critical thinking in nursing staff

The Value of Critical Thinking in Nursing

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

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

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

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

How Do Nurses Use Critical Thinking?

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

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

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

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

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

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

Top 5 Ways Nurses Can Improve Critical Thinking Skills

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

Case-Based Approach

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

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

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

Practice Self-Reflection

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

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

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

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

Develop a Questioning Mind

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

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

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

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

Practice Self-Awareness in the Moment

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

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

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

Use a Process

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

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

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

Common Critical Thinking Pitfalls in Nursing

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

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

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

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

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

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

An Essential Skill for All Nurses

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

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

Frequently Asked Questions About Critical Thinking in Nursing

How are critical thinking skills utilized in nursing practice.

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

How does nursing school develop critical thinking skills?

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

Do only nurse managers use critical thinking?

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

Meet Our Contributors

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

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

Jenna Liphart Rhoads, Ph.D., RN

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

Nicholas McGowan, BSN, RN, CCRN

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

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

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

What Is Critical Thinking In Nursing?

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

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

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The characteristic that distinguishes a professional nurse is cognitive rather than psychomotor ability. Nursing practice demands that practitioners display sound judgement and decision-making skills as critical thinking and clinical decision making is an essential component of nursing practice. Nurses’ ability to recognize and respond to signs of patient deterioration in a timely manner plays a pivotal role in patient outcomes (Purling & King 2012). Errors in clinical judgement and decision making are said to account for more than half of adverse clinical events (Tomlinson, 2015). The focus of the nurse clinical judgement has to be on quality evidence based care delivery, therefore, observational and reasoning skills will result in sound, reliable, clinical judgements. Clinical judgement, a concept which is critical to the nursing can be complex, because the nurse is required to use observation skills, identify relevant information, to identify the relationships among given elements through reasoning and judgement. Clinical reasoning is the process by which nurses observe patients status, process the information, come to an understanding of the patient problem, plan and implement interventions, evaluate outcomes, with reflection and learning from the process (Levett-Jones et al, 2010). At all times, nurses are responsible for their actions and are accountable for nursing judgment and action or inaction.

The speed and ability by which the nurses make sound clinical judgement is affected by their experience. Novice nurses may find this process difficult, whereas the experienced nurse should rely on her intuition, followed by fast action. Therefore education must begin at the undergraduate level to develop students’ critical thinking and clinical reasoning skills. Clinical reasoning is a learnt skill requiring determination and active engagement in deliberate practice design to improve performance. In order to acquire such skills, students need to develop critical thinking ability, as well as an understanding of how judgements and decisions are reached in complex healthcare environments.

As lifelong learners, nurses are constantly accumulating more knowledge, expertise, and experience, and it’s a rare nurse indeed who chooses to not apply his or her mind towards the goal of constant learning and professional growth. Institute of Medicine (IOM) report on the Future of Nursing, stated, that nurses must continue their education and engage in lifelong learning to gain the needed competencies for practice. American Nurses Association (ANA), Scope and Standards of Practice requires a nurse to remain involved in continuous learning and strengthening individual practice (p.26)

Alfaro-LeFevre, R. (2009). Critical thinking and clinical judgement: A practical approach to outcome-focused thinking. (4th ed.). St Louis: Elsevier

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Thompson, C., Aitken, l., Doran, D., Dowing, D. (2013). An agenda for clinical decision making and judgement in nursing research and education. International Journal of Nursing Studies, 50 (12), 1720 - 1726 Tomlinson, J. (2015). Using clinical supervision to improve the quality and safety of patient care: a response to Berwick and Francis. BMC Medical Education, 15(103)

Competing interests: No competing interests

Critical Thinking in Nursing

• First Online: 02 January 2023

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• Şefika Dilek Güven 3  

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

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

Graphical Abstract/Art Performance

Critical thinking in nursing.

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

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

Unless the individuals of a nation thinkers, the masses can be drawn in any direction. Mustafa Kemal Atatürk

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

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

By Hannah Meinke on 07/05/2021

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

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

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

Why are critical thinking skills in nursing important?

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

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

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

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

How are critical thinking skills acquired in nursing school?

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

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

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

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

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

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

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

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

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

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

How are critical thinking skills applied in nursing?

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

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

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

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

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

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

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

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

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

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

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

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

Beyond thinking

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

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

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

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Hannah Meinke

Posted in General Nursing

• nursing education

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Emerging Nurse Leader

A leadership development blog

Promote Critical Thinking Skills

March 11, 2019 by rose

By Rose O. Sherman, EdD, RN, FAAN

What is Critical Thinking?

A simple definition of critical thinking is that it is reasonable, reflective thinking focused on deciding what to believe or do.  In nursing, critical thinking for clinical decision-making is the ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process used to ensure safe nursing practice and quality care (Heaslip).  A key concept in critical thinking is the art of reflection.   Dr. Robert Ennis at Illinois State University has identified key behaviors of critical thinkers.  These include:

A critical thinker:

• Is open-minded and mindful of alternative
• Desires to be, and is, well-informed
• Judges well the credibility of sources
• Identifies reasons, assumptions, and conclusions
• Asks appropriate clarifying questions
• Judges well the quality of an argument, including its reasons, assumptions, evidence, and their degree of support for the conclusion
• Can well develop and defend a reasonable position regarding a belief or an action, doing justice to challenges
• Formulates plausible hypothesis
• Defines terms in a way appropriate for the context
• Draws conclusions when warranted – but with caution

The above are skills that we would like to see in our nursing staff.  Some nurses are intuitively better critical thinkers than others but there are strategies that nurse leaders can use in their environments to promote these skills.

Creating a Learning Environment to Promote Critical Thinking

Judith Ross in a 2009 Harvard Business Review Blog suggested that the most effective questions create value.  Here are some examples of the value that can be built and the sample questions that can be asked:

1.  To create clarity – Can you explain more about this situation?  What do you think the issue is here?

2.  To help staff think analytically and more critically – What are the consequences if you take this action?  If our organization does not take action to decrease our financial costs, what will happen when reimbursements decline?

3.  To inspire reflection – Why do you think you were successful in that situation?  What is different about today’s healthcare environment that when you initially began your career?

4.  To encourage breakthrough thinking – Is there another way that we could do this?  If you were redesigning care today with a blank slate, what type of delivery system would you develop?

5.  To challenge assumptions – What would happen if we fail to take action in view of what is happening with health reform?  Do you think that this type of care needs to be delivered in a hospital setting?

6.  To create ownership of solutions – Based on your nursing experience, what do you suggest that we do here?  What changes would be in the best interest of your patients?  How would you deal with the dilemma of the 12-hour tour?

With the focus today on evidence-based practice, nurse leaders need to promote a culture of critical thinking and inquiry.  A culture of inquiry begins by valuing the use of questions in one’s own leadership practice.  Without asking questions, you may falsely assume you have consensus or that staff understand an issue or problem.  Moving from telling to asking may be challenging but it is the way to help staff grow.

Read Rose Sherman’s new book available now –  The Nurse Leader Coach: Become the Boss No One Wants to Leave  

Read to Lead

Critical Thinking and Nursing.  The Critical Thinking Website

© emergingrnleader.com 2019

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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.

Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Critical thinking, critical practice

Affiliation.

• 1 College of Nursing, Wayne State University, Detroit, Mich., USA.
• PMID: 10373884

Nursing leaders in critical care can use strategies such as questioning, clinical scenarios, conferences, and context-dependent test items to assess and improve their staff's critical thinking skills.

• Clinical Competence / standards*
• Critical Care*
• Decision Making*
• Education, Nursing, Continuing / methods*
• Nursing Process*
• Nursing Staff, Hospital / education*
• Nursing Staff, Hospital / psychology
• Nursing, Supervisory / organization & administration

• Open access
• Published: 30 May 2024

Abusive supervision and nursing students’ intention to leave the nursing profession: a moderated mediation model of emotional exhaustion and the nurse-patient relationship

• Youjuan Hong 1   na1 ,
• Meijing Chen 1   na1 ,
• Caimei Chen 2 &
• Meichai Qiu 3  

BMC Nursing volume  23 , Article number:  361 ( 2024 ) Cite this article

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Metrics details

Exploration of the relationship between nursing students’ abusive supervision and their future intention to leave the nursing profession before completing the final clinical practicum is critical to the issue of nursing staff shortages and how to alleviate them. In order to further dissect the factors influencing turnover intention among student nurses in clinical practice, our study used the conservation of resources theory and job demands-resources model to explain the specific pathways that influence student nurses’ intention to leave the nursing profession, with particular focus on nursing students’ personality traits and certain organizational factors.

This study followed a cross-sectional design. Between March and May 2022, a convenience sampling method was used to select 531 nursing students from two medical universities in Fuzhou. The Abusive Supervision, Emotional Exhaustion, Nurse-Patient Relationship, and Turnover Intention Scales were employed to collect data. The PROCESS macro (Models 4 and 7) for SPSS 25.0 by Hayes and 5,000 bootstrap samples were used to examine the moderation and mediation impacts.

Abusive supervision was found to significantly positively predict nursing students’ intention to leave the nursing profession. Emotional exhaustion significantly mediated the relationship between abusive supervision and an intention to leave the nursing profession. The moderating effect of the nurse-patient relationship in the mediation model was also found to be significant.

Conclusions

Abusive supervision by clinical teaching staff is a work-related stressor that leads to emotional exhaustion, consequently decreasing nursing students’ future intention to work as a nurse. A nurse-patient relationship based on trust could buffer the negative effect of abusive supervision on emotional exhaustion. Healthcare organizations and nurse educators should implement programs that educate and train individuals about abusive supervision, emotion regulation, and positive nurse-patient relationships; this would serve to decrease nursing students’ intention to leave the nursing profession. This study provides relevant implications for helping nursing instructors develop effective intervention strategies to retain talented nursing personnel.

Peer Review reports

Introduction

Nursing shortages have become a pressing issue worldwide [ 1 , 2 ]. There are only 2.7 nurses per 1,000 people nationwide in China, less than half the average worldwide and far below the ratio in other developed countries such as the United States (8.3) and Switzerland (17.5). Lin (2020) found that as many as 45.4% of nursing students in China intend to leave the nursing profession [ 3 ]. Nursing students abandoning the nursing profession upon graduation exacerbates nursing workforce shortfalls, increases the financial burden on healthcare organizations [ 4 ], reduces the quality of patient care [ 5 ], and decreases patient satisfaction [ 6 ]. Understanding the influential factors and underlying mechanisms are especially important for identifying ways to reduce turnover among student nurses.

The final clinical practicum (FCP), which occurs just before graduation, provides a real-world context through which nursing students can acquire clinical skills; it can also help graduating students develop a positive attitude regarding their future nursing careers [ 7 ]. Nonetheless, nursing students often report dissatisfaction with their clinical placements, and the result is an intention to leave [ 8 ]. Several past studies have found that newly graduated nurses’ turnover intention was influenced by factors such as authentic leadership, organizational identification, occupational coping self-efficacy [ 9 ], empowerment [ 10 ], work-life fit, and work-life interference [ 11 ]. Explorations of abusive supervision have indicated that it is a prevalent problem in healthcare organizations [ 12 , 13 ]. However, little research has focused on the effects of abusive supervision among nursing students during their FCP. Reducing stress induced by abusive supervision will improve the retention of nursing students, a change that is vital for medical organizations. In addition, very few research studies have sought to investigate the moderated mediating functions operating between abusive supervision and turnover intention, particularly those moderators that could buffer the harmful effects of abusive supervision on student nurses’ turnover intention. Therefore, the potential relationship between abusive supervision and student nurses’ turnover intention during the FCP has yet to be analyzed.

The present research builds upon the literature and expands our understanding of the negative consequences of abusive supervision in relation to nursing students’ intention to work as a nurse after graduation. Abusive supervision is a negative leadership construct that has numerous adverse effects [ 14 , 15 ]. We drew upon the conservation of resources theory (COR) to explore emotional exhaustion as a potential mechanism for understanding why abusive supervision might lead to nursing students’ intention to leave the nursing profession [ 16 ]. We also examined the perceived nurse-patient relationship’s ability to act as a moderator, buffering the negative effects of abusive supervision on turnover intention due to its ability to supply the resources needed by nursing students.

Abusive supervision and nursing students’ intention to leave the nursing profession

Abusive supervision is defined as subordinates’ perceptions of their supervisor’s display of sustained hostile verbal or nonverbal behavior, including public criticism, rudeness, breaking promises, humiliation, and the “silent treatment” [ 17 ]. Previous studies have found abusive supervision to correlate with job satisfaction, psychological strain [ 18 ], psychological health [ 19 ], and an increased intent to quit [ 20 ]. Before graduating, nursing students must spend one year in a hospital internship to turn theoretical knowledge into skills, thus qualifying them to become nurses after graduation. Supervisors are nursing professionals who teach and monitor students; they play an important role in the nursing students’ onboarding process and influence their adjustment progression [ 21 , 22 ]. Negative experiences with supervisors have been associated with an intention to leave the nursing profession [ 23 ]. Abusive supervision may occur when a supervisor intends to show power over or control a subordinate. Favaro, Wong, and Oudshoorn (2021) found that younger and less experienced nurses of both genders experienced greater bullying from supervisors [ 10 ].

As new employees in a health organization, the quality of nursing students’ relationship with their supervisors is an important heuristic for making inferences about their connection with the health organization [ 22 ]. The more supervisors adopt abusive behavior, the more perceived injustice emerges. Nursing students may come to feel that their work is not recognized by their supervisors or they are not worthy of the organization [ 24 ]. In addition, student nurses experiencing this form of abuse tend to have bad relationships with their supervisors and feel that they have no concern for their wellbeing. Thus, abusive supervision is a work-related stressor that can lead to the voluntary or involuntary termination of employees [ 25 ]. One study found that abusive supervision increased nurses’ intention to leave their organization [ 18 ]. If they were not in contact with an abusive supervisor, their job satisfaction was enhanced and intention to leave reduced.

Emotional exhaustion as a mediator

Wright and Cropanzano (1998) defined emotional exhaustion as “a chronic state of physical and emotional depletion caused by excessive job demands and ongoing hassles” [ 26 ]. Abusive behavior by superiors is a persistent source of work stress that can result in emotional exhaustion and burnout [ 27 ]. Employees’ anxiety, despondency, and emotional exhaustion increase in parallel with their access to an aggressive supervisor. This is because when employees face abusive behavior from their superiors, they become agitated, perceive a threat to their identity and social position, and in certain situations, experience moral outrage [ 15 ].

Emotional exhaustion occurs when emotional demands exceed an individual’s coping potential, in this case due to interpersonal workplace interactions [ 28 ]. The COR can be used to explain the mediating mechanism through which abusive supervision affects turnover intention [ 16 ]. The theory posits that individuals have an intrinsic tendency to gain, preserve, and protect their resources. Therefore, nursing students experiencing emotional stress due to abusive supervision will fear losing resources, run the risk of doing so, and likely have trouble replacing them. As a result, they must exert additional psychological effort when faced with abusive supervision [ 29 ]. As a consequence of exerting this extra mental effort to deal with abusive superiors, nursing students’ emotional reserves are depleted, exacerbating their emotional fatigue. Without these resources, nursing students become dissatisfied and may decide to leave the profession [ 30 ]. According to previous research, emotional exhaustion significantly predicts both the intention to leave the nursing profession and actual turnover [ 19 , 31 ].

Nurse-patient relationship as a moderator

The nurse-patient relationship is a work-oriented, interpersonal, caregiving relationship that nurses establish with patients and their families through nursing activities [ 32 ]. Previous research has found that a bad nurse-patient relationship is positively correlated with low job satisfaction [ 33 ], high turnover intention [ 34 ], perceived stress, and reduced job involvement [ 35 ]. In contrast, a positive nurse-patient relationship aids nurses in terms of their socioemotional needs. Employees in a positive nurse-patient relationship are likely to conserve the emotional resources needed to survive and function in the workplace. Thus, according to the job demands-resources model (JDR), a positive nurse-patient relationship is a job resource that contributes to the alleviation of job burnout and role stress. Employees’ emotional exhaustion can vary in relation to differences in their perceived nurse-patient relationship. A better relationship positively affects nurses’ work status; the better the relationship, the more willing nurses are to engage fully in clinical work, thus improving patient health outcomes. Therefore, a good nurse-patient relationship is an important resource, helping employees handle the detrimental impacts of stress and stay focused on their roles [ 32 ]. For instance, Jiang (2022) found that the impact of stressors on emotional exhaustion tends to be strong for nurses who have a tense nurse-patient relationship [ 36 ]. Therefore, a positive nurse-patient relationship can directly provide resources effective for reducing the emotional exhaustion caused by abusive supervision. For example, one previous study found that patients’ lack of reciprocity moderated the positive relationship between abusive supervision and mental health risks among nurses [ 37 ]. Therefore, a positive nurse-patient relationship is likely to buffer the connection between abusive supervision and emotional exhaustion. Specifically, the influence of abusive supervision on emotional exhaustion is likely to be weaker for those with positive nurse-patient relationships. Thus, we propose the following:

The present study: goals and hypotheses

Drawing upon the COR and JDR, the present study explores why and when abusive supervision are associated with turnover intention in student nurses. Based on a literature review, we propose a moderated mediation model where the indirect effect of abusive supervision on turnover intention via emotional exhaustion depends on the level of positivity in the perceived nurse-patient relationship. The hypothesized moderated mediation model is presented in Fig.  1 and comprised of the following three hypotheses:

Hypothesis 1

Abusive supervision is positively correlated with nursing students’ intention to leave the nursing profession.

Hypothesis 2

Emotional exhaustion mediates the relationship between abusive supervision and an intention to leave the nursing profession.

Hypothesis 3

The perceived nurse-patient relationship moderates the relationship between abusive supervision and emotional exhaustion.

Proposed moderated mediation model

Participants

This research utilized a quantitative cross-sectional methodology. Data collection occurred between March and May 2022. It was mandatory that participants be senior nursing students participating in their last clinical practicum. All had or were in the process of completing a clinical practicum lasting more than six months and had been paired with one registered nurse instructor. A total of 590 participants responded to a cross-sectional research questionnaire. There were 531 valid questionnaires obtained after excluding those that were invalid (59 had missing values for abusive supervision, emotional exhaustion, and/or turnover intention). The participants included 410 females (77.21%), and the average age was 21.67 years (SD = 0.68). According to Bentler and Chou [ 38 ], the sample size should be more than 10 times the observed variables. Thus, a sample size of 531 met the requirement for further analysis.

Surveys were distributed to participants from two medical universities in southern China. After obtaining informed consent and emphasizing the anonymity of responses, participants completed the questionnaires on the Wenjuanxing website platform, which is a professional online questionnaire survey platform in China. Participants answered all the measurements in the Chinese language.

Ethical considerations

Ethical approval.

was granted by the Ethics Committee of Fujian Medical University. Informed consent was obtained during the initial stage of the study, prior to survey completion. All participants were informed of the study’s goal, assured of confidentiality and anonymity, and informed that they could withdraw at any moment and for any reason.

Measurements

The abusive supervision scale.

Abusive supervision was assessed using the Abusive Supervision Scale [ 39 ]. This scale has five items rated on a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). An example item is as follows: “My supervisor put me down in front of others during my internship.” Higher scores on the scale indicate higher levels of abusive supervision. The Cronbach’s alpha for this scale in the present study was 0.91, showing good internal consistency.

The emotional exhaustion scale

Emotional exhaustion was assessed using the Emotional Exhaustion Scale [ 40 ]. This scale has six items rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). An example item is as follows: “I feel very tired every morning when I think about facing a whole day’s work.” Higher scores on the scale indicate higher levels of emotional exhaustion. In our study this scale showed good internal consistency, with a Cronbach’s alpha of 0.88.

The nurse-patient relationship scale

The nurse-patient relationship was measured using the Chinese version of the Nurse-Patient Relationship Scale [ 41 ]. This scale has four items rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Higher scores indicate a better nurse-patient relationship. An example item is as follows: “I feel like patients treated me with respect during my internship.” In the present study, the Cronbach’s alpha for this scale was 0.76.

The turnover intention scale

The intention to leave the nursing profession was measured using the Chinese version of the Turnover Intention Scale [ 42 ]. This scale has four items rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). An example item is as follows: “I often think about leaving my current career.” Higher scores indicate a greater willingness to leave. In the present study, the Cronbach’s alpha for this scale was 0.74.

Statistical analysis

SPSS 26.0 and SPSS PROCESS v4.1 were used for the statistical analysis. First, descriptive analysis was used to describe the general demographic characteristics. Second, a Pearson’s correlation was applied to determine the correlations among abusive supervision, emotional exhaustion, nurse-patient relationship, and turnover intention. The issue of common method variance (CMV) was also verified using a Harman’s one-factor model [ 43 ]. Finally, the mediating role of emotional exhaustion operating between abusive supervision and turnover intention was first evaluated through the PROCESS macro (Model 4) of SPSS. In addition, the PROCESS macro (Model 7) was used to test the moderation of the nurse-patient relationship. The total, direct, and indirect effects of the model were evaluated and found to be statistically significant. If the 95% bootstrap confidence interval did not contain zero, a 95% bias-corrected CI based on 5,000 bootstrap samples was used.

Common method variance test

The data collected were self-reported, and thus could have caused a common method bias problem. In order to reduce the risk of common method bias, a Harman one-way factor analysis was conducted to determine the presence of common method bias. The findings indicated that only 31.67% of the variation was explained by a single component, which is less than the critical value of 40%. Thus, there was no serious common method bias problem in this study.

Sample characteristics

A total of 590 student nurses were initially included in this survey. Of these, 59 were then excluded due to missing data. The sex ratio of males to females was 1:29.51 and average age 21.67 ± 0.68 years. The average level of turnover intention was 12.28 ± 2.66. The details are shown in Table  1 .

Descriptive statistics

Means, standard deviations, and correlations among the variables are shown in Table  2 . The results show that abusive supervision was positively correlated with emotional exhaustion ( r  = 0.56, p  < 0.01) and an intention to leave the nursing profession ( r  = 0.48, p  < 0.01) and negatively related to the nurse-patient relationship ( r = -0.48, p  < 0.01), supporting Hypothesis 1 . The results also show that emotional exhaustion was positively correlated with an intention to leave the nursing profession ( r  = 0.58, p  < 0.01). Moreover, the nurse-patient relationship was negatively related to emotional exhaustion ( r = -0.53, p  < 0.01) and an intention to leave the nursing profession ( r = - 0.47, p  < 0.01).

Mediation of emotional exhaustion

The SPSS PROCESS macro Model 4 was used to examine the mediating role of emotional exhaustion. After controlling for gender and age, abusive supervision was found to significantly predict an intention to leave the nursing profession (Model 1: β  = 0.42, p  < 0.001) and emotional exhaustion (Model 2: β  = 0.57, p  < 0.001). Moreover, emotional exhaustion was significantly correlated with an intention to leave the nursing profession (Model 3: β  = 0.54, p  < 0.001), and the direct association between abusive supervision and an intention to leave the nursing profession remained significant (Model 3: β  = 0.15, p  < 0.05). The bias-corrected percentile bootstrap analyses showed that emotional exhaustion partially mediated the relationship between abusive supervision and an intention to leave the nursing profession (indirect effect = 0.31, Boot SE = 0.04, 95% CI = [0.23, 0.39]). The contribution rate of the mediating effect to the total effect was 67.84%. Therefore, Hypothesis 2 was supported (see Table  3 ).

Moderation of the nurse-patient relationship

In order to examine Hypothesis 3 , interaction effects were analyzed with the PROCESS macro Model 7. The results show that abusive supervision had a positive predictive effect on an intention to leave the nursing profession ( β  = 0.40, p  < 0.001); the interaction effect of abusive supervision and nurse-patient relationship on emotional exhaustion was significant ( ß = 0.13, p  < 0.001), and emotional exhaustion had a positive predictive effect on an intention to leave the nursing profession ( ß = 0.54, p  < 0.001). These findings indicate that the nurse-patient relationship moderated the association between abusive supervision and emotional exhaustion. Hypotheses 3 was supported (see Table  4 ).

Additionally, a simple slope analysis was conducted to analyze the moderating effect of the nurse-patient relationship. Figure  2 illustrates this effect at two moderator levels: low (M – SD) and high (M + SD). For participants in the high and low nurse-patient relationship groups, abusive supervision had a positive effect on emotional exhaustion. In addition, for participants with a high nurse-patient relationship, the effect of abusive supervision on turnover intention ( β  = 0.27, p  < 0.001) was weaker than for those in the low group ( β  = 0.51, p  < 0.001), confirming our hypothesis that a high nurse-patient relationship weakens the positive relationship between abusive supervision and turnover intention. Specifically, as abusive supervision increased, emotional exhaustion increased more markedly in the low nurse-patient relationship group than in the high.

Interaction between abusive supervision and nurse-patient relationship

The goal of this study was to examine the effect of abusive supervision on an intention to leave the nursing profession among nursing students engaged in their FCP, as well as explore the mediating role of emotional exhaustion and moderating effect of the nurse-patient relationship. The results support our belief that abusive supervision increases students’ intention to leave the nursing profession, and that the relationship is mediated by emotional exhaustion. In this process, the nurse-patient relationship was found to play a moderating role. Specifically, the effect of abusive supervision on turnover intention in the high nurse-patient relationship group was found to be weaker than what was exhibited by the low group.

The results show that abusive supervision was positively correlated with an intention to leave the nursing profession, as well as that the former directly influencing the latter. Previous studies have confirmed the effect of abusive supervision on an intention to leave the nursing profession [ 44 , 45 , 46 ]. However, to the best of our knowledge, this is the first study to explore the effect of abusive supervision on an intention to leave the nursing profession among nursing students engaged in their FCP; this is essential in order to highlight the critical role of the supervisor (i.e., clinical teaching staff) in enhancing student nurses’ retention. Abusive supervision may pose a threat to student nurses and make them insecure; they may perceive themselves as being treated as outgroup members [ 47 ]. Thus, consistent pressure from supervisors is likely to push student nurses towards negative reactions such as an intention to leave the nursing profession [ 48 ]. The results indicate that student nurse supervisors play an important role in building a positive or negative workplace climate, which can in turn either strengthen or harm students’ workplace sense of belonging. Therefore, abusive supervision is costly, as it results in an increase in an intention to leave the nursing profession.

Our results also show that abusive supervision positively but indirectly influenced student nurses’ intention to leave the nursing profession, and emotional exhaustion played a mediating role [ 11 ]. In other words, abusive supervision can augment emotional exhaustion in student nurses and thus increase their likelihood of forming an intention to leave the profession, a result that can be explained by the COR [ 49 ]. Abusive supervision is a form of workplace stress that drains student nurses’ mental resources. When such students work in a stressful environment caused by their supervisor’s behavior, they may experience a threat to their resources and feeling of tiredness, resulting in high emotional exhaustion [ 50 ]. According to the COR theory, individuals seek to obtain, retain, and protect their resources and minimize the threat of resource loss [ 51 ]. Thus, emotionally exhausted student nurses may feel helpless, decreasing their desire to remain in the nursing profession. Consequently, emotional exhaustion was shown to be a strong predictor of an intention to leave among the student nurses studied. These results support the notion that abusive supervision has a broader impact on newcomers (in this context, nursing students engaged in clinical practice), not only within companies but also in medical organizations.

Moreover, the results also show that the nurse-patient relationship moderated the linkage between abusive supervision and emotional exhaustion. Though the influence of abusive supervision on turnover intention has been confirmed in previous studies [ 47 , 52 ], there has been little research exploring the factors that might buffer its effects. To our knowledge, this is the first to provide empirical evidence of the effect of the nurse-patient relationship on the correlation between abusive supervision and an intention to leave the nursing profession among nursing students engaged in clinical practice. Therefore, it is a novel addition to the extant literature. The results are consistent with the JDR model [ 53 ]. Positive nursing-patient relationships are a job resource that contributes to the alleviation of role stress. An increase in the quality of the nurse-patient relationship was found to weaken the predictive effect of abusive supervision on emotional exhaustion. Student nurses with negative nurse-patient relationships rated stronger negative reactions to abusive supervision than did individuals with more positive relationships. Patient respect and trust is an important resource to help student nurses handle the detrimental impacts of stress and stay focused on their role [ 31 ]. Previous studies have focused more on the impact of poor nurse-patient relationships on an intention to leave the nursing profession, while this study confirmed the positive impact of positive nurse-patient relationships on positive psychological resources for nursing students engaged in clinical practice.

Implications

Our results will improve the greater understanding of the organizational and individual factors affecting student nurses’ intention to leave the nursing profession, thus assisting instructors with developing effective intervention strategies to retain talented nursing personnel. First, the results highlight key practical implications for healthcare organizations seeking to avoid the negative consequences of abusive supervision by clinical practice supervisors. Nurturing positive relationships among supervisors and nursing students, as well as mutual respect and support, and creating an ideal clinical learning environment are central to decreasing nursing students’ voluntary turnover. Healthcare organizations should adopt these findings and implement programs designed to educate, train, and support clinical teaching staff to avoid abusive supervision. Second, nurse educators should incorporate emotion regulation into their specific intervention strategies for handling emotional exhaustion resulting from abusive supervision. Third, a patient-nurse relationship based on trust has critical importance for the intention to remain. Such relationships allow student nurses to feel respected and trusted by their patients. Nurse educators should develop training to improve nurse-patient communication and trust skills for nursing students.

Limitations

There are several limitations of the current study that need to be considered. First, a cross-sectional design was adopted, and this restricted the analysis to the causal relationship between abusive supervision and an intention to leave the nursing profession. Longitudinal research should be conducted in the future, particularly as longitudinal studies are rarely adopted in the area of abusive supervision in clinical practice. Second, the data were collected through the self-reporting of nursing students via an online survey, which may have led to response bias based in social desirability. Other measurements should be adopted to draw stronger conclusions about the relationship between abusive supervision and its consequences. Third, this study did not explore the effects of different types of abusive supervision on the intention to leave the nursing profession. Different types of abusive supervision should be distinguished to confirm what particular types of abusive supervision can be appraised as most stressful.

This study represents a first look at abusive supervision in healthcare organizations, using a sample of student nurses in China. We proposed and tested a novel model for abusive supervision’s direct, indirect, and relaxation effects on the intention to leave the nursing profession among nursing students engaged in clinical practice. The present study’s findings emphasize the important role of abusive supervision, emotional exhaustion, and nurse-patient relationships in nursing students’ intention to leave the profession. The results indicate that abusive supervision significantly affects nursing students’ intention to leave. Emotional exhaustion is also significantly related to nursing students’ intention to leave. Furthermore, emotional exhaustion indirectly affects the relationship between abusive supervision and nursing students’ intention to leave the nursing profession. This research adds to this research domain by examining the moderating role of nurse-patient relationships based on trust and confirms that such nurse-patient relationships could moderate the association between abusive supervision and an intention to leave the nursing profession. Consequently, patient support may enable student nurses to feel cared about, significant, and capable, and thus help eliminate the harmful effects of abusive supervisors for those engaged in the FCP.

Data availability

The data supporting the findings of this study can be obtained from the corresponding author upon reasonable request.

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Acknowledgements

We would like to thank all nursing students who participated in this study.

This study was funded by grants from the Fujian Social Science Planning Project under Grant (grants Number: FJ2022BF018).

Author information

Youjuan Hong and Meijing Chen contributed equally to this work. Meijing Chen is the Co-first author.

Authors and Affiliations

School of Nursing, Fujian Medical University, Fuzhou, China

Youjuan Hong & Meijing Chen

Critical Care Department, Longyan People’s Hospital, Longyan, Fujian, China

Caimei Chen

Center for information Management, Fujian Provincial Hospital, Fuzhou, Fujian, China

Meichai Qiu

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Contributions

Y. H. contributed to the study design, data collection, data analysis and original draft writing. M. Ch. contributed to the data investigation, data analysis and writing review. C. Ch. and M. Q. contributed to the data investigation.

Corresponding author

Correspondence to Youjuan Hong .

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The study was approved by the Ethics Committee of Fujian Medical University, Fuzhou, China. Written informed consent was obtained from all participants. All methods were performed in accordance with the relevant guidelines and regulations.

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Hong, Y., Chen, M., Chen, C. et al. Abusive supervision and nursing students’ intention to leave the nursing profession: a moderated mediation model of emotional exhaustion and the nurse-patient relationship. BMC Nurs 23 , 361 (2024). https://doi.org/10.1186/s12912-024-02025-5

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Received : 27 November 2023

Accepted : 17 May 2024

Published : 30 May 2024

DOI : https://doi.org/10.1186/s12912-024-02025-5

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• Abusive supervision
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