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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?

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

Last updated on August 23rd, 2023

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

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

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

What is Critical Thinking?

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

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

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

Key aspects of critical thinking include:

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

Definition of Critical Thinking

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

What is Critical Thinking in Nursing?

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

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

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

This skill helps nurses to:

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

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

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

What are the Levels of Critical Thinking in Nursing?

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

The Kataoka-Yahiro and Saylor model outlines this progression.

1. Basic Critical Thinking:

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

2. Complex Critical Thinking:

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

3. Commitment:

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

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

Why Critical Thinking is Important in Nursing?

Critical thinking is important in nursing for several crucial reasons:

Patient Safety:

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

Clinical Judgment:

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

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

Enhances Decision-Making:

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

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

Promotes Problem-Solving:

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

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

Drives Creativity:

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

Fosters Effective Communication:

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

Aids Learning:

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

Improves Relationships:

Open-mindedness and empathy are essential in nursing relationships.

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

Empowers Independence:

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

Facilitates Adaptability:

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

Strengthens Critical Analysis:

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

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

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

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

Assess Patient Data:

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

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

Diagnose Patient Needs:

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

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

Plan and Implement Care:

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

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

Evaluate Interventions:

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

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

Prioritize Care:

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

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

Collaborate with the Healthcare Team:

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

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

Ethical Decision-Making:

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

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

Patient Education:

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

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

Adapt to Changes:

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

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

Critical Analysis of Information:

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

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

Making Sense of Critical Thinking Skills

What is the purpose of critical thinking in nursing.

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

Why critical thinking is important in nursing?

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

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

How is critical thinking used in the nursing process?

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

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

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

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

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

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

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

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

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

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

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

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

• 15 Attitudes of Critical Thinking in Nursing (Explained W/ Examples)
• Nursing Concept Map (FREE Template)
• Clinical Reasoning In Nursing (Explained W/ Example)
• 8 Stages Of The Clinical Reasoning Cycle
• How To Improve Critical Thinking Skills In Nursing? 24 Strategies With Examples
• What is the “5 Whys” Technique?
• What Are Socratic Questions?

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

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

Reading Recommendation

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

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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.

Six exercises for nurses to foster critical thinking

• Publish Date: Posted almost 5 years ago
• Author: by Kate Andrews

As a nurse, no matter what organization you work within, the ability to resolve issues before they turn into problems is crucial to ensure success in your role.  

To prepare for your next nursing position, we detail some fundamental critical thinking exercises that can help develop those all-important problem-solving skills.

What is critical thinking?

During your nursing studies, you will have undoubtedly come across the term ‘critical thinking’. It is the process of applying intentional higher-level thinking to describe a patient’s problem and examining the evidence-based practice in caring for them to make the right choices on the type of care that they require.

Fostering the right attributes and attitude that encourages critical thinking will help you excel in your nursing role and develop your career long into the future. These include:

The confidence to challenge convention

By nature, the nursing profession is driven by process and best practice, but sometimes the opportunity arises for individuals to enrich and change the way that things are done. This does not mean you have to upset the system, but simply that you should be confident enough to speak up and be afforded the opportunity to improve upon existing workplace practices.

Working independently

When you embark upon your career in nursing, you are likely to work under close supervision; however, certain situations may arise where there is an opportunity for you to work independently. If you have a particular skill-set or interest in a niche area, why not ask to take ownership? Not only will this demonstrate initiative and your willingness to develop in your profession, but it also improves your critical thinking skills too.

Practical experience

Practical, hands-on experience is crucial to excelling in any nursing role. Developing critical-thinking skills starts at the beginning of your career, not just in your first position but also the experience you obtain while studying. Anyone will tell you that gaining essential and varied work experience will help you secure the role that you deserve.

Working alongside leaders

There is a lot to be said about great leadership. Learning from senior nurses, not only on the job but also enquiring about their past experiences, mistakes, and learnings will help you to develop your critical thinking skills in any role.

Situational analysis

Continued professional development is a vital part of career success. It is not uncommon to be tested on what you have learned in your job. Commonly senior staff nurses may create hypothetical situations to test your critical thinking and development since starting your position. If this is not a common practice in your place of work, it is always worth asking for more training to ensure your nursing aptitude and critical thinking skills continue to evolve.

Existing case studies

Any nurse should brush up on their skills by reading case studies. These can be found in academic books or learning from a vast breadth of academic papers from established educational institutions, which are often accessible online.

Our experienced team helps to place the very best international nurses and US-based overseas graduates that have the desire to work in the US. We partner with leading healthcare organizations across 25 states who are committed to ethical, best practice long-term care nursing through practical training and development. At Conexus Medstaff, we’re passionate about building healthcare careers in the US. We’re keen to help graduates (and experienced nurses) from overseas embark on a career in nursing in America. To help you recognize what to expect from a career in long-term care nursing, download our free Conexus MedStaff Guide to Long-Term Care Nursing Careers today.

Critical Thinking Activities in Nursing Programs

Alyssa is an active RN and teaches Nursing and Leadership university courses. She also has a Doctorate in Nursing Practice and a Master's in Business Administration.

Table of Contents

Training the future healthcare workforce, practicing the concept: example activities, connecting theory with practice: example activities.

Certified Nurse Educators are tasked with developing ways to engage their students to think strategically and manage challenging patient assignments. Certified Nursing Educators (CNEs) function as expert nursing educators that are especially passionate about advancing the practice of the nursing profession, and have taken a national exam certifying their high level of knowledge and investment in the specialty of education.

CNEs may work with students in academic settings in colleges and universities. Nurse educators are considered valuable resources for fellow faculty members to build a strong nursing program and for the development of nursing students into confident and competent graduates. CNEs are well-respected by colleagues and students for their comprehensive teaching strategies and abilities to incorporate critical thinking activities into academic curriculum.

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About halfway through nursing school, students are exposed to simulated environments to apply theory by practicing skills. CNEs can promote critical thinking through the development and facilitation of engaging activities.

Simulated Patient Cases

Cheryl, a CNE, introduced simulation (mock situations that model real scenarios) to her fellow instructors, explaining that simulation is used to practice a variety of skills and allows students to demonstrate their progress. Her fellow instructors began creating simulated patient cases to help students develop critical thinking in the following domains:

• Physical, hands-on skills: medication administration, dressing changes, and assessments
• Communication techniques: practicing active listening, coaching, and teaching skills

Now that her team has developed a variety of simulated patient cases, she explains that the students can develop the ability to think critically by adding some challenging elements to the cases.

Medication Administration Simulation

• A simulated clinical setting
• Low fidelity manikin, or injectable task trainer with intravenous capabilities
• Mock set of provider orders
• IV pump (if simulating IV medication)

Directions:

• Instruct students to practice and demonstrate a variety of intravenous and intramuscular medications.
• Have students work independently or in groups of two.
• Provide mock doctor orders for medication.
• Instruct students to safely demonstrate safe medication administration.
• Provide feedback on critical thinking skills: identification of missing order items, identification of unsafe and inappropriate dosing, ability to program pump or drawing up of medication, and the ability to identify steps to correct presented issues.

To develop critical thinking skills, the patient cases should include medication relevant items like allergies to the medication, missing physician orders, and complex mathematics to calculate dosing. These case challenges bring an interesting element of engagement to the course, connecting theory to real-life job skills.

Simulating Dressing Changes

• Manikin or volunteer to act as a patient
• Moulage (makeup applied to look like an infected wound)
• Appropriate dressing supplies (gauze pads, sterile saline)
• Instruct patients on the purpose of the simulation.
• Separate students into small groups of two to four people.
• Provide realistic doctor's orders for a dressing change.
• Allow students to work through the scenario.
• Provide feedback on critical thinking skills: safe patient handling and body mechanics, accuracy of dressing change, depth of assessment, identification of wound infection, and proper plans for future patient care.

This simulation not only covers the equipment and supplies needed for safe and clean dressing changes, but also teaches students how to think critically in terms of caring for wounds. Students are presented with normal and infected wounds, and learn how to appropriately assess, document, and report wounds. By the end of this simulation session, students should understand when to report wounds to the doctor, and the implications of an infected wound on the overall health of their patients.

Further into their schooling, nursing students are introduced to the actual clinical environment. Assigning projects that require students to connect pathophysiology (what is happening inside the body) with their on-the-job responsibilities as nurses can help them improve patient outcomes.

Debriefing after a Clinical Day

• A private setting (i.e. conference room, break room)
• Gather your clinical group after a day on the unit.
• Confirm that the gathering is confidential, and is an opportunity for students to feel comfortable sharing sensitive or difficult patient encounters.
• Mention one or two challenging concepts from class that are relevant to the day's events.
• Encourage students to share their clinical experiences as they apply to these concepts.

While this activity doesn't require much in the way of materials, it does require the CNE to stay current on topics learned in class to ensure the day's clinical experience can build upon course curriculum. Privacy in this activity is paramount, as students may have difficulty sharing their experiences from the day.

Patient Case Synthesis

• Live patients
• Permission to interview patients
• Caregiver access to medical records
• Assign students a patient case.
• Instruct students to review the patient case, including medical records review and interviewing the patient.
• Assign students to identify one or more nursing diagnoses that correlate with the medical diagnosis and the patient preferences and wishes.
• Provide feedback on critical thinking skills: student ability to choose relevant and realistic nursing diagnoses, application of theory to practice, and student ability to relate to the patient and provide empathy.

This activity not only illustrates the connection between medicine and nursing practice, but also gives students the opportunity to practice real interviewing skills and communication.

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Fun Critical Thinking Activities for Nursing Students

Medical courses are popular for their complexity and demanding nature. For your everyday student fighting to pay tuition, rent, food, and loans, pursuing a career in the field can be a nightmare. Those who’ve made the journey understand the importance of critical thinking for nursing students. Every facet of the course requires thorough analysis and logical engagement. Nonetheless, educators can intervene to make the journey fun and memorable by introducing exciting activities into the classroom. Below are 10 projects to consider in your classroom.

The Importance of Critical Thinking for Nursing Students

There’s no denying that critical thinking is of utmost importance for nursing students. Well, no professional field would survive without analytical skills. But nursing is about people’s well-being, which makes the practice even more sacred. Below are a few reasons why critical thinking is essential to the practice:

Patient safety

The primary role of a RN is to care for their patients. But this isn’t always the case. Some nurses, e.g., Charles Cullen, have committed atrocities against their patients. Many others have harmed their patients unintentionally or due to negligence. In the medical field, the consequences of a wrong decision can be severe. As such, we need our nurses to be on top of their game. They must possess necessary critical thinking skills to identify potential risks and avert or remedy them.

Clinical judgment

Unlike popular opinion, the role of nurses isn’t limited to administering drugs and caring for them. There are many scenarios that demand clinical judgments, e.g., evaluating symptoms and making a diagnosis, deciding on appropriate medication dosage, recognizing signs of an allergic reaction, etc. These are delicate and life-defining matters that demand critical thinking skills.

Ethical decision-making

Nothing is as demanding as making an ethical decision. The dilemma involved can make or break even the best nurses. In training, they’re often advised to make the decisions they can live with, and in the best interest of their patients. We hope you can see the catch. Whatever the situation, such cases require weighing different ethical principles, values, and perspectives, making them almost impossible to deal with. Handling critical thinking questions during training can make it a bit easier.  

Completing course assignments

All medical courses have a heavy workload of assignments, practicals, and clinical placements. If you add personal life requirements, it becomes almost impossible to handle. In some courses, students handle voluminous works that require days and weeks of reading. The vastness aside, you must be smart to understand the terminology and concepts in nursing. This is where most students fail. However, there’s no cause for alarm. You can always seek help when stranded with your essays and dissertations. There are reputable companies that specialize in nursing writing that can come through on short notice. WriteMyPaperHub , for instance, has very creative and highly trained PhD writers in nursing and medicine who can deliver complex papers within the deadline you need.

Stimulating the Mind: 10 Fun Critical Thinking Activities for Nursing Students

There are several fun critical thinking activities for nursing students to consider. However, many can be costly, time-consuming, or too demanding. For an ordinary classroom, group activities should be simple and interesting. Here, we’ve assembled 10 activities and critical thinking games for nursing students.

1. Case studies

Nursing is a very practical course. As such, any opportunity to explore real-life patient scenarios is highly welcome. This exercise provides just that. Students can organize themselves into small groups and tackle a problem, for example, examine a wound, identify its probable causes, and propose how to treat it.

There’s no better way of sharpening your critical thinking skills than through open discourses. Let your students disagree to agree, for they will gain so much more from being corrected by their peers than rote memorization. Therefore, occasionally pick a controversial or ethical topic and let them debate on it. Just ensure that the engagement is structured for maximum impact.    

3. Reflection journals

Journals can be a student’s best companion. Medical courses can be demanding, putting undue pressure on college students. However, with proper planning and focus, dedicated persons are likely to make it through. A diary can help you organize yourself, appreciate the difficulties you’ve overcome, reflect on your clinical experiences, and motivate you to keep pushing. But keeping it isn’t enough. You must read and reflect on your journey if you’re to stay on track.

4. Simulation exercises

Advances in technology have significantly impacted medical training. For instance, Virtual Reality (VR) is helping instructors to deliver realistic scenarios to their learners remotely. Imagine creating and sharing realistic images of viruses, pathogens, or sick people with your learners and asking them to explore them under pressure and deliver a verdict. It’s like being in the lab!

5. Critical thinking worksheets

Also commonly referred to as critical thinking flow sheets, this activity can be instrumental in testing students’ abilities. It’s a step-by-step process involving clinical scenarios that require extensive research. Here, learners are supposed to gather data on a specific issue, analyze it carefully, and arrive at a diagnosis. It’s a thorough process that employs logic and problem-solving skills.

6. Role-playing

Nursing schools don’t train nurses to be just subordinates. Their curriculum entails everything about patient care and simple diagnosis. In fact, in remote areas with no clinicians, they’re the doctors of the day. Their instructors can organize scenarios that expose them to such situations and let them act as the physicians in charge. They can also act as other people in the healthcare team, e.g., clerks, therapists, and pharmacists. Organizing such critical thinking activities can enhance their preparation and training.

7. Flipped classroom

Even though nursing is quite hands-on, its trainers can deliver their courses and instructions remotely. A flipped classroom is a dynamic approach to learning that allows students to explore their materials at home. Technological advances have made it possible for remote collaboration, making this one of the most enjoyable and fun activities.

8. Group discussions

Unlike debates that pit groups and individuals against each other, group discussions are less confrontational, making them ideal for younger learners. These setups are also suitable for discussing ethical dilemmas. While it’s often hard to find common ground for such issues, challenging assumptions are critical for nursing practice.

9. Decision-making games

The life of a nurse involves making numerous critical decisions. Some of these big resolutions require an instant response. This requires rigorous training. Trainers can use board games, for instance, to pressure students into making healthcare-related decisions fast. This can help them in making informed choices under pressure.

10. Mind mapping

You can introduce this activity as a visual instrument for arranging, generating, and investigating ideas and the links between different nursing concepts.

Critical Thinking for Critical Patient Support!

Nurses are the pillars that hold the healthcare system together. However, their services are only as good as their training and abilities. If we want the best out of our nurses, we must sharpen their critical thinking skills and make them ready for service. In this short article, we’ve explored a few activities that can help nursing trainees develop critical thinking skills essential for their future roles as healthcare professionals.

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9 Fun and Educational Nursing Games

Nursing is an extremely challenging and stressful job. You’ll need to spend most of your day caring for patients and making sure that they get their medications and treatment on time. You’ll also need to assess them routinely to make sure nothing bad happens to them while they are under your care.

If you fail to unwind once in a while, you can end up with burnout that can easily make you want to leave the profession. Now, before that happens, try out a few nursing games .

Below is a really handy list of games that aren’t just educational but fun, too.

Fun and Educational Nursing Games

1. prognosis: your diagnosis.

If you’re always getting a busy shift but still want to brush up your critical thinking skills while on the go, then Prognosis: Your Diagnosis shouldn’t be out of your list of nursing games. This app can help you assess your knowledge about diseases, test your clinical knowledge, and apply what you know in a risk-free environment.

The game presents engaging scenarios that will really test you out as a nurse. Available on iOS devices, this game is designed for busy people like you.

2. Study Shack

Study Shack features more than 1,000 words and terms that nurses should know. Choose from crosswords, unscramble, and more.

Learning new words can be painful and hard. But this educational game will take both away because it is fun to play and goes from simple nursing words and terms to harder ones.

3. RNtertainment

• Traditional game board format  gives you the flexibility to create a competitive group atmosphere with fellow students/ colleagues, or to review on your own.
• Clinical questions and scenarios covering all the major nursing categories  provide an engaging review alternative to fully prepare you for the NCLEX® exam.
• Hundreds of challenging questions and rationales  from student-favorite NCLEX® exam expert  Linda Silvestri  reflect content on the latest NCLEX® test-plan.

RNtertainment has a lot of topics that will really challenge you. Its topics include Safe and Effective Care Management, Health Promotion, and so much more.

It comes in a traditional game format which can give you the opportunity to create a competitive atmosphere for you and your colleagues. It has over 800 questions that aren’t only educational but engaging, too.

The questions vary in format. You can encounter multiple-choice, fill-in-the-blanks, and prioritizing types of questions. These are all great if you’re preparing for an exam, like the NCLEX. You can also find rationales in a separate book so you’ll be properly guided in playing the game.

4. Infection

Infection is all about diseases and medicine. Two to eight players can start the game with 5 disease cards and $500. Those disease cards contain causes, treatments, and symptoms of about 80 medical conditions.

You can pass them to your neighbors, leave them in public places, or get them treated by a Voodoo doctor. The first one to be disease-free and healthy wins the game.

5. Medical Monopoly

If you aren’t into apps and mobile games, then try Medical Monopoly . This board game is best played with your co-nurses during your day off or whenever you need to take a break and relax.

The game resembles the way modern healthcare works in that you need to compete with other hospitals to get the most number of patients. With $500 to start with, you’ll need to buy organs and perform transplant operations. You’ll need to properly diagnose patients, too.

6. Role-Playing

Role-playing is one of the best nursing games you should try if you are teaching nursing students. It’s interactive and encourages students to be more active and involved.

For example, you can group students into groups of two or three. Ask each student to assume a role. It can be a difficult patient, doctor, or relative. Instruct them to act out a common scenario in the hospital that can challenge a nurse’s skill or patience.

7. Quarantine

• Ages 13 and up
• For 2 to 4 players
• Playable in about 60 minutes

Quarantine is another board game where you need to build the biggest and most effective hospital while making sure patients and doctors are well attended to. It’s a form of a tile-laying game where you need to acquire the most number of tiles by beating other players.

Take note that there are highly contagious patients that can spread infections and shut down your hospital.

8. Pixel Hospital

Time management is critical skill nurses have to master if they want to be successful in their chosen profession. This is exactly where Pixel Hospital can help you.

The game puts you in charge of a busy ER attending to the victims of a pandemic that has hit the city. Being in charge, you need to utilize all the resources, staff, and equipment to make sure every patient gets attended to.

9. Trust Walk

Technically, this game won’t test out a nurse’s knowledge or skills. Instead, it can teach you about trusting your co-workers.

Surviving a busy shift when you’re alone won’t be easy. You’ll need help from your colleagues to ensure that you get all your tasks done and that all patients are safe and properly treated.

For Trust Walk, you’ll need a large room, chairs, traffic cones, and small blocks. Create groups of two. One player needs to go through the course blindfolded as his partner guides him with verbal cues.

Bonus: Nurse Bingo

A hectic shift can really do a number on morale. You can liven up your shift with a fun game of bingo. Download your free nurse bingo card here .

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7 Interactive Nursing Games: A Fun Way to Learn Critical Skills

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Captivating the interest of nursing students, particularly digitally-savvy Gen Z learners, can be a daunting task. To overcome the hurdle of disengagement, an option for educators is to embrace the power of interactive nursing games—innovative and stimulating tools that resonate with the lifestyles of learners in nursing school while fostering active engagement in the learning process.

Research reveals that nursing students can achieve a more profound understanding of the content through the use of serious games. This innovative approach to learning not only sparks excitement but also enhances engagement, retention, and problem-solving abilities. Furthermore, it empowers students to self-assess their learning capabilities and, crucially, hone their critical thinking skills. With such an arsenal of benefits, interactive games emerge as the ultimate tool in the modern instructor's toolkit.

We’ve highlighted 5  games that are a fun way to learn critical skills.

Nursing Games

1. create and swap nclex ®  exam questions.

This can be a collaborative game designed to help nursing students create, review, and exchange NCLEX ®  exam questions to enhance their understanding, critical thinking, and test-taking skills. Nursing students work in teams to develop challenging questions, which they then swap with other teams for review and practice. The game fosters a supportive learning environment, encouraging students to discuss concepts, clarify misunderstandings, and share insights. By actively engaging in question creation and peer review, students gain a deeper understanding of the exam material and build confidence in their test-taking abilities.

2. Healthcare education board games

Healthcare education board games offer an interactive and engaging approach to learning, allowing nursing students to develop critical skills in a fun and collaborative environment. These board games focus on various aspects of healthcare education, ranging from clinical decision-making to teamwork and communication. Here are a few examples:

• Friday Night at the ER
• The Ward Game
• Medical Monopoly

3. Immersive virtual reality

Immersive virtual reality (VR) has emerged as a powerful interactive nursing game tool, offering innovative and interactive experiences that enhance students' learning and skill development. It’s fun and involving while being serious. Through VR technology, nursing students can access realistic simulations that closely replicate real-life clinical situations. This immersive experience enables them to practice various skills in a safe and controlled environment without the risk of harming actual patients.

Introducing UbiSim , a VR training platform specific to nursing! We offer serious games that immerse nurse learners in a virtual world where they can tend to patients, respond to family members, and discuss treatment options with providers.

Here’s what an instructor using UbiSim had to say about the experience: “We’re bridging theory to practice and students really enjoy it because it makes it fun to learn,” Dr. Tina Barbour-Taylor, Nurse Educator in UWF’s School of Nursing , said. “It develops critical thinking and prioritization skills, and that’s the most important thing.”

4. Traditional role-playing games

Traditional role-playing games in nursing education immerse students in realistic healthcare scenarios. By assuming different roles, students gain a deeper understanding of nursing and empathy for patients and colleagues. They can also play other members of the healthcare team. These games provide a safe environment to practice skills and make mistakes without causing harm. Additionally, they encourage peer learning and teamwork, as students often work together to resolve complex situations. Role-playing games enhance the nursing education experience by combining learning with engaging, interactive gameplay.

5. Nursing jeopardy

Nursing Jeopardy transforms the renowned TV show "Jeopardy!" into a quiz game tailored for aspiring healthcare professionals. Students can dive into a world of nursing knowledge, navigating diverse categories and point-based questions that fuel their intellectual curiosity. The game sparks teamwork, bolsters knowledge retention, and sharpens critical thinking skills.

6. Escape room-style challenges

Some educational institutions and healthcare facilities organize escape room-style challenges for nursing students. These events require participants to solve puzzles and complete tasks related to patient care and nursing skills within a time limit. They promote teamwork and critical thinking.

There are six key design aspects to escape room-style nursing challenges: 

• Participant characteristics 
• Learning objectives and outcomes
• Puzzles and equipment

7.  Acting out medication commercials

Creating medication commercials as an educational game in nursing school involves students researching and crafting engaging advertisements for selected medications. It can even be an opportunity to use some humor! This exercise deepens their understanding of pharmaceuticals, including indications, contraindications, and side effects, while also honing their communication. Working in groups, nurse learners develop scripts and choose presentation formats, such as video, audio, or live demonstrations, to convey essential medication information effectively. 

Embracing the future of nursing education requires a dynamic shift that transcends conventional methods. By integrating interactive nursing games, educators can unlock the full potential of a new generation of learners. These games ensure that nursing students stay captivated and motivated as they navigate the challenges of their chosen profession.

As an integral center of UbiSim's content team, Ginelle pens stories on the rapidly changing landscape of VR in nursing simulation. Ginelle is committed to elevating the voices of practicing nurses, nurse educators, and program leaders who are making a difference.

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Creative Ways to Enhance and Assess Critical Thinking in Nursing Students

Affiliation.

• 1 About the Author Kimberly C. Parker, DNP, RN, is a clinical instructor, University of Alabama Capstone College of Nursing, Tuscaloosa, Alabama. For more information, contact her at [email protected].
• PMID: 34107521
• DOI: 10.1097/01.NEP.0000000000000830

Nursing students should be challenged to implement critical thinking decisions regarding conclusions they implement for patient care. This article reinforces common techniques and introduces new practices to teach critical thinking. Many ways are currently recognized utilizing an assortment of techniques. The concepts from an escape room are a great way to deliver opportunities for students to practice this skill and can be provided economically and easily. Being creative in managing these concepts will offer an exciting chance to introduce critical thinking for your students.

Copyright © 2021 National League for Nursing.

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The author has declared no conflict of interest.

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Nightingale Challenge Meeting: Critical Thinking in Nursing Education

By hallie bensinger, dnp, apn, fnp | november 30, 2020.

The ability to solve problems through critical thinking is a necessary skill for all nurses. As nurse educators, we often assume that students already know how to critically think, but in an informal Facebook poll among educators, while many pointed out that their students do know how to think critically in general―they just do not know how to apply it in nursing. Therefore, honing the student’s ability to critically think is something educators must focus on throughout our curriculums.  

The objectives for this presentation were to:

• Define critical thinking
• Explain why we need critical thinking in nursing
• Understand how critical thinking skills are formed
• Implement different methods used to teach critical thinking,

What is Critical Thinking and Why is it Critically Important?  

It has been defined in many ways by many people. In short, critical thinking is defined as, “the process of analyzing and understanding how and why we reach a certain conclusion” (Morrison, Smith and Britt, 1996.) It is connecting the dots among factors and how they influence a situation; analyzing and evaluating the effects of those factors on outcomes. The ability to do this comes from knowledge, common sense and experience. 

In an article that I read a few years ago (that unfortunately I cannot for the life of me find,) a study had shown that a nurse makes at least 500 critical thinking decisions in an eight-hour shift (unknown) or in other words, nurses can be required to make critical decisions about patient care at least every 30 seconds (Bucknall, 2000.) Nurses must prioritize problems and care, make decisions regarding treatment, respond to treatment, and provide care while managing one or more patients.

Nurses must recognize trends in their patients’ conditions in order to be proactive in care as opposed to being reactive. This is important in preventing failure to rescue, a common error that results in preventable hospital deaths. James (2013) found that “nearly 210,000-400,000 deaths occur annually from preventable hospital errors.” This number is more than double the 1999 Institute of Medicine Report, and may be underestimated. Another study found that 25% of new nursing graduates lack the thinking skills necessary to recognize critical situations and/or critical lab values that should be acted upon. This can result in failure to rescue. As most nurse educators are aware, the National Council State Board of Nursing is changing the certification exam to more accurately reflect the ability to critically think after their research suggested that only 20% of employers are satisfied with new graduates' ability to critically think (NCSBN, 2018.)  

Developing Critical Thinking Skills—Knowledge, Common Sense, and Experience

According to the National Council State Board of Nursing (NCSBN) Clinical Judgment Measurement Model , critical thinkers must be able to recognize and analyze cues, formulate and prioritize hypotheses, generate solutions, take actions and evaluate the plan (NCSBN, 2018.)  

Some people are better with critical thinking skills than others. Certain qualities must be present.  

Critical thinkers should be: 

• Willing to change
• Open minded
• Knowledgeable
• Able to think outside the box
• Good communicators.

(Iggy.navigtious; Chao, Liu, Wu, Clark & Tan, 2013; Scheffer & Rubenfeld, 2000)

Deterrents and Barriers to Teaching Critical Thinking

Deterrents and barriers to teaching critical thinking (besides the fact that it is difficult to teach) include students with egocentric thinking (the world revolves around them) and sociocentric thinking ( students are influenced by their peers and/or society.) These barriers can exist not only in the students, but they can also exist in the faculty which could therefore affect the way critical thinking is taught and/or encouraged in the classroom. Furthermore, it may be easy for educators to assume that if students memorize facts that they are naturally able to apply them. This is not the case. It is only with practice in applying these principles under guidance of the educator that critical thinking can occur.  

If educators do not feel like they are experts in the content that they are teaching, they may be reluctant to step outside of the box of lectures to try to engage students in active learning. This can have an impact on how teaching critical thinking is done.

Lastly, the learning environment is extremely important. The student has to feel comfortable answering questions and engaging in discussions. Some students will shut down if called upon directly as they lack the confidence to answer the question. They may feel intimidated. This is a barrier to critical thinking in school.

Deterrents and Barriers to Critical Thinking in The Workplace

In the workforce, critical thinking is impeded by the amount of time nurses have to spend on tasks, interruptions, and unpredictability (Shoulders & Follett, 2014.) Things in the workplace that are “conducive to critical thinking include …team support, staffing that allows continuity of care and exposure to multiple patient care situations,” (p. 212.)

Patricia Benner, as most of us know, set the foundation for many nurse educators. Her Novice to Expert theories illustrate the evolution of critical thinking in nurses. Experience is our greatest teacher which supports the fact that novice nurses are initially task-oriented—task-focused. They follow the rules, consider everything as equally important and really do not know what they do not know. The novice nurse is not yet able to draw on his or her experiences to help put the big picture together before making decisions like the proficient or expert nurse is able to do.  According to Benner, it takes 2-3 years for the new nurse to become competent and 5 years or more to become an expert—able to easily handle and think through critical problems and issues (Benner, 2011.)

Styles of Learning Are Important in Developing Critical Thinking Skills

There are many types of learners. Three are basic—auditory, visual and kinesthetic. Students may learn better by being exposed to one type of presentation or several combinations. 

• The audio learner benefits from audio taping lectures and discussions. Saying and hearing things out loud helps the auditory learner.  
• The visual learner benefits most through pictures and videos or seeing demonstrations.
• The kinesthetic learner is a “hands on learner.” They learn by touching and experiencing things. Writing things down and manipulating the information helps these students learn. 
• Additionally, some students learn through reflections . This is important in nursing as reflection is an excellent way to teach critical thinking.

Understanding the different ways that students learn is important in order to serve all learners in ways that work for them. In our past Nightingale Challenge presentations , there have been discussions on passive versus active learning/teaching.  Many educators rely on passive teaching —lecturing “sage on the stage” style, which is a great way to deliver large amounts of content. Many students prefer this as they take notes and will memorize the content later. Memorizing content, however, is not conducive to applying content, which is necessary for developing critical thinking. Active teaching /learning, on the other hand, requires students to be engaged and offers the opportunities to apply the content that they are learning.  

Stimulate Critical Thinking Through Active Teaching/Learning

This style of teaching/learning can appeal to all types of learners. Remember how we talked about experience being one of our greatest teachers and how experience leads to better critical thinking?  Active learning activities lends themselves more to building experience for the learners. Let’s look at each:

• Case Studies : Students work on these alone or together. Doing as a class activity allows the instructor to show students how to pull concepts together and apply knowledge.
• Flipped Classroom: Puts the responsibility of learning on the students and allows the instructor to make sure students are on track with their thinking.
• Group Exams : Students work together to take an exam. They learn from bouncing ideas off of each other.  
• Team-based Learning Exercises : Again, this method encourages students to work together and learn from each other.
• Games: Bring out the competitive side of students, can be fun and engaging, and students can learn without realizing that is what they are doing
• Simulation : Allows students to experience caring for patients in a safe environment—hands on experience where students can do no harm.
• Clinical Experiences : Real hands-on experience. Dedicated Education Units (DEUs) may provide a more immersive experience for the student than traditional clinicals with faculty.
• Socratic Questioning : Woven throughout all of the above, this is an effective way to stimulate critical thinking.

The Socratic Method

The Socratic Method is an active learning process that really stimulates critical thinking. Socrates was an ancient Greek philosopher who taught by questioning and by stimulating questioning in his students. This style of teaching allows students to actively participate in their learning. Of course, it is difficult to use this method if students do not have some basis of knowledge to work from. On the other hand, with information at the tips of our fingers―if they don’t know the answer, they can quickly research it.  

Douglas Oyler and Frank Romanelli had a really good article that came out in the American Journal of Pharmaceutical Education in 2014.  They listed these questions as excellent Socratic questions that can be used with students. When writing case studies and/or working in clinicals, these are excellent questions to pose to students to stimulate critical thinking.  Key concepts of Socratic questioning that the authors pointed out were that the questions should, “raise basic issues, probe beneath the surface, pursue problematic areas of thought, aid students in discovering the truth of their own, aid them in developing sensitivity to clarity, accuracy, relevance and depth; aid students in arriving at judgments through their own reasoning and help them analyze thinking and thought including its purposes, assumptions, questions, points of view, information, inferences, concepts, and implications.”  (Oyler & Romanelli, 2014, p. 5.) 

Questions to post to students during class and clinical from the article are outlined below:

• Precision —Can you be more specific?
• Accuracy —How can we test for that?
• Perspective —Is there another point of view we could examine?
• Equity —What conflicts of interest exist here?
• Relevance —How does this relate to the problem?
• Complexity —What makes this a difficult question to answer?
• Logic —Does this all make sense?
• Importance —What is the most important issue on which to focus?
• Perspicuity —What do you mean? 

Key Takeaways

• Critical thinking is something that must be learned and continually honed.
• Critical thinking is an imperative skill for nurses—good critical thinkers save lives and prevent hospital error.
• Experience is a great teacher of critical thinking so it is important that faculty provide as many opportunities in the classroom and clinical areas for students to apply the knowledge that they are learning.
• Active teaching styles lend themselves well to developing critical thinking as they require the student to become engaged and apply concepts.

Boaigo, L. (2013). Training consultants: Learning styles and strategies. Training Folks Blog. Retrieved from http://www.trainingfolks.com/blog/bid/318881/Training-Consultants-Learning-Styles-and-Strategies

Benner , P., Sutphen, M., Leonard, V., & Day, L. (2010). Education nurses: A call for radical transformation. Stanford, CA: Jossey-Bass.

Benner, P. (2011, September 9, 2011). From novice to expert. Nursing Theories--a Companion to nursing theories and models.  Retrieved 3/20/2012, from http://currentnursing.com/nursing_theory/Patricia_Benner_From_Novice_to_Expert.html

Bucknall T. Critical care nurses’ decision-making activities in the natural clinical setting. Journal of Clinical Nursing. 2000;9(1):25–35.

Caputti, L. (2015). Lecture. Faculty Development Conference, Scottsdale, AZ

Cassum, S., Gul, R., & Profe o-McGrath, J. (2015). Facilitators and deterrents of critical thinking in classrooms: A multidisciplinary perspective in higher education in Karachi, Pakistan. International Journal of Nursing Education, 7(2), 60-64. doi: 10.5958/0974-9357.2015.00075.6

Chao, S., Liu, H., Chang, W., Clark, M., & Tan, J. (2013). Identifying critical thinking indicators and critical thinker attributes in nursing practice. The Journal of Nursing Research, 21(3), 204-210. doi: 10.1097/jnr.0b13c3182a0ace9

Fero, L., Witsberger, C., Wesmiller, S., Zullo, T., & Hoffman, L. (2009). Journal of Advanced Nursing. 65(1). P. 1-17. doi: 10.1111/j.1365-2648.0483.x.

IOM. (1999). To err is human, building a safer health system. National Academy Press Retrieved from http://www.iom.edu/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf.

James, J. T. (2013). A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care. Journal of Patient Safety, 9(3), 122-128 110.1097/PTS.1090b1013e3182948a3182969.

Kelly, M. (2015). Learning styles: understanding and using learning styles. About Education.  Retrieved 10/11/15, from http://712educators.about.com/od/learningstyles/a/learning_styles.htm

Kowalczyk, N. (2011). Review of teaching methods and critical thinking skills. Radiologic Technology, 83(2), 120-132.

Oyler, D., & Romanelli, F. (2014). The fact of ignorance revisiting the Socratic method as a tool for teaching critical thinking. American Journal of Pharmaceutical Education, 78(7), 1-9 Article 144. 

National Council State Board of Nursing (2018). NCLEX examination series: next generation NCLEX (NGN) project [webinar]. Retrieved fromhttps://www.ncsbn.org/13064.htm

Panettieri, R. (2015). Can critical-thinking skills be taught? Radiologic Technology, 86(6), 686-688. 

Popil, I. (2010). Promotion of critical thinking by using case studies as teaching method. Nurse Education Today, 31, 204-207. 

Shoulders, B., CFollett, C., & Eason, J. (2014). Enhancing critical thinking in clincal practice. Dimensions of Critical Care Nursing, 33(4), 207-214. doi: 10.1097/DCC.00000000000053

View our Next Generation NCLEX faculty resources .

View more of our recent blog posts .

NCLEX® is a registered trademark of the National Council of State Boards of Nursing, Inc. Test names are the property of the respective trademark holders, none of whom endorse or are affiliated with Kaplan.

Dr. Bensinger is a Family Nurse Practitioner with over ten years of teaching experience at the undergraduate and graduate level.  She specializes in women's health.  She has served as an Assistant Professor and BSN/MSN Program director.  Her passion is in the area of teaching critical thinking and clinical reasoning.  She joined Kaplan in 2017 and enjoys working with faculty to promote student success.

See more posts by Hallie Bensinger, DNP, APN, FNP

#yearofthenurse , #nightingalechallenge , #nurseeducators , #undergraduatenursing , #criticalthinking , #mentorship

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2.4 Critical Thinking and Clinical Reasoning

Prioritization of patient care should be grounded in critical thinking rather than just a checklist of items to be done. Critical thinking is a broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.” [1] Certainly, there are many actions that nurses must complete during their shift, but nursing requires adaptation and flexibility to meet emerging patient needs. It can be challenging for a novice nurse to change their mindset regarding their established “plan” for the day, but the sooner a nurse recognizes prioritization is dictated by their patients’ needs, the less frustration the nurse might experience. Prioritization strategies include collection of information and utilization of clinical reasoning to determine the best course of action. Clinical reasoning  is defined as, “A complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions.” [2]

When nurses use critical thinking and clinical reasoning skills, they set forth on a purposeful course of intervention to best meet patient-care needs. Rather than focusing on one’s own priorities, nurses utilizing critical thinking and reasoning skills recognize their actions must be responsive to their patients. For example, a nurse using critical thinking skills understands that scheduled morning medications for their patients may be late if one of the patients on their care team suddenly develops chest pain. Many actions may be added or removed from planned activities throughout the shift based on what is occurring holistically on the patient-care team.

Additionally, in today’s complex health care environment, it is important for the novice nurse to recognize the realities of the current health care environment. Patients have become increasingly complex in their health care needs, and organizations are often challenged to meet these care needs with limited staffing resources. It can become easy to slip into the mindset of disenchantment with the nursing profession when first assuming the reality of patient-care assignments as a novice nurse. The workload of a nurse in practice often looks and feels quite different than that experienced as a nursing student. As a nursing student, there may have been time for lengthy conversations with patients and their family members, ample time to chart, and opportunities to offer personal cares, such as a massage or hair wash. Unfortunately, in the time-constrained realities of today’s health care environment, novice nurses should recognize that even though these “extra” tasks are not always possible, they can still provide quality, safe patient care using the “CURE” prioritization framework. Rather than feeling frustrated about “extras” that cannot be accomplished in time-constrained environments, it is vital to use prioritization strategies to ensure appropriate actions are taken to complete what must be done. With increased clinical experience, a novice nurse typically becomes more comfortable with prioritizing and reprioritizing care.

• Klenke-Borgmann, L., Cantrell, M. A., & Mariani, B. (2020). Nurse educator’s guide to clinical judgment: A review of conceptualization, measurement, and development. Nursing Education Perspectives, 41 (4), 215-221. https://doi.org/10.1097/01.nep.0000000000000669 ↵

A broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.”

A complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions.

Leadership and Management of Nursing Care Copyright © 2022 by Kim Belcik and Open Resources for Nursing is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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

Associated data.

Data are contained within the article.

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

1. Introduction

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

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

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

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

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

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

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

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

2. Materials and Methods

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

2.1. Search Strategy

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

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

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

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

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

2.2. Eligibility Criteria and Study Selection

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

2.3. Data Collection and Extraction

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

2.4. Risk of Bias

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

2.5. Ethical Considerations

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

3.1. Search Results

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

Flowchart of screening of clinical reasoning RCTs that underwent review.

3.2. Risk of Bias in CASP Results

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

3.3. Data Extraction

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

3.4. Teaching Strategies

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

3.4.1. Clinical Simulation

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

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

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

3.4.2. Learning Programs

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

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

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

4. Discussion

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

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

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

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

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

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

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

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

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

5. Limitations

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

6. Conclusions

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

Funding Statement

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

Author Contributions

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

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Data availability statement, conflicts of interest.

The authors declare no conflict of interest.

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Critical thinking definition

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

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

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

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

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

• Developing technical and problem-solving skills
• Engaging in more active listening
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• Opening up their curiosity in an intellectual way etc.

Is critical thinking useful in writing?

Critical thinking can help in planning your paper and making it more concise, but it's not obvious at first. We carefully pinpointed some the questions you should ask yourself when boosting critical thinking in writing:

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• What degree of technical knowledge should the report assume its audience has?
• What is the most effective way to show information?
• How should the report be organized?
• How should it be designed?
• What tone and level of language difficulty should the document have?

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

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

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