Third, the principal investigator (PI) reflected on her assumptions, experiences, expectations, and feelings weekly. In addition, the PI maintained a detailed audit trail of study details and progress. The nursing faculty conducted the study with experience in qualitative research and nursing education. This report was prepared following the Standard for Reporting Qualitative Research (SRQR) protocol [ 31 ].

Data analysis

Quantitative data were entered in SPSS version 24 and analyzed using simple descriptive analysis using means, standard deviations, and percentages. After computing the means of each questionnaire item, an average of the means was calculated to identify the perceived efficacy rate. A similar technique was used to calculate the rate of acceptability and clinical competencies. The percentage was calculated based on the mean: gained score/total score* 100. In addition, the investigators carried out an independent t-test to determine the relationship between the perceived efficacy and students’ GPA.

The qualitative data were analyzed using the framework analysis method. In our analysis, we followed the seven interconnected stages of framework analysis: (1) transcription, (2) familiarization with the interview, (3) coding, (4) developing a working analytical framework, (5) applying the analytical framework, (6) charting data into framework matrix and (7) interpreting the data [ 32 ]. Two members of the team separately analyzed the transcriptions. Then, they discussed the coding, and discrepancies were solved with discussion.

Mixed method integration

In our study, the quantitative and qualitative data were analyzed separately, and integration occurred at the interpretation level by merging the data [ 33 ]. As a measure of integration between qualitative and quantitative data, findings were assessed through confirmation, expansion, and discordance. If both data sets confirmed each other’s findings, it was considered confirmation, and if they expanded each other’s insight, it was considered expansion. Discordance was determined if the findings were contradictory.

Ethical considerations

Ethical approval was obtained from the Research and Ethics Committee of the College of Nursing, SQU (CON/NF/2023/18). Informed consent was collected, and no identifiable information was reported. For the focus group interviews, students were reassured that their grades were finalized, and their participation would not affect their grades. Also, the interviewers were instructed to maintain a non-judgmental and non-biased position during the interview. Data were saved in a locked cabinet inside a locked office room. The electronic data were saved in a password-protected computer.

The results section will present findings from the study’s quantitative and qualitative components. The integration of the two data types is described after each qualitative finding.

Quantitative findings

We analyzed the data of 67 participants, representing a 73.6% response rate. The mean age was 21.0 years old (SD 0.73) and 36.4% were male students. See Table  3 for more details.

The descriptive analysis showed that the mean value of the perceived efficacy of case analysis as an assessment method was 3.20 (SD = 0.53), demonstrating an 80% agreement rate. Further analysis indicated that 78.5% of the students concurred the acceptability of case analysis as an assessment method (mean = 3.14, SD = 0.58) and 80.3% (m = 3.21, SD = 0.60) assented the clinical competencies associated with it.

For the items representing acceptability, 81.8% of the students agreed that the case analysis was written clearly, and 80.3% reported that it was well organized. As per the questions, 81% described they were appropriate to their level, and 79.8% agreed upon their alignment with the course objectives. Moreover, the time allocated was adequate for 74.5% of the students, and 73.5% recommend using case analysis as an evaluation strategy for other clinical written examinations.

Regarding the clinical competencies, 77.3% of students agreed that the case analysis motivated them to prepare well for the exam, 81.3% reported that it encouraged them to be active in learning, and 81.0% indicated that it stimulated their interest in the topics discussed in the course. Additionally, 76.5% of the students agreed that the case analysis encouraged them to collaborate with other students when studying for the exam. Among the students, 82.5% reported that the case analysis as an assessment method enhanced their critical thinking skills, 81.0% agreed that it helped them practice decision-making skills, and 81.8% indicated that it improved their problem-solving abilities. See Table  4 .

The independent t-test analysis revealed no significant difference in the perceived efficacy between students with lower and higher GPAs (t [61] = 0.05, p  > 0.05). Further analysis showed that the means of acceptability and clinical competencies were not significantly different between the lower GPA group and higher GPA group, t [62] = 0.72, p  > 0.05 and t [63] = -0.83, p  > 0.05, respectively (Table  5 ).

Qualitative findings

A total of 22 had participated in four focus groups, each group had 5–6 students. The qualitative framework analysis revealed three main findings; case analysis is a preferred assessment method to students when compared to MCQs, case analysis assesses students’ knowledge, and case analysis assesses students’ cognitive skills.

Qualitative Finding 1: case analysis is a preferred assessment method to students when compared to MCQs

Most of the students’ statements about the case analysis as an assessment method were positive. One student stated, “Previously, we have MCQs in clinical exams, but they look as if they are theory exams. This exam makes me deal with cases like a patient, which is good for clinical courses.” . At the same time, many students conveyed optimism about obtaining better grades with this exam format. A student stated, “Our grades, with case analysis format, will be better, … may be because we can write more in open-ended questions, so we can get some marks, in contrast to MCQs where we may get it right or wrong” . On the other hand, a few students suggested adding multiple-choice questions, deleting the emergency department section, and lessening the number of care plans in the ward section to secure better grades.

Although the case analysis was generally acceptable to students, they have repeatedly expressed a need to allocate more time for this type of exam. A student stated, “The limited time with the type of questions was a problem, …” . When further discussion was prompted to understand this challenge, we figured that students are not used to handwriting, which has caused them to be exhausted during the exam. An example is “writing is time-consuming and energy consuming in contrast to MCQs …” . These statements elucidate that the students don’t necessarily mind writing but recommend more practice as one student stated, “More experience of this type of examination is required, more examples during clinical practice are needed.” Some even recommended adopting this format with other clinical course exams by saying “It’s better to start this method from the first year for the new cohort and to apply it in all other courses.”

Mixed Methods Inference 1: Confirmation and Expansion

The abovementioned qualitative impression supports the high acceptability rate in quantitative analysis. In fact, there is a general agreement that the case analysis format surpasses the MCQs when it comes to the proper evaluation strategies for clinical courses. Expressions in the qualitative data revealed more details, such as the limited opportunities to practice handwriting, which negatively impacted the perceived adequacy of exam time.

Qualitative Finding 2: case analysis assesses students’ knowledge

Students conferred that they were reading more about the disease pathophysiology, lab values, and nursing care plans, which they did not usually do with traditional means of examination. Examples of statements include “… before we were not paying attention to the normal lab results but …in this exam, we went back and studied them which was good for our knowledge” and “we cared about the care plan. In previous exams, we were not bothered by these care plans”. Regarding the burden that could be perceived with this type of preparation, the students expressed that this has helped them prepare for the theory course exam; as one student said, “We also focus on theory lectures to prepare for this exam …. this was very helpful to prepare us for the theory final exam as well.” However, others have highlighted the risks of limiting the exam’s content to one case analysis. The argument was that some students may have not studied the case completely or been adequately exposed to the case in the clinical setting. To solve this risk, the students themselves advocated for frequent case group discussions in the clinical setting as stated by one student: “There could be some differences in the cases that we see during our clinical posting, for that I recommend that instructors allocate some time to gather all the students and discuss different cases.” Also, the participants advocated for more paper-based case analysis exercises as it is helpful to prepare them for the exams and enhance their knowledge and skills.

Mixed Methods Inferences 2: Confirmation and Expansion

The qualitative finding supports the quantitative data relevant to items 6, 7, and 8. Students’ expressions revealed more insights, including the acquisition of deeper knowledge, practicing concept mapping, and readiness for other course-related exams. At the same time, students recommended that faculty ensure all students’ exposure to common cases in the clinical setting for fair exam preparation.

Qualitative Finding 3. case analysis assesses students’ cognitive skills

Several statements conveyed how the case analysis format helped the students use their critical thinking and analysis skills. One student stated, “It, the case analysis format, enhanced our critical thinking skills as there is a case with given data and we analyze the case….” . Therefore, the case analysis format as an exam is potentially a valid means to assess the student’s critical thinking skills. Students also conveyed that the case analysis format helped them link theory to practice and provided them with the platform to think like real nurses and be professional. Examples of statements are: “…we connect our knowledge gained from theory with the clinical experience to get the answers…” and “The questions were about managing a case, which is what actual nurses are doing daily.” Another interesting cognitive benefit to case analysis described by the students was holistic thinking. For example, one student said, “Case analysis format helped us to see the case as a whole and not only from one perspective.”

Mixed Methods Inferences 3: Confirmation

The quantitative data indicated mutual agreement among the students that the case analysis enhanced their critical thinking, decision-making, and problem-solving skills. The students’ statements from the interviews, including critical thinking, linking theory to practice, and holistic thinking, further supported these presumptions.

This research presents the findings from a mixed methods study that explored undergraduate nursing students’ perceived efficacy of using case analysis as an assessment method. The perceived efficacy was reflected through acceptability and association with two core competencies: knowledge and cognitive skills. The study findings showed a high rate of perceived efficacy of case analysis as an assessment method among nursing students. Additionally, three findings were extracted from the qualitative data that further confirmed the perceived efficacy: (1) case analysis is a preferred assessment method to students compared to MCQs, (2) case analysis assesses students’ knowledge, and (3) case analysis assesses students’ cognitive skills. Moreover, the qualitative findings revealed details that expanded the understanding of the perceived efficacy among nursing students.

Previous literature reported students’ preference for case analysis as a teaching method. A randomized controlled study investigated student’s satisfaction levels with case-based teaching, in addition to comparing certain outcomes between a traditional teaching group and a case-based teaching group. They reported that most students favored the use of case-based teaching, whom at the same time had significantly better OSCE scores compared to the other group [ 34 ]. As noted, this favorable teaching method ultimately resulted in better learning outcomes and academic performance. Although it may be challenging since no answer options are provided, students appreciate the use of case analysis format in their exams because it aligns better with the course objectives and expected clinical competencies. The reason behind students’ preference for case analysis is that it allows them to interact with the teaching content and visualize the problem, leading to a better understanding. When case analysis is used as an assessment method, students can connect the case scenario presented in the exam to their clinical training, making it more relevant.

In this study, students recognized the incorporation of nursing knowledge in the case analysis exam. They also acknowledged improved knowledge and learning abilities similar to those observed in case-based teaching. Boney et al. (2015) reported that students perceived increased learning gains and a better ability to identify links between different concepts and other aspects of life through case-based teaching [ 35 ]. Additionally, case analysis as an exam promotes students’ in-depth acquirement of knowledge through the type of preparation it entails. Literature suggested that case-based teaching promotes self-directed learning with high autonomous learning ability [ 34 , 36 ]. Thus, better achievement in the case analysis exam could be linked with a higher level of knowledge, making it a suitable assessment method for knowledge integration in nursing care.

The findings of this study suggest that case analysis can be a useful tool for evaluating students’ cognitive skills, such as critical thinking, decision-making, and problem-solving. A randomized controlled study implied better problem-solving abilities among the students in the case-based learning group compared to those in the traditional teaching methods group [ 12 ]. Moreover, students in our study conveyed that case analysis as an exam was an opportunity for them to think like real nurses. Similar to our findings, a qualitative study on undergraduate nutrition students found that case-based learning helped students develop professional competencies for their future practice, in addition to higher-level cognitive skills [ 37 ]. Therefore, testing students through case analysis allows educators to assess the student’s readiness for entry-level professional competencies, including the thinking process. Also, to evaluate students’ high-level cognitive skills according to Bloom’s taxonomy (analysis, synthesis, and evaluation), which educators often find challenging.

Case analysis as an assessment method for clinical courses is partially integrated in case presentation or OSCE evaluation methods. However, the written format is considered to be more beneficial for both assessment and learning processes. A qualitative study was conducted to examine the impact of paper-based case learning versus video-based case learning on clinical decision-making skills among midwifery students. The study revealed that students paid more attention and were able to focus better on the details when the case was presented in a paper format [ 38 ]. Concurrently, the students in our study recommended more paper-based exercises, which they believed would improve their academic performance.

This study has possible limitations. The sample size was small due to the limited experience of case analysis as a clinical written exam in the program. Future studies with larger sample sizes and diverse nursing courses are needed for better generalizability.

Implications

Little evidence relates to the efficacy of case analysis as an evaluation method, suggesting the novelty of this study. Despite the scarcity of case-based assessment studies, a reader can speculate from this study’s findings that there is a potential efficacy of case analysis as an assessment method in nursing education. Future research is warranted to validate the effectiveness of case-analysis assessment methods and investigate the effects of case-analysis exams on academic and clinical performance.

Overall, our findings are in accordance with the evidence suggesting students’ perceived efficacy of case analysis as a teaching method. This study adds a potential for the case analysis to be acceptable and relevant to the clinical competencies when used as an assessment method. Future research is needed to validate the effectiveness of case analysis exams in other nursing clinical courses and examine their effects on academic and clinical performance.

Data availability

The datasets used and/or analyzed during the current study are available fromthe Principal Investigator (BAY) upon reasonable request.

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Acknowledgements

The authors wish to thank the nursing students at SQU who voluntarily participated in this study.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Dr. Basma Mohammed Al Yazeedi contributed to conceptualization, methods, data collection, data analysis, writing the draft, and reviewing the final draft. Ms. Lina Mohamed Wali Shakman contributed to conceptualization, data collection, data analysis, writing the draft, and reviewing the final draft. Ms. Sheeba Elizabeth John Sunderraj contributed to conceptualization, methods, data collection, writing the draft, and reviewing the final draft.Ms. Harshita Prabhakaran contributed to conceptualization, data collection, writing the draft, and reviewing the final draft.Dr. Judie Arulappan contributed to conceptualization and reviewing the final draft.Dr. Erna Roach contributed to conceptualization writing the draft and reviewing the final draft.Ms. Aysha Al Hashmi contributed to the conceptualization and reviewing the final draft. Dr. Zeinab Al Azri contributed to data collection, data analysis, writing the draft, and reviewing the final draft.All auhors reviewed and approved the final version of the manuscirpt.

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Yazeedi, B.M.A., Shakman, L.M.W., Sunderraj, S.E.J. et al. Perceived efficacy of case analysis as an assessment method for clinical competencies in nursing education: a mixed methods study. BMC Nurs 23 , 441 (2024). https://doi.org/10.1186/s12912-024-02102-9

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Critical Thinking Skills in Nursing Students: a Comparison Between Freshmen and Senior Students

Ismail azizi-fini.

1 School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, IR Iran

Ali Hajibagheri

2 Department of Medical Surgical Nursing, Faculty of Nursing and Midwifery, Kashan University of Medical Sciences, Kashan, IR Iran

Mohsen Adib-Hajbaghery

3 Trauma Nursing Research Center, Kashan University of Medical Sciences, Kashan, IR Iran

Background:

Critical thinking is one of the most important concepts in the field of education. Despite studies published on nursing students’ critical thinking skills (CTS), some suggest that there is not enough evidence supporting the relationship between content of nursing education programs and nursing students’ CTS.

Objectives:

Given the existing discrepancies, this study aimed to compare the critical thinking skills of freshmen and senior nursing students.

Patients and Methods:

This comparative study was conducted on 150 undergraduate freshmen and senior nursing students in Kashan University of Medical Sciences, during 2012. The students in the first and the last semesters of their study in nursing were entered in the study using the census method. Data were collected using a questionnaire including questions on demographic data and the California Critical Thinking Skills Test, form B. Data analysis was performed using the SPSS v.13 software. Descriptive statistics were calculated. Moreover, independent sample t-test and Spearman and Pearson’s correlation coefficients were used in the data analysis.

Both the freshmen and senior nursing students had low CTS. The mean critical thinking scores were 11.79 ± 4.80 and 11.21 ± 3.17 for the freshmen and the senior students, respectively (P = 0.511). Moreover, no significant correlation was found between the students’ score in CTS and their age, gender, high school grade point average (GPA), rank in university entrance examination (RUEE) and interest in the nursing profession.

Conclusions:

The students were low skilled in critical thinking and their CTS did not significantly change during their nursing degree. Thus it may be concluded that the nursing education program did not affect the CTS of its students. Longitudinal studies are suggested for assessing nursing students’ critical thinking over time. Moreover, revising the curriculum and preparing nursing educators for implementing innovative and active teaching strategies are suggested.

1. Background

Critical thinking is one of the most important concepts involved in the field of education. Enabling students to think critically is not only a primary purpose of higher education, but also facilitates the dynamics of academies and universities and helps them survive, develop and promotes scientific societies ( 1 ).

Introducing the concept of critical thinking into nursing education is a turning point in the process of professionalization. Despite different definitions for critical thinking, no consensus has yet been reached ( 2 , 3 ). However, critical thinking is generally defined as "a process of purposeful, interactive reasoning, criticism and judgment about what we believe and do" ( 4 ). Some have also defined critical thinking in nursing as "the process of reflective and reasonable thinking about nursing problems without a single solution and is focused on deciding what to believe and do" ( 5 ).

In the recent decades, as a result of the rapid advances in knowledge and technology, dramatic changes have occurred in healthcare organizations. Consequently, people’s demand has been increased for higher quality healthcare services, with lower costs and shorter length of hospital stay. Moreover, the aging population, complex disease processes and increased patients’ awareness, have evolved modern nursing. Thus, nurses are in need to continually improve their knowledge and competencies, to be able to provide safe and quality care in a context of constantly changing clinical situations ( 6 ).

In this changing environment, nurses need to develop their thinking and reasoning skills in order to meet the patients and families’ caring needs in collaboration with other healthcare professionals ( 7 ). Nurses as healthcare providers should be creative, self-directed and critical thinkers to be able to make appropriate decisions and solve clinical problems ( 8 ).

Karadag et al. investigated nurse educators and clinical nurses’ attitudes towards critical thinking and reported that both nurses and nurse educators believed in the crucial role of critical thinking skills (CTS) in the context of increasing complexity in modern healthcare ( 9 ). Simpson et al. also stressed that nurses should be skilled in reasoning and critical thinking to be able to appraise new knowledge. Highlighting the vital importance of CTS, the American Nurse Association also emphasizes that the nurses’ CTS should be measured as a criterion for validating outcomes of nurse education programs ( 6 ).

Several nursing authors have written about teaching methods used to strengthen CTS ( 4 ). According to Alfaro-LeFevre ( 10 ), there are at least two main reasons for nurses to learn CTS. Firstly, thinking is the key for problem solving; while, nurses without such skills are themselves part of the problem. Secondly, in critical situations, nurses should be able to take major decisions, independently and quickly. Critical thinking skills enable them to identify necessary data and distinguish problems requiring immediate intervention from those that are not life threatening. Thus, they will be able to consider the possible consequences of each action and make the right decision ( 3 ).

Bakalis et al. suggest that it is essential to establish a dialogue between teachers and students to promote CTS among learners ( 11 ). Studies have also shown a link between the students’ level of CTS and their level of academic education, age and clinical experience ( 4 , 12 ).

Despite many studies published on nurses and nursing students’ CTS, Duchscher suggests that there is no strong evidence supporting the relationship between content of nursing education programs and the nurses or nursing students’ CTS ( 12 ). Some other authors believe that there is a lack of appropriate tools for assessing nurse's CTS ( 13 , 14 ). However, Magnussen et al. ( 15 ) have reported that traditional teaching methods may hinder the ability of critical thinking while research-based learning, as a teaching method, can increase CTS.

Studies in Iran have shown mixed results in terms of nursing students’ critical thinking. Two studies by Rezaei et al. ( 16 ) and Eslami et al. ( 3 ) reported that nursing students had poor CTS. They found no significant difference between the levels of CTS in freshmen and senior nursing students. However, in two other studies, Khalili et al. ( 17 ) and McCarthy et al. ( 18 ) reported that the levels of CTS were significantly higher among senior compared to junior nursing students. Therefore, the question is whether CTS differs among nursing students at the start and the end of their nursing studies. The answer of this question would not only be important globally but also at the national level because this answer might help us evaluate the nursing curriculum and nursing educators as the main role models in the process of nursing education.

2. Objectives

Given the importance of CTS in nursing, and discrepancies in previous studies, this study aimed to compare the CTS of freshmen and senior nursing students of Kashan University of Medical Sciences (KAUMS), during year 2012.

3. Patients and Methods

A comparative study was conducted on 150 undergraduate freshmen and senior nursing students at KAUMS. All nursing students in the first and the last semester of their nursing program were entered in this study using the census method. Exclusion criteria were: being a guest student or being transferred from other universities, having an additional academic degree, and having passed some courses on critical thinking.

Data were collected using a two-part questionnaire. The first part of the questionnaire consisted of questions on demographic data (i.e. gender, age, the students’ high school grade point average (GPA), the students’ rank in university entrance examination (RUEE), and interest in the nursing profession). The second part of the questionnaire was the California Critical Thinking Skills Test, form B (CCTS form B). The CCTS form B is frequently used to assess the students' CTS ( 3 ). This scale consists of 34 questions, each with options, which are designed to evaluate critical thinking at the post-secondary level.

The CCTS form B was specifically designed to assess CTS in five areas of interpretation, analysis, evaluation, inductive reasoning and deductive reasoning. Each question is scored either one or zero for each correct or wrong answer, respectively. Thus, the lowest overall score is zero and the highest is 34 ( 19 ). The time each student spent to respond to the questionnaire was about 45 minutes.

The CCTS form B was previously translated to the Persian language by Akhoundzadeh et al. ( 20 ), and showed appropriate psychometric properties. They also confirmed the instrument’s content validity and reliability using the Kuder-Richardson coefficient, which was 0.62. The test was able to distinguish between CTS of nursing and philosophy students ( 21 ).

After obtaining permission from the authorities of the university, the instrument was passed to selected students in their breaks between classes. All students were asked to respond to the questionnaires in a private environment and returned their answers back to the researchers (the first or the second authors of this manuscript) or the secretary of the nursing department on the same day.

3.1. Ethical Considerations

Permission for this study was through the ethics committee of KAUMS. Other ethical issues in this study involved the assurance of confidentiality and anonymity of the participants. All participants were informed about the purpose and design of this research, and that their participation was voluntary. Participants signed a written informed consent for their participation.

3.2. Data Analysis

Data analysis was performed using the SPSS v.13 software. Descriptive statistics were calculated. Independent sample t-test was used to examine significant differences between mean quantitative variables of the two groups. Moreover, the Spearman and Pearson’s correlation coefficients were used to examine the correlation between the students’ scores in CTS and their age, gender, high school GPA, RUEE and interest in the nursing profession. The level of significance was considered less than 0.05.

Among all participants, 24.6% (n = 37) were freshmen and 75.4% (n = 113) were senior students. In total, 65.5% of the freshmen students and 65.3% of the seniors were females (P > 0.05). The mean age of the students was 20.5 ± 1.73 years and 22.41 ± 1.51 years, for freshmen and senior students, respectively (P > 0.05). The mean high school grade point averages of the students were 17.58 ± 1.65 and 18.38 ± 1.03 for the freshmen and seniors, respectively, (P > 0.05). The students’ mean ranks in the university entrance examination were 5186.6 and 6283.1 for the freshmen and seniors, respectively, (P > 0.05). Overall, 10.8% of freshmen students reported that they are very interested in the nursing profession, while 10.8% and 78.4% were moderately interested in or uninterested in the profession, respectively. In terms of senior students, 27.4% were very interested in the nursing profession, while 61.1% and 11.5% were moderately interested or uninterested in the profession, respectively.

The mean critical thinking scores were 11.79 ± 4.80 and 11.21 ± 3.17 for freshmen and senior students, respectively (P = 0.511). As shown in Table 1 , no significant differences were found between freshmen and senior students in terms of their mean scores for the interpretation, analysis, evaluation, inductive reasoning and deductive reasoning subscales. Both freshmen and senior students obtained the highest and the lowest mean scores in deductive reasoning and analysis subscales, respectively.

a All values are presented as Mean ± SD.

Using Pearson’s correlation coefficient, no significant correlation was found between the students’ CTS scores and their age, high school GPA, and RUEE ( Table 2 ). Moreover, using Spearman’s correlation coefficient, no significant correlation was found between the students’ CTS score and their gender and interest in the nursing profession ( Table 2 ).

5. Discussion

This study aimed to compare the CTS of freshmen and senior nursing students to determine if the current nursing education program is effective on its students CTS. Results showed that the mean critical thinking scores of freshmen and senior nursing students were at a low level. Moreover, no significant difference was observed between the mean critical thinking scores of freshmen and senior nursing students. In addition, no significant association was found between the students’ scores in CTS and variables such as gender, high school GPA, RUEE and level of interest in the nursing profession. These findings are consistent with the results of previous studies ( 22 ). Previous studies on the assessment of Iranian nursing students and nurses’ CTS have reported that the majority of nursing students and nurses in Iran have poor CTS ( 3 , 23 - 25 ). Consistent with this study, other studies have also found no significant difference between freshmen and senior nursing students' CTS ( 3 , 26 ). However, Khalili et al. ( 17 ), Babamohamadi and Khalili ( 23 ) have reported significant differences between the critical thinking scores of freshmen and senior nursing students, which is not in line with the results of the present study. These inconsistencies might not only be attributed to probable differences in learning styles of students ( 27 ) but also to the relatively different teaching styles of different nursing schools.

The results of this study showed no statistically significant positive correlations between demographic data and CTS. While Zhang and Lambert ( 27 ) and Noohi et al. ( 28 ) reported that a number of positive and negative correlations exist between demographic data and critical thinking skills. The lack of correlation between demographic data and CTS in the present study might be attributed to the characteristics of universities and their students; Mahmoodabad et al. ( 29 ), in a study from Iran, reported that students attending larger universities are somewhat different considering their GPA and RUEE, and this may affect their CTS. Another probably reason is that many of the senior students in Kashan are employed as part time nurses in healthcare centers. Therefore, as Bittencourt and Crossetti ( 30 ) have reported, students that work part time have less time to spend on intellectual activities. It seems that when students are employed in clinical settings, they spend more time in performing nursing techniques and following the routines instead of using the scientific knowledge they learned at the university. Working according to the routines usually does not need much thinking skills, and nurses simply follow the doctors’ orders. Working in this manner, would gradually affect the nurses cognitive, critical thinking and humanistic skills such as communication skills.

Furthermore, studies have reported that not only the content of education but also the teaching-learning methods at all levels of the education system in Iran (i.e. elementary, secondary and university) basically concentrate on transferring theoretical knowledge and do not focus on development of critical thinking and problem-solving skills in learners (4). Amini et al. ( 31 ) reported that this is a global problem in nursing education, and several studies indicate a lack of critical thinking and problem solving skills in undergraduate nursing programs. It has also been reported that although basic skills of critical thinking are taught to nursing students, they cannot apply them in solving problems they commonly encounter, and this may be considered as a sign of failure in nursing education systems ( 32 ). Moreover, overuse of lectures and multiple choice questions, and overlooking the nursing process in education may be among other possible reasons for the lack of CTS in Iranian nursing students ( 23 , 33 ).

It seems that nursing students have less opportunity to apply CTS in clinical settings. While techniques, such as questioning, Socratic method, learning in small groups, discussions and debates, writing diaries, problem based teaching and learning, use of case studies and other types of participative learning, have been shown to be effective in developing CTS ( 20 , 34 ). Previous studies have shown that the nursing curriculum in Iran contains a considerable amount of theoretical, redundant, unnecessary and inapplicable knowledge and nurse educators are under pressure to teach a large content in a limited time ( 4 , 35 ). Thus, making a balance between the course content and time available may be the first step in preparing the context for educators to assign more time for the development of the students’ CTS. Moreover, as Moattari et al. ( 35 ) reported, nurse educators should be prepared to implement active, student-centered, collaborative and problem-focused teaching strategies to foster the students’ CTS.

The results showed that nursing students had low CTS and these skills did not significantly change during their studies in nursing. Therefore, it may be concluded that the studied nursing education program did not affect its students’ CTS. However, the low critical thinking scores of the participants in the present study and other studies conducted in Iran may be attributed to the instruments used by these studies. Most of these studies used instruments such as CCTS Form B, and as mentioned previously, some nursing researchers believe that this instrument is not appropriate for assessing nurses or nursing students’ CTS. Thus, appropriate indigenous instruments should be developed for assessment of critical thinking in nurses. In addition, we tested our participants only one time. It is better to evaluate the evolution of critical thinking over time. Longitudinal studies are suggested for assessing the nursing students’ critical thinking over time. Moreover, revising the curriculum and preparing nurse educators for implementation of innovative and active teaching strategies are suggested. Then, the effects of such interventions can be assessed.

Acknowledgments

The researchers would like to express their gratitude to all the participants who were involved in this study.

Authors’ Contributions: All authors contributed equally in this study.

Funding/Support: This project was funded by the research deputy of Kashan University of Medical Sciences (grant No. 9017).