promoting critical thinking in nursing

ANA Nursing Resources Hub

Search Resources Hub

Critical Thinking in Nursing: Tips to Develop the Skill

4 min read • February, 09 2024

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

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

What Is Critical Thinking in Nursing?

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

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

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

How Is Critical Thinking Important for Nurses? 

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

Elements of Critical Thinking in Nursing

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

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

How to Develop and Apply Critical-Thinking Skills in Nursing

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

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

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

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

Images sourced from Getty Images

Related Resources

Item(s) added to cart

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

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

What Is Critical Thinking In Nursing?

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

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

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

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.

Promoting critical thinking through an evidence-based skills fair intervention

Journal of Research in Innovative Teaching & Learning

ISSN : 2397-7604

Article publication date: 23 November 2020

Issue publication date: 1 April 2022

The lack of critical thinking in new graduates has been a concern to the nursing profession. The purpose of this study was to investigate the effects of an innovative, evidence-based skills fair intervention on nursing students' achievements and perceptions of critical thinking skills development.

Design/methodology/approach

The explanatory sequential mixed-methods design was employed for this study.

The findings indicated participants perceived the intervention as a strategy for developing critical thinking.

Originality/value

The study provides educators helpful information in planning their own teaching practice in educating students.

Critical thinking

Evidence-based practice, skills fair intervention.

Gonzalez, H.C. , Hsiao, E.-L. , Dees, D.C. , Noviello, S.R. and Gerber, B.L. (2022), "Promoting critical thinking through an evidence-based skills fair intervention", Journal of Research in Innovative Teaching & Learning , Vol. 15 No. 1, pp. 41-54. https://doi.org/10.1108/JRIT-08-2020-0041

Emerald Publishing Limited

Copyright © 2020, Heidi C. Gonzalez, E-Ling Hsiao, Dianne C. Dees, Sherri R. Noviello and Brian L. Gerber

Published in Journal of Research in Innovative Teaching & Learning . Published by Emerald Publishing Limited. This article is published under the Creative Commons Attribution (CC BY 4.0) licence. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial and non-commercial purposes), subject to full attribution to the original publication and authors. The full terms of this licence may be seen at http://creativecommons.org/licences/by/4.0/legalcode

Introduction

Critical thinking (CT) was defined as “cognitive skills of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting, and transforming knowledge” ( Scheffer and Rubenfeld, 2000 , p. 357). Critical thinking is the basis for all professional decision-making ( Moore, 2007 ). The lack of critical thinking in student nurses and new graduates has been a concern to the nursing profession. It would negatively affect the quality of service and directly relate to the high error rates in novice nurses that influence patient safety ( Arli et al. , 2017 ; Saintsing et al. , 2011 ). It was reported that as many as 88% of novice nurses commit medication errors with 30% of these errors due to a lack of critical thinking ( Ebright et al. , 2004 ). Failure to rescue is another type of error common for novice nurses, reported as high as 37% ( Saintsing et al. , 2011 ). The failure to recognize trends or complications promptly or take action to stabilize the patient occurs when health-care providers do not recognize signs and symptoms of the early warnings of distress ( Garvey and CNE series, 2015 ). Internationally, this lack of preparedness and critical thinking attributes to the reported 35–60% attrition rate of new graduate nurses in their first two years of practice ( Goodare, 2015 ). The high attrition rate of new nurses has expensive professional and economic costs of $82,000 or more per nurse and negatively affects patient care ( Twibell et al. , 2012 ). Facione and Facione (2013) reported the failure to utilize critical thinking skills not only interferes with learning but also results in poor decision-making and unclear communication between health-care professionals, which ultimately leads to patient deaths.

Due to the importance of critical thinking, many nursing programs strive to infuse critical thinking into their curriculum to better prepare graduates for the realities of clinical practice that involves ever-changing, complex clinical situations and bridge the gap between education and practice in nursing ( Benner et al. , 2010 ; Kim et al. , 2019 ; Park et al. , 2016 ; Newton and Moore, 2013 ; Nibert, 2011 ). To help develop students' critical thinking skills, nurse educators must change the way they teach nursing, so they can prepare future nurses to be effective communicators, critical thinkers and creative problem solvers ( Rieger et al. , 2015 ). Nursing leaders also need to redefine teaching practice and educational guidelines that drive innovation in undergraduate nursing programs.

Evidence-based practice has been advocated to promote critical thinking and help reduce the research-practice gap ( Profetto-McGrath, 2005 ; Stanley and Dougherty, 2010 ). Evidence-based practice was defined as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of the individual patient” ( Sackett et al. , 1996 , p. 71). Skills fair intervention, one type of evidence-based practice, can be used to engage students, promote active learning and develop critical thinking ( McCausland and Meyers, 2013 ; Roberts et al. , 2009 ). Skills fair intervention helps promote a consistent teaching practice of the psychomotor skills to the novice nurse that decreased anxiety, gave clarity of expectations to the students in the clinical setting and increased students' critical thinking skills ( Roberts et al. , 2009 ). The researchers of this study had an opportunity to create an active, innovative skills fair intervention for a baccalaureate nursing program in one southeastern state. This intervention incorporated evidence-based practice rationale with critical thinking prompts using Socratic questioning, evidence-based practice videos to the psychomotor skill rubrics, group work, guided discussions, expert demonstration followed by guided practice and blended learning in an attempt to promote and develop critical thinking in nursing students ( Hsu and Hsieh, 2013 ; Oermann et al. , 2011 ; Roberts et al. , 2009 ). The effects of an innovative skills fair intervention on senior baccalaureate nursing students' achievements and their perceptions of critical thinking development were examined in the study.

Literature review

The ability to use reasoned opinion focusing equally on processes and outcomes over emotions is called critical thinking ( Paul and Elder, 2008 ). Critical thinking skills are desired in almost every discipline and play a major role in decision-making and daily judgments. The roots of critical thinking date back to Socrates 2,500 years ago and can be traced to the ancient philosopher Aristotle ( Paul and Elder, 2012 ). Socrates challenged others by asking inquisitive questions in an attempt to challenge their knowledge. In the 1980s, critical thinking gained nationwide recognition as a behavioral science concept in the educational system ( Robert and Petersen, 2013 ). Many researchers in both education and nursing have attempted to define, measure and teach critical thinking for decades. However, a theoretical definition has yet to be accepted and established by the nursing profession ( Romeo, 2010 ). The terms critical literacy, CT, reflective thinking, systems thinking, clinical judgment and clinical reasoning are used synonymously in the reviewed literature ( Clarke and Whitney, 2009 ; Dykstra, 2008 ; Jones, 2010 ; Swing, 2014 ; Turner, 2005 ).

Watson and Glaser (1980) viewed critical thinking not only as cognitive skills but also as a combination of skills, knowledge and attitudes. Paul (1993) , the founder of the Foundation for Critical Thinking, offered several definitions of critical thinking and identified three essential components of critical thinking: elements of thought, intellectual standards and affective traits. Brunt (2005) stated critical thinking is a process of being practical and considered it to be “the process of purposeful thinking and reflective reasoning where practitioners examine ideas, assumptions, principles, conclusions, beliefs, and actions in the contexts of nursing practice” (p. 61). In an updated definition, Ennis (2011) described critical thinking as, “reasonable reflective thinking focused on deciding what to believe or do” (para. 1).

The most comprehensive attempt to define critical thinking was under the direction of Facione and sponsored by the American Philosophical Association ( Scheffer and Rubenfeld, 2000 ). Facione (1990) surveyed 53 experts from the arts and sciences using the Delphi method to define critical thinking as a “purposeful, self-regulatory judgment which results in interpretation, analysis, evaluation, and inference, as well as an explanation of the evidential, conceptual, methodological, criteriological, or contextual considerations upon which judgment, is based” (p. 2).

To come to a consensus definition for critical thinking, Scheffer and Rubenfeld (2000) also conducted a Delphi study. Their study consisted of an international panel of nurses who completed five rounds of sequenced questions to arrive at a consensus definition. Critical thinking was defined as “habits of mind” and “cognitive skills.” The elements of habits of mind included “confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection” ( Scheffer and Rubenfeld, 2000 , p. 352). The elements of cognitive skills were recognized as “analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting, and transforming knowledge” ( Scheffer and Rubenfeld, 2000 , p. 352). In addition, Ignatavicius (2001) defined the development of critical thinking as a long-term process that must be practiced, nurtured and reinforced over time. Ignatavicius believed that a critical thinker required six cognitive skills: interpretation, analysis, evaluation, inference, explanation and self-regulation ( Chun-Chih et al. , 2015 ). According to Ignatavicius (2001) , the development of critical thinking is difficult to measure or describe because it is a formative rather than summative process.

Fero et al. (2009) noted that patient safety might be compromised if a nurse cannot provide clinically competent care due to a lack of critical thinking. The Institute of Medicine (2001) recommended five health care competencies: patient-centered care, interdisciplinary team care, evidence-based practice, informatics and quality improvement. Understanding the development and attainment of critical thinking is the key for gaining these future competencies ( Scheffer and Rubenfeld, 2000 ). The development of a strong scientific foundation for nursing practice depends on habits such as contextual perspective, inquisitiveness, creativity, analysis and reasoning skills. Therefore, the need to better understand how these critical thinking habits are developed in nursing students needs to be explored through additional research ( Fero et al. , 2009 ). Despite critical thinking being listed since the 1980s as an accreditation outcome criteria for baccalaureate programs by the National League for Nursing, very little improvement has been observed in practice ( McMullen and McMullen, 2009 ). James (2013) reported the number of patient harm incidents associated with hospital care is much higher than previously thought. James' study indicated that between 210,000 and 440,000 patients each year go to the hospital for care and end up suffering some preventable harm that contributes to their death. James' study of preventable errors is attributed to other sources besides nursing care, but having a nurse in place who can advocate and critically think for patients will make a positive impact on improving patient safety ( James, 2013 ; Robert and Peterson, 2013 ).

Adopting teaching practice to promote CT is a crucial component of nursing education. Research by Nadelson and Nadelson (2014) suggested evidence-based practice is best learned when integrated into multiple areas of the curriculum. Evidence-based practice developed its roots through evidence-based medicine, and the philosophical origins extend back to the mid-19th century ( Longton, 2014 ). Florence Nightingale, the pioneer of modern nursing, used evidence-based practice during the Crimean War when she recognized a connection between poor sanitary conditions and rising mortality rates of wounded soldiers ( Rahman and Applebaum, 2011 ). In professional nursing practice today, a commonly used definition of evidence-based practice is derived from Dr. David Sackett: the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient ( Sackett et al. , 1996 , p. 71). As professional nurses, it is imperative for patient safety to remain inquisitive and ask if the care provided is based on available evidence. One of the core beliefs of the American Nephrology Nurses' Association's (2019) 2019–2020 Strategic Plan is “Anna must support research to develop evidence-based practice, as well as to advance nursing science, and that as individual members, we must support, participate in, and apply evidence-based research that advances our own skills, as well as nursing science” (p. 1). Longton (2014) reported the lack of evidence-based practice in nursing resulted in negative outcomes for patients. In fact, when evidence-based practice was implemented, changes in policies and procedures occurred that resulted in decreased reports of patient harm and associated health-care costs. The Institute of Medicine (2011) recommendations included nurses being leaders in the transformation of the health-care system and achieving higher levels of education that will provide the ability to critically analyze data to improve the quality of care for patients. Student nurses must be taught to connect and integrate CT and evidence-based practice throughout their program of study and continue that practice throughout their careers.

One type of evidence-based practice that can be used to engage students, promote active learning and develop critical thinking is skills fair intervention ( McCausland and Meyers, 2013 ; Roberts et al. , 2009 ). Skills fair intervention promoted a consistent teaching approach of the psychomotor skills to the novice nurse that decreased anxiety, gave clarity of expectations to the students in the clinical setting and increased students' critical thinking skills ( Roberts et al. , 2009 ). The skills fair intervention used in this study is a teaching strategy that incorporated CT prompts, Socratic questioning, group work, guided discussions, return demonstrations and blended learning in an attempt to develop CT in nursing students ( Hsu and Hsieh, 2013 ; Roberts et al. , 2009 ). It melded evidence-based practice with simulated CT opportunities while students practiced essential psychomotor skills.

Research methodology

Context – skills fair intervention.

According to Roberts et al. (2009) , psychomotor skills decline over time even among licensed experienced professionals within as little as two weeks and may need to be relearned within two months without performing a skill. When applying this concept to student nurses for whom each skill is new, it is no wonder their competency result is diminished after having a summer break from nursing school. This skills fair intervention is a one-day event to assist baccalaureate students who had taken the summer off from their studies in nursing and all faculty participated in operating the stations. It incorporated evidence-based practice rationale with critical thinking prompts using Socratic questioning, evidence-based practice videos to the psychomotor skill rubrics, group work, guided discussions, expert demonstration followed by guided practice and blended learning in an attempt to promote and develop critical thinking in baccalaureate students.

Students were scheduled and placed randomly into eight teams based on attributes of critical thinking as described by Wittmann-Price (2013) : Team A – Perseverance, Team B – Flexibility, Team C – Confidence, Team D – Creativity, Team E – Inquisitiveness, Team F – Reflection, Team G – Analyzing and Team H – Intuition. The students rotated every 20 minutes through eight stations: Medication Administration: Intramuscular and Subcutaneous Injections, Initiating Intravenous Therapy, ten-minute Focused Physical Assessment, Foley Catheter Insertion, Nasogastric Intubation, Skin Assessment/Braden Score and Restraints, Vital Signs and a Safety Station. When the students completed all eight stations, they went to the “Check-Out” booth to complete a simple evaluation to determine their perceptions of the effectiveness of the innovative intervention. When the evaluations were complete, each of the eight critical thinking attribute teams placed their index cards into a hat, and a student won a small prize. All Junior 2, Senior 1 and Senior 2 students were required to attend the Skills Fair. The Skills Fair Team strove to make the event as festive as possible, engaging nursing students with balloons, candy, tri-boards, signs and fun pre and postactivities. The Skills Fair rubrics, scheduling and instructions were shared electronically with students and faculty before the skills fair intervention to ensure adequate preparation and continuous resource availability as students move forward into their future clinical settings.

Research design

Institutional review board (IRB) approval was obtained from XXX University to conduct this study and protect human subject rights. The explanatory sequential mixed-methods design was employed for this study. The design was chosen to identify what effects a skills fair intervention that had on senior baccalaureate nursing students' achievements on the Kaplan Critical Thinking Integrated Test (KCTIT) and then follow up with individual interviews to explore those test results in more depth. In total, 52 senior nursing students completed the KCTIT; 30 of them participated in the skills fair intervention and 22 of them did not participate. The KCTIT is a computerized 85-item exam in which 85 equates to 100%, making each question worth one point. It has high reliability and validity ( Kaplan Nursing, 2012 ; Swing, 2014 ). The reliability value of the KCTIT ranged from 0.72 to 0.89. A t -test was used to analyze the test results.

A total of 11 participants were purposefully selected based on a range of six high achievers and five low achievers on the KCTIT for open-ended one-on-one interviews. Each interview was conducted individually and lasted for about 60 minutes. An open-ended interview protocol was used to guide the flow of data collection. The interviewees' ages ranged from 21 to 30 years, with an average of 24 years. One of 11 interviewees was male. Among them, seven were White, three were Black and one was Indian American. The data collected were used to answer the following research questions: (1) What was the difference in achievements on the KCTIT among senior baccalaureate nursing students who participated in the skills fair intervention and students who did not participate? (2) What were the senior baccalaureate nursing students' perceptions of internal and external factors impacting the development of critical thinking skills during the skills fair intervention? and (3) What were the senior baccalaureate nursing students' perceptions of the skills fair intervention as a critical thinking developmental strategy?

Inductive content analysis was used to analyze interview data by starting with the close reading of the transcripts and writing memos for initial coding, followed by an analysis of patterns and relationships among the data for focused coding. The intercoder reliability was established for qualitative data analysis with a nursing expert. The lead researcher and the expert read the transcript several times and assigned a code to significant units of text that corresponded with answering the research questions. The codes were compared based on differences and similarities and sorted into subcategories and categories. Then, headings and subheadings were used based on similar comments to develop central themes and patterns. The process of establishing intercoder reliability helped to increase dependability, conformability and credibility of the findings ( Graneheim and Lundman, 2004 ). In addition, methods of credibility, confirmability, dependability and transferability were applied to increase the trustworthiness of this study ( Graneheim and Lundman, 2004 ). First, reflexivity was observed by keeping journals and memos. This practice allowed the lead researcher to reflect on personal views to minimize bias. Data saturation was reached through following the recommended number of participants as well as repeated immersion in the data during analysis until no new data surfaced. Member checking was accomplished through returning the transcript and the interpretation to the participants to check the accuracy and truthfulness of the findings. Finally, proper documentation was conducted to allow accurate crossreferencing throughout the study.

Quantitative results

Results for the quantitative portion showed there was no difference in scores on the KCTIT between senior nursing students who participated in the skills fair intervention and senior nursing students who did not participate, t (50) = −0.174, p  = 0.86 > 0.05. The test scores between the nonparticipant group ( M  = 67.59, SD = 5.81) and the participant group ( M  = 67.88, SD = 5.99) were almost equal.

Qualitative results

Initial coding.

The results from the initial coding and generated themes are listed in Table 1 . First, the participants perceived the skills fair intervention as “promoting experience” and “confidence” by practicing previously learned knowledge and reinforcing it with active learning strategies. Second, the participants perceived the skills fair intervention as a relaxed, nonthreatening learning environment due to the festive atmosphere, especially in comparison to other learning experiences in the nursing program. The nonthreatening environment of the skills fair intervention allowed students to learn without fear. Third, the majority of participants believed their critical thinking was strengthened after participating. Several participants believed their perception of critical thinking was “enhanced” or “reinforced” rather than significantly changed.

Focused coding results

The final themes were derived from the analysis of patterns and relationships among the content of the data using inductive content analysis ( Saldana, 2009 ). The following was examined across the focused coding process: (1) factors impacting critical thinking skills development during skills fair intervention and (2) skills fair intervention a critical thinking skills developmental strategy.

Factors impacting critical thinking skills development . The factors impacting the development of critical thinking during the skills fair intervention were divided into two themes: internal factors and external factors. The internal factors were characteristics innate to the students. The identified internal factors were (1) confidence and anxiety levels, (2) attitude and (3) age. The external factors were the outside influences that affected the students. The external factors were (1) experience and practice, (2) faculty involvement, (3) positive learning environment and (4) faculty prompts.

I think that confidence and anxiety definitely both have a huge impact on your ability to be able to really critically think. If you start getting anxious and panicking you cannot think through the process like you need too. I do not really think gender or age necessarily would have anything to do with critical thinking.

Definitely the confidence level, I think, the more advanced you get in the program, your confidence just keeps on growing. Level of anxiety, definitely… I think the people who were in the Skills Fair for the first time, had more anxiety because they did not really know to think, they did not know how strict it was going to be, or if they really had to know everything by the book. I think the Skills Fair helped everyone's confidence levels, but especially the Jr. 2's.

Attitude was an important factor in the development of critical thinking skills during the skills fair intervention as participants believed possessing a pleasant and positive attitude meant a student was eager to learn, participate, accept responsibility for completing duties and think seriously. Participant 6 believed attitude contributed to performance in the Skills Fair.

I feel like, certain things bring critical thinking out in you. And since I'm a little bit older than some of the other students, I have had more life experiences and am able to figure stuff out better. Older students have had more time to learn by trial and error, and this and that.

Like when I had clinical with you, you'd always tell us to know our patients' medications. To always know and be prepared to answer questions – because at first as a Junior 1 we did not do that in the clinical setting… and as a Junior 2, I did not really have to know my medications, but with you as a Senior 1, I started to realize that the patients do ask about their meds, so I was making sure that I knew everything before they asked it. And just having more practice with IVs – at first, I was really nervous, but when I got to my preceptorship – I had done so many IVs and with all of the practice, it just built up my confidence with that skill so when I performed that skill during the Fair, I was confident due to my clinical experiences and able to think and perform better.

I think teachers will always affect the ability to critically think just because you want [to] get the right answer because they are there and you want to seem smart to them [Laugh]. Also, if you are leading in the wrong direction of your thinking – they help steer you back to [in] the right direction so I think that was very helpful.

You could tell the faculty really tried to make it more laid back and fun, so everybody would have a good experience. The faculty had a good attitude. I think making it fun and active helped keep people positive. You know if people are negative and not motivated, nothing gets accomplished. The faculty did an amazing job at making the Skills Fair a positive atmosphere.

However, for some of the participants, a positive learning environment depended on their fellow students. The students were randomly assigned alphabetically to groups, and the groups were assigned to starting stations at the Skills Fair. The participants claimed some students did not want to participate and displayed cynicism toward the intervention. The participants believed their cynicism affected the positive learning environment making critical thinking more difficult during the Skills Fair.

Okay, when [instructor name] was demonstrating the Chevron technique right after we inserted the IV catheter and we were trying to secure the catheter, put on the extension set, and flush the line at what seemed to be all at the same time. I forgot about how you do not want to put the tape right over the hub of the catheter because when you go back in and try to assess the IV site – you're trying to assess whether or not it is patent or infiltrated – you have to visualize the insertion site. That was one of the things that I had been doing wrong because I was just so excited that I got the IV in the vein in the first place – that I did not think much about the tape or the tegaderm for sterility. So I think an important part of critical thinking is to be able to recognize when you've made a mistake and stop, stop yourself from doing it in the future (see Table 2 ).

Skills fair intervention as a developmental strategy for critical thinking . The participants identified the skills fair intervention was effective as a developmental strategy for critical thinking, as revealed in two themes: (1) develops alternative thinking and (2) thinking before doing (See Table 3 ).

Develops alternative thinking . The participants perceived the skills fair intervention helped enhance critical thinking and confidence by developing alternative thinking. Alternative thinking was described as quickly thinking of alternative solutions to problems based on the latest evidence and using that information to determine what actions were warranted to prevent complications and prevent injury. It helped make better connections through the learning of rationale between knowledge and skills and then applying that knowledge to prevent complications and errors to ensure the safety of patients. The participants stated the learning of rationale for certain procedures provided during the skills fair intervention such as the evidence and critical thinking prompts included in the rubrics helped reinforce this connection. The participants also shared they developed alternative thinking after participating in the skills fair intervention by noticing trends in data to prevent potential complications from the faculty prompts. Participant 1 stated her instructor prompted her alternative thinking through questioning about noticing trends to prevent potential complications. She said the following:

Another way critical thinking occurred during the skills fair was when [instructor name] was teaching and prompted us about what it would be like to care for a patient with a fractured hip – I think this was at the 10-minute focused assessment station, but I could be wrong. I remember her asking, “What do you need to be on the look-out for? What can go wrong?” I automatically did not think critically very well and was only thinking circulation in the leg, dah, dah, dah. But she was prompting us to think about mobility alterations and its effect on perfusion and oxygenation. She was trying to help us build those connections. And I think that's a lot of the aspects of critical thinking that gets overlooked with the nursing student – trouble making connections between our knowledge and applying it in practice.

Thinking before doing . The participants perceived thinking before doing, included thinking of how and why certain procedures, was necessary through self-examination prior to taking action. The hands-on situational learning allowed the participants in the skills fair intervention to better notice assessment data and think at a higher level as their previous learning of the skills was perceived as memorization of steps. This higher level of learning allowed participants to consider different future outcomes and analyze pertinent data before taking action.

I think what helped me the most is considering outcomes of my actions before I do anything. For instance, if you're thinking, “Okay. Well, I need to check their blood pressure before I administer this blood pressure medication – or the blood pressure could potentially bottom out.” I really do not want my patient to bottom out and get hypotensive because I administered a medication that was ordered, but not safe to give. I could prevent problems from happening if I know what to be on alert for and act accordingly. So ultimately knowing that in the clinical setting, I can prevent complications from happening and I save myself, my license, and promote patient safety. I think knowing that I've seen the importance of critical thinking already in practice has helped me value and understand why I should be critically thinking. Yes, we use the 5-rights of medication safety – but we also have to think. For instance, if I am going to administer insulin – what do I need to know or do to give this safely? What is the current blood sugar? Has the patient been eating? When is the next meal scheduled? Is the patient NPO for a procedure? Those are examples of questions to consider and the level of thinking that needs to take place prior to taking actions in the clinical setting.

Although the results of quantitative data showed no significant difference in scores on the KCTIT between the participant and nonparticipant groups, during the interviews some participants attributed this result to the test not being part of a course grade and believed students “did not try very hard to score well.” However, the participants who attended interviews did identify the skills fair intervention as a developmental strategy for critical thinking by helping them develop alternative thinking and thinking before doing. The findings are supported in the literature as (1) nurses must recognize signs of clinical deterioration and take action promptly to prevent potential complications ( Garvey and CNE series 2015 ) and (2) nurses must analyze pertinent data and consider all possible solutions before deciding on the most appropriate action for each patient ( Papathanasiou et al. , 2014 ).

The skills fair intervention also enhanced the development of self-confidence by participants practicing previously learned skills in a controlled, safe environment. The nonthreatening environment of the skills fair intervention allowed students to learn without fear and the majority of participants believed their critical thinking was strengthened after participating. The interview data also revealed a combination of internal and external factors that influenced the development of critical thinking during the skills fair intervention including confidence and anxiety levels, attitude, age, experience and practice, faculty involvement, positive learning environment and faculty prompts. These factors should be considered when addressing the promotion and development of critical thinking.

Conclusions, limitations and recommendations

A major concern in the nursing profession is the lack of critical thinking in student nurses and new graduates, which influences the decision-making of novice nurses and directly affects patient care and safety ( Saintsing et al. , 2011 ). Nurse educators must use evidence-based practice to prepare students to critically think with the complicated and constantly evolving environment of health care today ( Goodare, 2015 ; Newton and Moore, 2013 ). Evidence-based practice has been advocated to promote critical thinking ( Profetto-McGrath, 2005 ; Stanley and Dougherty, 2010 ). The skills fair intervention can be one type of evidence-based practice used to promote critical thinking ( McCausland and Meyers, 2013 ; Roberts et al. , 2009 ). The Intervention used in this study incorporated evidence-based practice rationale with critical thinking prompts using Socratic questioning, evidence-based practice videos to the psychomotor skill rubrics, group work, guided discussions, expert demonstration followed by guided practice and blended learning in an attempt to promote and develop critical thinking in nursing students.

The explanatory sequential mixed-methods design was employed to investigate the effects of the innovative skills fair intervention on senior baccalaureate nursing students' achievements and their perceptions of critical thinking skills development. Although the quantitative results showed no significant difference in scores on the KCTIT between students who participated in the skills fair intervention and those who did not, those who attended the interviews perceived their critical thinking was reinforced after the skills fair intervention and believed it was an effective developmental strategy for critical thinking, as it developed alternative thinking and thinking before doing. This information is useful for nurse educators who plan their own teaching practice to promote critical thinking and improve patient outcomes. The findings also provide schools and educators information that helps review their current approach in educating nursing students. As evidenced in the findings, the importance of developing critical thinking skills is crucial for becoming a safe, professional nurse. Internal and external factors impacting the development of critical thinking during the skills fair intervention were identified including confidence and anxiety levels, attitude, age, experience and practice, faculty involvement, positive learning environment and faculty prompts. These factors should be considered when addressing the promotion and development of critical thinking.

There were several limitations to this study. One of the major limitations of the study was the limited exposure of students' time of access to the skills fair intervention, as it was a one-day learning intervention. Another limitation was the sample selection and size. The skills fair intervention was limited to only one baccalaureate nursing program in one southeastern state. As such, the findings of the study cannot be generalized as it may not be representative of baccalaureate nursing programs in general. In addition, this study did not consider students' critical thinking achievements prior to the skills fair intervention. Therefore, no baseline measurement of critical thinking was available for a before and after comparison. Other factors in the nursing program could have affected the students' scores on the KCTIT, such as anxiety or motivation that was not taken into account in this study.

The recommendations for future research are to expand the topic by including other regions, larger samples and other baccalaureate nursing programs. In addition, future research should consider other participant perceptions, such as nurse educators, to better understand the development and growth of critical thinking skills among nursing students. Finally, based on participant perceptions, future research should include a more rigorous skills fair intervention to develop critical thinking and explore the link between confidence and critical thinking in nursing students.

Initial coding results

Factors impacting critical thinking skill development during skills fair intervention

Skills fair intervention as a developmental strategy for critical thinking

American Nephrology Nurses Association (ANNA) ( 2019 ), “ Learning, leading, connecting, and playing at the intersection of nephrology and nursing-2019–2020 strategic plan ”, viewed 3 Aug 2019, available at: https://www.annanurse.org/download/reference/association/strategicPlan.pdf .

Arli , S.D. , Bakan , A.B. , Ozturk , S. , Erisik , E. and Yildirim , Z. ( 2017 ), “ Critical thinking and caring in nursing students ”, International Journal of Caring Sciences , Vol. 10 No. 1 , pp. 471 - 478 .

Benner , P. , Sutphen , M. , Leonard , V. and Day , L. ( 2010 ), Educating Nurses: A Call for Radical Transformation , Jossey-Bass , San Francisco .

Brunt , B. ( 2005 ), “ Critical thinking in nursing: an integrated review ”, The Journal of Continuing Education in Nursing , Vol. 36 No. 2 , pp. 60 - 67 .

Chun-Chih , L. , Chin-Yen , H. , I-Ju , P. and Li-Chin , C. ( 2015 ), “ The teaching-learning approach and critical thinking development: a qualitative exploration of Taiwanese nursing students ”, Journal of Professional Nursing , Vol. 31 No. 2 , pp. 149 - 157 , doi: 10.1016/j.profnurs.2014.07.001 .

Clarke , L.W. and Whitney , E. ( 2009 ), “ Walking in their shoes: using multiple-perspectives texts as a bridge to critical literacy ”, The Reading Teacher , Vol. 62 No. 6 , pp. 530 - 534 , doi: 10.1598/RT.62.6.7 .

Dykstra , D. ( 2008 ), “ Integrating critical thinking and memorandum writing into course curriculum using the internet as a research tool ”, College Student Journal , Vol. 42 No. 3 , pp. 920 - 929 , doi: 10.1007/s10551-010-0477-2 .

Ebright , P. , Urden , L. , Patterson , E. and Chalko , B. ( 2004 ), “ Themes surrounding novice nurse near-miss and adverse-event situations ”, The Journal of Nursing Administration: The Journal of Nursing Administration , Vol. 34 , pp. 531 - 538 , doi: 10.1097/00005110-200411000-00010 .

Ennis , R. ( 2011 ), “ The nature of critical thinking: an outline of critical thinking dispositions and abilities ”, viewed 3 May 2017, available at: https://education.illinois.edu/docs/default-source/faculty-documents/robert-ennis/thenatureofcriticalthinking_51711_000.pdf .

Facione , P.A. ( 1990 ), Critical Thinking: A Statement of Expert Consensus for Purposes of Educational Assessment and Instruction , The California Academic Press , Millbrae .

Facione , N.C. and Facione , P.A. ( 2013 ), The Health Sciences Reasoning Test: Test Manual , The California Academic Press , Millbrae .

Fero , L.J. , Witsberger , C.M. , Wesmiller , S.W. , Zullo , T.G. and Hoffman , L.A. ( 2009 ), “ Critical thinking ability of new graduate and experienced nurses ”, Journal of Advanced Nursing , Vol. 65 No. 1 , pp. 139 - 148 , doi: 10.1111/j.1365-2648.2008.04834.x .

Garvey , P.K. and CNE series ( 2015 ), “ Failure to rescue: the nurse's impact ”, Medsurg Nursing , Vol. 24 No. 3 , pp. 145 - 149 .

Goodare , P. ( 2015 ), “ Literature review: ‘are you ok there?’ The socialization of student and graduate nurses: do we have it right? ”, Australian Journal of Advanced Nursing , Vol. 33 No. 1 , pp. 38 - 43 .

Graneheim , U.H. and Lundman , B. ( 2014 ), “ Qualitative content analysis in nursing research: concepts, procedures, and measures to achieve trustworthiness ”, Nurse Education Today , Vol. 24 No. 2 , pp. 105 - 12 , doi: 10.1016/j.nedt.2003.10.001 .

Hsu , L. and Hsieh , S. ( 2013 ), “ Factors affecting metacognition of undergraduate nursing students in a blended learning environment ”, International Journal of Nursing Practice , Vol. 20 No. 3 , pp. 233 - 241 , doi: 10.1111/ijn.12131 .

Ignatavicius , D. ( 2001 ), “ Six critical thinking skills for at-the-bedside success ”, Dimensions of Critical Care Nursing , Vol. 20 No. 2 , pp. 30 - 33 .

Institute of Medicine ( 2001 ), Crossing the Quality Chasm: A New Health System for the 21st Century , National Academy Press , Washington .

James , J. ( 2013 ), “ A new, evidence-based estimate of patient harms associated with hospital care ”, Journal of Patient Safety , Vol. 9 No. 3 , pp. 122 - 128 , doi: 10.1097/PTS.0b013e3182948a69 .

Jones , J.H. ( 2010 ), “ Developing critical thinking in the perioperative environment ”, AORN Journal , Vol. 91 No. 2 , pp. 248 - 256 , doi: 10.1016/j.aorn.2009.09.025 .

Kaplan Nursing ( 2012 ), Kaplan Nursing Integrated Testing Program Faculty Manual , Kaplan Nursing , New York, NY .

Kim , J.S. , Gu , M.O. and Chang , H.K. ( 2019 ), “ Effects of an evidence-based practice education program using multifaceted interventions: a quasi-experimental study with undergraduate nursing students ”, BMC Medical Education , Vol. 19 , doi: 10.1186/s12909-019-1501-6 .

Longton , S. ( 2014 ), “ Utilizing evidence-based practice for patient safety ”, Nephrology Nursing Journal , Vol. 41 No. 4 , pp. 343 - 344 .

McCausland , L.L. and Meyers , C.C. ( 2013 ), “ An interactive skills fair to prepare undergraduate nursing students for clinical experience ”, Nursing Education Perspectives , Vol. 34 No. 6 , pp. 419 - 420 , doi: 10.5480/1536-5026-34.6.419 .

McMullen , M.A. and McMullen , W.F. ( 2009 ), “ Examining patterns of change in the critical thinking skills of graduate nursing students ”, Journal of Nursing Education , Vol. 48 No. 6 , pp. 310 - 318 , doi: 10.3928/01484834-20090515-03 .

Moore , Z.E. ( 2007 ), “ Critical thinking and the evidence-based practice of sport psychology ”, Journal of Clinical Sport Psychology , Vol. 1 , pp. 9 - 22 , doi: 10.1123/jcsp.1.1.9 .

Nadelson , S. and Nadelson , L.S. ( 2014 ), “ Evidence-based practice article reviews using CASP tools: a method for teaching EBP ”, Worldviews on Evidence-Based Nursing , Vol. 11 No. 5 , pp. 344 - 346 , doi: 10.1111/wvn.12059 .

Newton , S.E. and Moore , G. ( 2013 ), “ Critical thinking skills of basic baccalaureate and accelerated second-degree nursing students ”, Nursing Education Perspectives , Vol. 34 No. 3 , pp. 154 - 158 , doi: 10.5480/1536-5026-34.3.154 .

Nibert , A. ( 2011 ), “ Nursing education and practice: bridging the gap ”, Advance Healthcare Network , viewed 3 May 2017, available at: https://www.elitecme.com/resource-center/nursing/nursing-education-practice-bridging-the-gap/ .

Oermann , M.H. , Kardong-Edgren , S. , Odom-Maryon , T. , Hallmark , B.F. , Hurd , D. , Rogers , N. and Smart , D.A. ( 2011 ), “ Deliberate practice of motor skills in nursing education: CPR as exemplar ”, Nursing Education Perspectives , Vol. 32 No. 5 , pp. 311 - 315 , doi: 10.5480/1536-5026-32.5.311 .

Papathanasiou , I.V. , Kleisiaris , C.F. , Fradelos , E.C. , Kakou , K. and Kourkouta , L. ( 2014 ), “ Critical thinking: the development of an essential skill for nursing students ”, Acta Informatica Medica , Vol. 22 No. 4 , pp. 283 - 286 , doi: 10.5455/aim.2014.22.283-286 .

Park , M.Y. , Conway , J. and McMillan , M. ( 2016 ), “ Enhancing critical thinking through simulation ”, Journal of Problem-Based Learning , Vol. 3 No. 1 , pp. 31 - 40 , doi: 10.24313/jpbl.2016.3.1.31 .

Paul , R. ( 1993 ), Critical Thinking: How to Prepare Students for a Rapidly Changing World , The Foundation for Critical Thinking , Santa Rosa .

Paul , R. and Elder , L. ( 2008 ), “ Critical thinking: the art of socratic questioning, part III ”, Journal of Developmental Education , Vol. 31 No. 3 , pp. 34 - 35 .

Paul , R. and Elder , L. ( 2012 ), Critical Thinking: Tools for Taking Charge of Your Learning and Your Life , 3rd ed. , Pearson/Prentice Hall , Boston .

Profetto-McGrath , J. ( 2005 ), “ Critical thinking and evidence-based practice ”, Journal of Professional Nursing , Vol. 21 No. 6 , pp. 364 - 371 , doi: 10.1016/j.profnurs.2005.10.002 .

Rahman , A. and Applebaum , R. ( 2011 ), “ What's all this about evidence-based practice? The roots, the controversies, and why it matters ”, American Society on Aging , viewed 3 May 2017, available at: https://www.asaging.org/blog/whats-all-about-evidence-based-practice-roots-controversies-and-why-it-matters .

Rieger , K. , Chernomas , W. , McMillan , D. , Morin , F. and Demczuk , L. ( 2015 ), “ The effectiveness and experience of arts‐based pedagogy among undergraduate nursing students: a comprehensive systematic review protocol ”, JBI Database of Systematic Reviews and Implementation Reports , Vol. 13 No. 2 , pp. 101 - 124 , doi: 10.11124/jbisrir-2015-1891 .

Robert , R.R. and Petersen , S. ( 2013 ), “ Critical thinking at the bedside: providing safe passage to patients ”, Medsurg Nursing , Vol. 22 No. 2 , pp. 85 - 118 .

Roberts , S.T. , Vignato , J.A. , Moore , J.L. and Madden , C.A. ( 2009 ), “ Promoting skill building and confidence in freshman nursing students with a skills-a-thon ”, Educational Innovations , Vol. 48 No. 8 , pp. 460 - 464 , doi: 10.3928/01484834-20090518-05 .

Romeo , E. ( 2010 ), “ Quantitative research on critical thinking and predicting nursing students' NCLEX-RN performance ”, Journal of Nursing Education , Vol. 49 No. 7 , pp. 378 - 386 , doi: 10.3928/01484834-20100331-05 .

Sackett , D. , Rosenberg , W. , Gray , J. , Haynes , R. and Richardson , W. ( 1996 ), “ Evidence-based medicine: what it is and what it isn't ”, British Medical Journal , Vol. 312 No. 7023 , pp. 71 - 72 , doi: 10.1136/bmj.312.7023.71 .

Saintsing , D. , Gibson , L.M. and Pennington , A.W. ( 2011 ), “ The novice nurse and clinical decision-making: how to avoid errors ”, Journal of Nursing Management , Vol. 19 No. 3 , pp. 354 - 359 .

Saldana , J. ( 2009 ), The Coding Manual for Qualitative Researchers , Sage , Los Angeles .

Scheffer , B. and Rubenfeld , M. ( 2000 ), “ A consensus statement on critical thinking in nursing ”, Journal of Nursing Education , Vol. 39 No. 8 , pp. 352 - 359 .

Stanley , M.C. and Dougherty , J.P. ( 2010 ), “ Nursing education model. A paradigm shift in nursing education: a new model ”, Nursing Education Perspectives , Vol. 31 No. 6 , pp. 378 - 380 , doi: 10.1043/1536-5026-31.6.378 .

Swing , V.K. ( 2014 ), “ Early identification of transformation in the proficiency level of critical thinking skills (CTS) for the first-semester associate degree nursing (ADN) student ”, doctoral thesis , Capella University , Minneapolis , viewed 3 May 2017, ProQuest Dissertations & Theses database .

Turner , P. ( 2005 ), “ Critical thinking in nursing education and practice as defined in the literature ”, Nursing Education Perspectives , Vol. 26 No. 5 , pp. 272 - 277 .

Twibell , R. , St Pierre , J. , Johnson , D. , Barton , D. , Davis , C. and Kidd , M. ( 2012 ), “ Tripping over the welcome mat: why new nurses don't stay and what the evidence says we can do about it ”, American Nurse Today , Vol. 7 No. 6 , pp. 1 - 10 .

Watson , G. and Glaser , E.M. ( 1980 ), Watson Glaser Critical Thinking Appraisal , Psychological Corporation , San Antonio .

Wittmann-Price , R.A. ( 2013 ), “ Facilitating learning in the classroom setting ”, in Wittmann-Price , R.A. , Godshall , M. and Wilson , L. (Eds), Certified Nurse Educator (CNE) Review Manual , Springer Publishing , New York, NY , pp. 19 - 70 .

Corresponding author

Related articles, all feedback is valuable.

Please share your general feedback

Report an issue or find answers to frequently asked questions

Contact Customer Support

Emerging Nurse Leader

A leadership development blog

Promoting Critical Thinking Skills in Nursing

May 5, 2014 by rose

By Rose O. Sherman, EdD, RN, FAAN

“ The important thing is to not stop questioning.  Curiosity has its own reason for existing.”   Albert Einstein

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?

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.

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?

With the focus today on evidence-based practice, nurse leaders need to promote a culture of 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.

– See more at: https://emergingrnleader.com/nurseleaderdevelopment/#sthash.RiUgAZS7.dpuf

Read to Lead

Critical Thinking and Nursing.  The Critical Thinking Website

Critical Thinking – A Definition.  Critical Thinking. Net Website

Fastest Nurse Insight Engine

• MEDICAL ASSISSTANT
• Abdominal Key
• Anesthesia Key
• Basicmedical Key
• Otolaryngology & Ophthalmology
• Musculoskeletal Key
• Obstetric, Gynecology and Pediatric
• Oncology & Hematology
• Plastic Surgery & Dermatology
• Clinical Dentistry
• Radiology Key
• Thoracic Key
• Veterinary Medicine
• Gold Membership

Strategies to promote critical thinking and active learning

15 Strategies to promote critical thinking and active learning Connie J. Rowles, DSN, RN Nursing faculty spend a considerable amount of their time planning experiences to facilitate student learning. The selection of teaching strategies and learning experiences traditionally has been governed by behavioral objectives. However, nursing education has been undergoing a major revolution, with attention focused on how to teach students to think critically. Therefore nurse educators are continually reexamining the “best” way to teach and to empower students for learning. The purpose of this chapter is to identify strategies that students and faculty can use to promote learning. The chapter begins with a discussion of critical thinking as the basis for any teaching strategy. Developing effective learning experiences comes next. A variety of teaching strategies are then presented with a discussion of their use, advantages, disadvantages, and tips for making the learning experience interactive and meaningful. Critical thinking and active learning Thinking, reflective thinking, and critical thinking have been topics of discussion among educators for many years ( Bandman & Bandman, 1995; Brookfield , 1987, 1995; Dewey , 1933; Facione , 1990; Halpern et al., 1994; Hunkins , 1985; Kurfiss , 1988; McPeck , 1981; Norris & Ennis, 1989; Paul , 1995; Perry , 1970; Siegel , 1980; Watson & Glaser, 1984). A recent search in the Cumulative Index to Nursing and Allied Health (CINAHL) located 58 articles about critical thinking even when the search was limited to full-length articles in English in the time frame of July 2009 through July 2010. One excellent source from the search is Romeo (2010). She reviewed the critical thinking literature and found issues related to the definition of critical thinking as well as issues in the use of instruments to measure critical thinking. She also cited the lack of findings that show a clear-cut correlation with factors that interest nurse educators, such as licensing exam pass rates and changes in critical thinking over time in the program. So, while there is still a lot in the literature about critical thinking, there are some who recommend a change in the dialogue about thinking in nursing. A brief discussion of some of the newer terms found in the literature follows. A common thread with the newer ideas is that they all build on a foundation of critical thinking. Clinical reasoning Clinical reasoning is the ability of the nurse to use critical thinking skills in the ever-changing clinical environment. It should include the “. . . context and concerns of the patient and family” ( Benner , Sutphen, Leonard, & Day, 2010, p. 85). Clinical imagination and reflection are also part of clinical reasoning ( Benner et al., 2010). The thought is that critical thinking is more a snapshot in time while clinical reasoning can accommodate the changing nature in clinical settings. Clinical judgment Clinical judgment can be defined as “an interpretation or conclusion about a patient’s needs, concerns, or health problems, and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patient’s response” ( Tanner , 2006, p. 204). Tanner acknowledges that problem solving, critical thinking, decision making, and clinical judgment are often used in the literature to mean the same thing. Metacognition Metacognition is the “self-communication process in which a person engages before, during and after performing a task” ( Beitz , 1996, p. 23) and more commonly thought of as thinking about thinking. It is an active process of monitoring your own thinking. Kuiper and Pesut (2004) contend that it is the combination of metacognition (reflective thinking) and critical thinking that better describes the thinking necessary in nursing. Clinical reasoning, clinical judgment, and metacognition are all important in nursing. However, the basis of all of these is critical thinking. This chapter focuses on critical thinking, the ideal critical thinker, and the related cognitive skills. The ideal critical thinker defined Most experts agree that if an individual is a critical thinker, he or she not only has well-developed critical thinking skills but also exhibits what are variously described as the disposition, attitude, or traits of a critical thinker ( Baron & Sternberg, 1986; Facione , Facione, & Sanchez, 1994; Ford & Profetto-McGrath, 1994; Kataoka-Yahiro & Saylor, 1994; Paul , 1995; Pless & Clayton, 1993; Turner , 2005; Watson & Glaser, 1984). This chapter uses Facione’s (1990) definition of an ideal critical thinker. This description was derived by a consensus of experts in critical thinking who participated in a Delphi study. The panel of experts included “46 scholars, educators and leading figures in critical thinking theory and critical thinking assessment research” (p. 34). The experts essentially agreed that The ideal critical thinker is habitually inquisitive, well-informed, trustful of reason, open-minded, flexible, fair-minded in evaluation, honest in facing personal biases, prudent in making judgments, willing to reconsider, clear about issues, orderly in complex matters, diligent in seeking relevant information, reasonable in the selection of criteria, focused in inquiry, and persistent in seeking results which are as precise as the subject and the circumstances of inquiry permit. (p. 3) Facione et al. (1994) suggest that the Delphi study description of an ideal critical thinker describes a nurse with ideal clinical judgment. Cognitive skills (subskills) of critical thinking were also delineated in Facione’s (1990) Delphi study. These include the cognitive skills and subskills of analysis (examining ideas, identifying arguments, analyzing arguments), evaluation (assessing claims, assessing arguments), inference (querying evidence, conjecturing alternatives, drawing conclusions), interpretation (categorizing, decoding significance, clarifying meaning), explanation (stating results, justifying procedures, presenting arguments), and self-regulation (self-examination and self-correction) ( Facione , 1990). Critical thinking in nursing and nursing education Nurses need a high level of critical thinking skills and a critical thinking disposition because nurses encounter multiple patients with the same health care needs. However, each patient responds to those needs differently. Therefore nurses are required to use their holistic nursing knowledge base to think through each situation to provide individualized, effective (evidence-based) care rather than simply to follow routine procedures. Jones and Brown (1993) believe that nursing is practiced in complex environments with humans, who are complex beings. Technological advances and a knowledge explosion have also changed the face of health care. Thinking skills of the nurse become more important than the ability to perform the associated psychomotor skills. Case (1994) discussed the changing arenas for decision making as being not only at the bedside but also in quality assurance processes, delegation activities, shared governance, and management and executive roles. As health care reform extends patient care from the predominantly structured inpatient arena to the more unstructured outpatient or community arenas, critical thinking skills and empowerment become even more important. Carlson-Catalano (1992), in discussing empowering nurses, believed that traditional curricula encourage students to be obedient, dependent, and fearful in caring for patients. She suggests that nurses in professional practice should be empowered and that students need to be treated as valued members of the profession. She offers analytic nursing, change activities, collegiality, and sponsorship as strategies for empowering nurses. These strategies would be addressed if nursing faculty adopted the principles of critical thinking as the foundation for practice. Students must develop higher-order thinking skills. Brigham (1993) contends that faculty need to assist students to recognize how systems respond to specific health problems. Students need to know what nursing measures will be needed when they read laboratory reports with abnormal results; they do not need to memorize normal laboratory values. Jones and Brown (1991) argue that nurse educators can no longer convey facts to nursing students. “There are far too many facts, but there are far too many facts that become erroneous over time” ( Jones & Brown, 1991, p. 533). Miller (1992) concurs: More emphasis should be given to the mental processes students engage in as they solve nursing problems and less given to simply identifying the correct answer. Focusing on making clinical inferences from given data, recognizing unstated assumptions, deductive reasoning, weighing of evidence and distinguishing between weak and strong arguments emphasizes the importance of the processes of thinking. (p. 1406) Scheffer and Rubenfeld (2000) conducted a Delphi study to develop a consensus statement about critical thinking in nursing education. A panel of 55 experts from 9 countries determined that Critical thinking in nursing is an essential component of professional accountability and quality nursing care. Critical thinkers in nursing exhibit these habits of the mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection. Critical thinkers in nursing practice [possess] the cognitive skills of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting and transforming knowledge. (p. 357) In summary, Jackson (1995) states, “Every patient deserves caregivers who think critically . . . . The ability to think critically can be empowering. Practitioners must commit to a struggle of balancing an explosion of objective and intuitive information in an explosive health care environment” (p. 187). Therefore nurse educators are challenged to help students develop necessary critical thinking skills as the students progress through the curriculum. Roles of faculty and students in developing critical thinking skills The development of students’ critical thinking skills and dispositions requires faculty to reconsider their philosophy of teaching. The faculty-dominated classroom is not conducive to development of critical thinking. It is the responsibility of faculty to think about the roles of the teacher and student, as well as to create an environment that empowers students. Transmitting information through rote lecture to students does not guarantee learning. Students must be actively engaged with the information for it to be transformed into knowledge. Lesson plans must be designed to foster the development of critical thinking skills (cognitive) and a critical thinking disposition (affective) as students engage with the theoretical, affective, and psychomotor content that is nursing. Students must become empathetic, empowered, and able to critically think about every situation if they are to succeed in nursing ( Bevis , 1993; Ford & Profetto-McGrath, 1994). Faculty roles Faculty must become facilitators of learning rather than teachers of content ( Bevis , 1993; Brigham , 1993; Brookfield , 1995; Creedy , Horsfall, & Hand, 1992; Jones & Brown , 1993). Ford and Profetto-McGrath (1994) believe that the teacher–student relationship must become a “working with” relationship—an egalitarian relationship. Burns and Egan (1994) suggest that faculty should demonstrate critical thinking as content is presented. For example, when teaching content such as medical acidosis and alkalosis, faculty could demonstrate their own problem-solving skills by thinking aloud as they discuss a relevant case study. Students should think aloud while interacting with the content so that faculty can identify inappropriate thinking processes and provide immediate constructive feedback. Creedy et al. (1992) propose that faculty can empower students by valuing their contributions, encouraging expression of their opinions, exploring mistakes objectively without demeaning the students, and promoting risk taking. Brookfield (1987) cites the following principles that will facilitate students to think critically: •  Affirm the critical thinkers’ self-worth ( p. 72 ). •  Listen attentively to critical thinkers ( p. 73 ). •  Show that you support critical thinkers’ efforts ( p. 74 ). •  Reflect and mirror critical thinkers’ ideas and actions ( p. 75 ). •  Motivate people to think critically ( p. 76 ). •  Regularly evaluate progress ( p. 78 ). •  Help critical thinkers create networks ( p. 79 ). •  Be critical teachers ( p. 80 ). •  Model critical thinking ( p. 85 ). Thus according to Brookfield (1987), the facilitator of learning must enter into an egalitarian relationship to support the learners’ attempts to engage in critical thinking. Faculty can only provide learning experiences for students; faculty cannot teach (impart knowledge); they can only share their knowledge. Students must transform the content into their own knowledge. Student roles Learning to think critically requires active student participation ( Meyers , 1986); students must become active creators of their own knowledge ( Creedy et al., 1992). At this time, it can be assumed most students have come from faculty-dominated classrooms in which the students have been the recipients of endless amounts of facts to be memorized and recalled for examinations ( Valiga , 1983). Students have probably not been asked to apply those facts to real-life situations. Therefore students will have to be assisted with the transition from the passive to active learner role. Faculty need to create a risk-free environment that is conducive to active student participation. The discussion later in this chapter related to creation of an anticipatory set serves as an example of helping students to make the transition from passive to active learners. Repeated encounters with active learning situations are needed before students can become comfortable with the active learner role. Active learners must come to class prepared. They cannot rely on the faculty to tell them what they need to know. “Preclass written assignments, study guides, quizzes and short in-class writings” ( Brigham , 1993, p. 52) are effective in stimulating students to come to class prepared to engage with the content while interacting with faculty and fellow students in planned learning activities. Classroom environment for the development of critical thinking skills The classroom environment changes when the principles of critical thinking are adopted. Active learning can be a very threatening situation. Faculty must create a risk-free environment that allows students to explore the content, make mistakes, reflect on the content, associate the content with experience, and transform the content into knowledge ( McCabe , 1992). Brigham (1993) suggests that faculty set the stage by sharing that their philosophy of teaching is to enhance critical thinking. This should be done when students are being introduced to the course. Students need to know that learning experiences have been designed for them to actively engage with the information and with each other while faculty facilitate the activities and learning process. Students must understand that, through the interactions, information will be converted into knowledge ( Bevis , 1993). Classroom environments should establish a sense of connection between faculty and students and among students themselves. Students should understand that neither faculty nor students have all of the answers and that no one answer is correct in all situations. Open discussion and student willingness to take risks should be supported while faculty guide the group toward the preestablished learning outcome. Students need to be aware that there are conflicting ideas about some concepts. Faculty at some schools of nursing do not adopt a specific textbook for their courses; rather, the bookstore stocks appropriate textbooks by different authors and students select the textbook they would like to use. This particular idea is intriguing because it certainly provides a basis for discussion of information from multiple points of view. When contradictions are found, it helps students recognize that the written word should be questioned. The physical component of the classroom is important; however, any classroom can be conducive to active student learning. Students should be able to make eye contact with each other and with faculty. MacIntosh (1995) suggests rearranging chairs into small or large circles. Faculty can be creative in modifying the physical characteristics of the classroom. For example, in classrooms where desks are bolted down, students could sit on the tops of the desks to be able to face others in the group. Student responses to active learning Beck (1995) conducted a study using a cooperative learning model based on feminist pedagogy that resulted in positive teacher–student and student–student interactions and satisfactory learning. Hezekiah (1993) cites the five basic feminist goals for the classroom—“atmosphere of mutual respect, trust and community, shared leadership, cooperative structure, integration of cognitive and affective learning, and action oriented field work” (pp. 55–56)—that would establish an environment for the development of critical thinking skills as the learner transforms information to knowledge. Wake , Coleman, and Kneeland (1992) discuss shared governance in the classroom. They note that shared governance in nursing education produces professional nurses who will be prepared to practice in an ever-changing health care environment. Price (1991) found that “interaction between the student and teacher ranked high as a positive contributor to learning” ( p. 170 ). Price cited the following student responses to the benefits of an interactive classroom: What’s good is your understanding of conflicts we may be facing as new students, your continual encouragement, and the fact that you’re always available to answer questions . . . I don’t function well, never have, when the question is memorizing. . . . I tend to learn very abstractly and not sequentially; my learning is not textbook learning. . . . I really find that I learn the most when I can apply it to myself and to someone else; that’s the thing I can underline and say, “Yes, I learned that very well.” . . . It’s practical application, where it’s applied to life, where your pattern of behavior is changed, something you can apply in your relationship with another human being. (pp. 170–171) Summary Nurses must possess a high level of critical thinking skills and a critical thinking disposition. Faculty must create opportunities for students to develop critical thinking as they progress through the curriculum. Faculty must become facilitators of learning and students must become active learners. Critical thinking should be at the forefront of planning learning experiences for nursing students. If educators believe that “students can and should think their way through the content of their courses, . . . gain some grasp of the logic of what they study, . . . develop explicit intellectual standards, then they can find many ways to move instruction in this direction” ( Barnes , 1992, p. 22). Faculty must create an environment that develops the traits of an ideal critical thinker and plan learning experiences that include strategies to develop the cognitive skills and subskills of critical thinking. Planning learning experiences Planning challenging encounters that will entice students to learn and develop critical thinking skills is a major task for any faculty member. Effective planning of any kind requires much time and effort; planning learning experiences is no exception. Careful planning of each learning experience gives teachers more self-confidence and aids in formative and summative evaluation of teaching. At least six steps are used in designing learning experiences: 1.  Determine the learning outcomes for the specific class period. 2.  Create an anticipatory set. 3.  Select teaching and learning strategies. 4.  Consider implementation issues. 5.  Design closure to the learning experience. 6.  Design formative and summative evaluation strategies. Each of the stages is discussed in detail. All steps can be planned by both students and faculty. Novice faculty may find it helpful to design learning experiences in great detail ( Table 15-1 ), whereas more experienced faculty may use only a more general outline form. Table 15-1 Sample Plan for a Learning Experience: Ethics in Leadership 1.  Outcomes: Identify ethical theory used for own decision making. Discuss implications of use of ethical theories in the workplace. Activity Content Time Strategies 2.  Anticipatory set a.  Preclass assignment b.  In-class exercise a.  Ethical theories b.  Ethical case examples c.  Ethical situations a.  2 hr b.  10 min a.  Text reading b.  Ethical survey c.  Individual reflection to identify the most difficult question on the survey and write how and why answered 3.  Implementation tools a.  Projector b.  PowerPoint slides a.  Three ethical theories from text b.  Application (1)  Identify own theory used. (2)  Apply to familiar situation. (3)  Apply to new situation. (4)  Apply to workplace decision making. a.  40 min b.  30 min a.  Large group discussion (1)  Slides of the theories’ main points (2)  At each main point ask, “What does this mean to you?” and “Give an example of how the point would be seen in practice.” b.  Small group discussion (1)  “Which theory do you use?” (2)  “Give example of how you used the theory.” (3)  “How would a nurse administrator use the theory to make ethical decisions?” (4)  “How could use of the theories lead to conflict in the workplace?” 4.  Closure Emphasize class outcomes. 20 min a.  Small group reports b.  Overall summary Determining the learning outcomes The first step is to determine the learning outcomes of the class. Several activities must be carried out before specific outcomes for any class period are developed. The first activity is assessment of the overall curriculum outcomes and the placement of the specific course in meeting these outcomes. Typically, general curriculum outcomes are stated in very broad terms and will likely not give the teacher any information about what to include in a specific class period. However, a thorough understanding of the broad curriculum goals is necessary so teachers can “connect” the specifics for the day to the broad curriculum outcomes. Course objectives and outcomes need to be reviewed to ascertain how the particular course “fits” within the curriculum ( Ayer , 1986; Torres & Stanton, 1982). See Chapters 8 to 11 for additional information. Teachers tend to design learning experiences within their own belief and value systems. Their own philosophies about teaching, learning, the curriculum, the ability of students, and how and what a nurse educator “should” do all influence the development of activities for a specific class period. Teachers need to be aware of these value systems and recognize the influence of them on their teaching and selection of teaching strategies ( Creedy et al., 1992). With these activities in mind, outcomes for a given experience can be established. There are several ways to identify outcomes. One way is to use behavioral objectives (see Chapters 9 and 10 ). For many, however, behavioral objectives imply rigid lists of specific content, faculty-dominated classrooms, and only one right answer to each examination question. Some believe that specific behavioral objectives need to be abandoned, given the important issue of development of critical thinking abilities in students ( Bevis , 1993). In another approach, general outcomes or competencies are identified, and the path to achieving them is left open. How they are written depends on individual school requirements, the overall curriculum design, the content of the course, and the beliefs or values of the individual faculty member. Creating an anticipatory set The second major step in planning a learning experience is to create an environment that invites all students to become interested in the content and to participate in the learning process. This activity is referred to as creating an anticipatory set ( Ayer , 1986; deTornyay & Thompson, 1982; Maas , 1990). The activity typically takes little in-class time and merely sets the stage for active involvement in the learning process. Maas (1990) includes three elements in an anticipatory set: active participation, relevance to the students, and relevance to the class period. Preclass readings; active, thought-provoking questions; and a class exercise that emphasizes students’ prior knowledge are examples of activities that can be used as an anticipatory set. The anticipatory set prepares students for the main activity or content of the class period. Selecting a teaching strategy Selecting the particular teaching strategy is the third step in lesson planning. Faculty must consider multiple factors as they select a particular strategy. The first factor is the content itself. For example, teaching abstract concepts is probably better accomplished through mind mapping ( Rooda , 1994), whereas psychomotor skills are better taught through demonstration ( Kelly , 1992). The philosophy underlying the broad curriculum outcomes also influences the selection of teaching strategies. In a school that has adopted the principles of critical thinking, the traditional lecture would seldom be used as a strategy. Last, faculty must consider teaching strategies that are feasible. Questions to consider may include the amount of time available, room size, distance learning delivery system being used, the availability of equipment, the number of students, time and money costs for both the teacher and the student, and learning styles of the students. With these factors in mind, many different teaching strategies would be appropriate for any student group and class content. Throughout the course it is important to vary the strategies. Using the same type of anticipatory set followed by lecture and then the same closure can be very boring for students. For example, faculty may create interest for the students by using lecture some of the time and role play, demonstration, and reflection at other times. Varying the strategies also has the advantage of appealing to all types of learners (see Chapter 2 ). Few of the teaching strategies are equally stimulating to all types of learners. It is not particularly important that teachers use strategies that appeal to all learners in every class, but it is important for them to use strategies that appeal to all types of learners throughout the course. Questioning is a teaching strategy that should be used consistently; it can even be used in every class ( Paul , 1995). “Helping students to ask their own questions should perfect their ability to think critically about information and how to process it” ( Hunkins , 1985, p. 296). Strategies that appeal to one type of learner can also be used for the preclass assignments or activities, and strategies for other types of learners can be used for the classroom experience. Teaching strategies and critical thinking The actual steps in designing learning experiences do not change when critical thinking concepts are applied to the curriculum. Teaching strategies should be selected for the development of critical thinking skills. Development of these skills in students should be a planned activity throughout all stages of the curriculum. Any strategy selected should be selected for a particular reason, and all strategies should lead to the development of advancing levels of critical thinking. Cognitive levels Cognitive levels must be considered during lesson planning. Several theorists have written about the various cognitive levels of students. Perry (1970) identifies four levels including nine stages of intellectual development. Belenky , Clinchy, Goldberger, and Tarule (1986) have demonstrated that women and men differ in intellectual development in several major areas. One example is that women typically have a silent stage of cognitive development, which is the first level. This stage is characterized by a powerless, dependent fear of authority figures. Men typically do not go through the silent stage. Hickman (1993) examined the theories of Perry (1970), Belenky et al. (1986), and others and integrated their thinking on cognitive levels with Benner’s (1984) levels of skill acquisition. Hickman’s (1993) thoughts are related directly to the licensed nurse, but her ideas can also be applied to the undergraduate nursing student. The beginning nursing student is a novice in critical thinking. Thinking is characterized as dualistic (everything is black or white). Little or no critical thinking is used. The novice depends on authority for knowledge and is usually silent. The next cognitive level is the advanced beginner. In this stage, thinking at the multiplicity level occurs. Students use subjective knowledge to begin seeing recurring themes, but they fail to differentiate important cues. Students at this level require assistance in establishing priorities. The next stage is the competent student nurse. At this stage, students continue to use subjective knowledge, but they do so consciously and they use the subjective knowledge in deliberate planning activities. The last cognitive level is the proficient student nurse, who is at the relativistic level of intellectual development. Relativism is the recognition that opinions differ in quality and require supporting evidence to be valid. Relativism is equated with procedural knowledge, connected knowledge, or both. Students no longer see information as only black and white; they begin to see how things “fit” together and notice where information is missing. They begin to think critically. It would be hoped that students completing a basic nursing education program would have attained the relativism level of cognitive development. Most undergraduate students will not have attained the final level, which is commitment in relativism. Commitment in relativism describes the expert nurse who integrates knowledge with experience and uses personal reflection to derive constructed knowledge ( Hickman , 1993). Many graduate students will have already moved to this level. Undergraduate nursing students will likely move to the final level of cognitive development after they are licensed and have many more real-life nursing experiences and the time to reflect on and integrate those experiences. The cognitive level of students must be addressed when learning experiences are designed. Moving students from the cognitive level of dualism to the level of relativism should be a major goal of nursing education. The level of cognitive development also influences the selection of teaching strategies. Bowers and McCarthy (1993) suggest that students who exhibit thinking at the informed commitment (relativistic) level would probably feel frustrated if they were expected to think at a dualistic level. For example, proficient student nurses would rather discuss implications of abnormal blood gas values (relativistic thinking) than respond to questions about normal findings (dualistic thinking). Implementation issues The fourth stage of lesson planning is implementation of the learning experience. In this stage, two major activities are considered. The first is the timing. How much time will be spent on the strategies selected to develop the anticipatory set? What backup plans are made to account for a lesson that takes much less or more time than anticipated? What can be cut or what can be added? What are the most crucial concepts to be covered if time is short? The sample plan (see Table 15-1 ) contains estimated times, with more detail included in a more extensive version of the plan. The second activity in this stage is to plan for the tools needed to implement the class. In this case, tools can refer to many things. Tools can be instructional media and equipment such as a projector, computer, or video information system (see Table 15-1 ). Tools can also refer to the information technology tools used to establish the learning community, such as computer conferencing or video conferencing. Plan to check the equipment for correct working order. Nothing can ruin a well-planned learning experience quite as effectively as instructional media that do not work! Tools could also be the classroom itself. How should the chairs be arranged? Do you want to use a podium? Does the screen for the projector or computer work? The last set of tools is the paper products. What handouts does the faculty member need? How much lead time is needed for typing and copying the handouts? Are the computer slides or transparencies ready? Are there items that need to have copyrights cleared? Who does that and how much time does it take? Assessing and planning for the amount of time and the tools necessary for implementation of the teaching strategy are activities that should not be left to the last minute. Designing closure The last step in designing the learning experience is planning for closure. Closure may be as simple as a few sentences that summarize the major concepts. In this case, the time allowed for closure would be very short. However, closure can take a large amount of class time, especially when dealing with sensitive or emotional content. Applying major concepts to similar or new areas of interest is another example of a closure technique ( deTornyay & Thompson, 1987). This time may also be used to create the anticipatory set for the next class period by discussing how the content of the class relates to the content of the next class period. Designing formative and summative evaluation strategies During the lesson planning phase, both formative and summative evaluation need to be considered ( Ayer , 1986). Chapter 16 contains information about classroom assessment, and Chapters 24 to 26 contain information about assessment of learning outcomes. These chapters should assist in this stage of planning. Evaluation activities should occur throughout the learning experience. Many formative evaluation techniques are available (see Chapter 16 ). Frequent formative evaluation is important for assessment of students’ understanding of content. Varying the types of formative evaluation used is important. For example, sometimes the objectives can be evaluated and at other times the teaching strategy used can be evaluated. Frequent self-evaluation is critical. Faculty should ask whether the time, tools, strategy, and content were organized and planned effectively and what could have been done differently to enhance student learning. Summary Designing effective learning experiences involves at least six distinct stages. A well-designed experience that enhances student learning cannot be done in a haphazard manner or at the last minute. Enhanced student learning and the development of critical thinking skills are the outcomes of well-planned learning experiences. Teaching strategies There are many different teaching strategies. Those with the most application to nursing education are presented throughout the rest of the chapter. Each strategy is described with its advantages and disadvantages, teaching tips, and additional references where the reader may find a more detailed description of the strategy. Simulation is a teaching strategy that is growing in use in nursing education; it is discussed in detail in Chapter 20 . Other teaching strategies may be more appropriate for the online learning environment. A detailed discussion can be found in Chapter 23 . Any discussion about teaching strategies would be incomplete without a review of learning resources, including instructional media or distance education delivery systems. These are discussed in Chapters 19 to 23 . The lecture is presented first, because this teaching strategy is frequently used by many teachers. Many other strategies can be used in nursing education. These strategies are alphabetized for ease of location. Each strategy discussed may have its place in a course, but its use depends on the content, the teacher, and the learners. Most of the strategies described after the lecture involve active learner participation in the learning process and emphasize adult learning and critical thinking concepts. Both teachers and students may resist this type of learning because the strategies are more flexible and less teacher centered than those typically used in the traditional college classroom. However, if one accepts that the learner must actively engage with the content or information to transform it into knowledge, the classroom should become student centered. Thus the traditional lecture may not always be the most appropriate strategy. Lecture Definition. Teacher presentation of content to students, usually accompanied by some type of visual aid or handout. Use. Clarify complex, confusing, or conflicting concepts; provide background information not available to students; change of pace from more experiential learning strategies; cover background information from scattered sources. Teaching Tips. 1.  Increased student participation can be achieved if the format of the feedback lecture is used ( Fuszard , 1995). For example, in a feedback lecture of 1 hour, a 6- to 10-minute group discussion period is inserted between two 20-minute lecture times. 2.  Use visual aids, handouts, and study guides so students can follow the sequence of the lecture. 3.  Students learn in various ways so add activities to the lecture that stimulate all learners. 4.  Read the article “What Is the Most Difficult Step We Must Take to Become Great Teachers?” by Nelson (2001) for some ideas on how to decrease the amount of class time devoted to lecture. Advantages. Time efficient for covering complex material; should raise further student questions that lend themselves to other teaching strategies. Disadvantages. Decreases student involvement in learning when content is readily available and easy to understand in a text or other reading assignment; lengthy preparation time for faculty; little involvement in the topic for students other than sitting through the lecture; may have a high cost in preparation and development of handouts and visual aids. Additional Reading. Amerson , 2006; Beers & Bowden, 2005; deTornyay & Thompson, 1982; Fuszard , 1995; Hoover , 1980; Johnson & Mighten, 2005; McKeachie , 1986; Nelson , 2001. Algorithms Definition. Step-by-step procedure for solving a complex procedure; breaks tasks into yes or no steps. Use. Any course in which frequent practice is required for student mastery of content, in which rules aid in problem solving, or in which the content can be broken into yes or no stages. Teaching Tips. 1.  Assess content for appropriate use of algorithm as a teaching strategy. 2.  Develop algorithm and accompanying student explanations of how to use. 3.  Allow 6 to 8 hours for the development of the first algorithms. 4.  Additional algorithms on similar content typically take less time to develop. Advantages. Shows students how to “spot” the most relevant information for problem solving; develops reliable, complex problem-solving abilities even in novice students; decreases the amount of one-on-one instruction often required when teaching problem-solving techniques; effective in teaching complex procedures that involve many steps; when used with case studies, may enhance learning; saves faculty teaching time over lecture type of presentations; saves student time in trying to remember and understand complex phenomena. Disadvantages. Teacher must clearly define the steps or students will not be able to complete the task accurately; students may need to be taught how to use algorithms in problem solving; development of algorithms can be time consuming for faculty. Additional Reading. Connor & Tillman, 1990; Rathbun & Ruth-Sahd, 2009. Argumentation, debate, structured controversy, and dilemmas Definition. The process of inquiry or reasoned judgment on a proposition aimed at demonstrating the truth or falsehood of something; involves the construction of logical arguments and oral defense of a proposition; requires the recognition of assumptions and evidence and use of inductive and deductive reasoning skills; allows identification of relationships. Teaching Tips. 1.  Strategy works best in an issues or topics course for students at a higher level of cognitive thinking. 2.  For the purpose of forming productive debate teams, it is helpful for students to know each other. 3.  Faculty should introduce the basic topics and structure the debate format early in the course to allow students adequate preparation time. 4.  Debate teams usually consist of five students: two students debate for the topic, two debate against the topic, and the fifth acts as the moderator. 5.  Debates follow a specified format, including opening comments, presentation of affirmative and negative viewpoints, rebuttal, and summary ( Fuszard , 1995). 6.  Encouraging students to debate the opposite of their personal opinion will increase student learning. Advantages. Develops analytical skills; develops ability to recognize complexities in many health care issues; broadens views of controversial topics; develops communication skills; increases student abilities to work in groups. Disadvantages. Requires a fairly high level of knowledge about the subject on the parts of both those presenting the debate and the audience; may require teaching students the art of debate; requires increased student preparation time; can create anxiety and conflict for students because of the confrontational nature of debate; students without adequate public speaking skills may also have increased anxiety; high time cost for students to work in groups. Additional Reading. Brookfield , 1992; Candela , Michael, & Mitchell, 2003; Fuszard , 1995; Garity , 2008; Garrett , Schoener, & Hood, 1996; Metcalf & Yankou, 2003; Mottola & Murphy, 2001; Pederson , 1993.

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related posts:

• The evaluation process: an overview
• Improving teaching and learning: classroom assessment techniques
• Teaching and learning in online learning communities
• Developing and using classroom tests

Stay updated, free articles. Join our Telegram channel

Comments are closed for this page.

Full access? Get Clinical Tree

• Open access
• Published: 17 June 2024

The effects of simulation-based education on undergraduate nursing students' competences: a multicenter randomized controlled trial

• Lai Kun Tong 1 ,
• Yue Yi Li 1 ,
• Mio Leng Au 1 ,
• Wai I. Ng 1 ,
• Si Chen Wang 1 ,
• Yongbing Liu 2 ,
• Yi Shen 3 ,
• Liqiang Zhong 4 &
• Xichenhui Qiu 5  

BMC Nursing volume  23 , Article number:  400 ( 2024 ) Cite this article

83 Accesses

Metrics details

Education in nursing has noticed a positive effect of simulation-based education. There are many studies available on the effects of simulation-based education, but most of those involve a single institution, nonrandomized controlled trials, small sample sizes and subjective evaluations of the effects. The purpose of this multicenter randomized controlled trial was to evaluate the effects of high-fidelity simulation, computer-based simulation, high-fidelity simulation combined with computer-based simulation, and case study on undergraduate nursing students.

A total of 270 nursing students were recruited from five universities in China. Participants were randomly divided into four groups at each institution: the high-fidelity simulation group, the computer-based simulation group, the high-fidelity simulation combined with computer-based simulation group, and the case study group. Finally, 239 participants completed the intervention and evaluation, with 58, 67, 57, and 57 participants in each group. The data were collected at three stages: before the intervention, immediately after the intervention, and three months after the intervention.

The demographic data and baseline evaluation indices did not significantly differ among the four groups. A statistically significant difference was not observed between the four methods for improving knowledge, interprofessional collaboration, critical thinking, caring, or interest in learning. While skill improvement differed significantly among the different groups after the intervention ( p  = 0.020), after three months, no difference was observed ( p  = 0.139). The improvement in skill in the computer-based simulation group was significantly lower at the end of the intervention than that in the high-fidelity simulation group ( p  = 0.048) or the high-fidelity simulation combined with computer-based simulation group ( p  = 0.020).

Conclusions

Nursing students benefit equally from four methods in cultivating their knowledge, interprofessional collaboration, critical thinking, caring, and interest in learning both immediately and over time. High-fidelity simulation and high-fidelity simulation combined with computer-based simulation improve skill more effectively than computer-based simulation in the short term. Nursing educators can select the most suitable teaching method to achieve the intended learning outcomes depending on the specific circumstances.

Trial registration

This clinical trial was registered at the Chinese Clinical Trial Registry (clinical trial number: ChiCTR2400084880, date of the registration: 27/05/2024).

Peer Review reports

Introduction

There are many challenges nursing students face in the clinical setting because of the gap between theory and practice, the lack of resources, and unfamiliarity with the medical environment [ 1 ]. Nursing education needs an innovative teaching method that is more closely related to the clinical environment. Simulation-based education is an effective teaching method for nursing students [ 2 ]. It provides students with an immersive clinical environment for practicing skills and gaining experience in a safe, controlled setting [ 3 ]. This educational approach not only supports the development of various competencies [ 2 , 4 ], including knowledge, skill, interprofessional collaboration, critical thinking, caring, and interest in learning, but also enables students to apply learned concepts to complex and challenging situations [ 5 ].

Manikin-based and computer-based simulations are commonly employed simulators in nursing education. Manikin-based simulation involves the use of a manikin to mimic a patient’s characteristics, such as heart and lung sounds [ 6 ]. Computer-based simulation involves the modeling of real-life processes solely using computers, usually with a keyboard and monitor as inputs and outputs [ 6 ]. According to a recent meta-analysis, manikin-based simulation improves nursing students' knowledge acquisition more than computer-based simulation does, but there are no significant differences in confidence or satisfaction with learning [ 4 ].

Based on the level of fidelity, manikin-based simulation can be categorized as low, medium, or high fidelity [ 7 ]. High-fidelity simulation has become increasingly popular since it replaces part of clinical placement without compromising nursing student quality [ 8 ]. Compared to other teaching methods, high-fidelity simulation is associated with elevated equipment and labor costs [ 9 ]. To enhance cost-effectiveness, it is imperative to maximize the impact of high-fidelity simulation. To improve learning outcomes, mixed learning has gained popularity across higher education in recent years [ 10 ]. The most widely used mixed learning method for simulation education in the nursing field is high-fidelity simulation combined with computer-based simulation. There have been only a few studies on the effect of high-fidelity simulation combined with computer-based simulation on nursing students, and these are either pre-post comparison studies without control groups [ 11 ] or quasi-experimental studies without randomization [ 12 ]. To obtain a better grasp of the effects of combining high-fidelity simulation and computer-based simulation, a randomized controlled trial is needed.

In addition to enhancing effectiveness, optimizing cost-effectiveness can be achieved by implementing cost reduction measures. Case study, which eliminates the need for additional equipment, offers a relatively low-cost alternative. A traditional case study provides all pertinent information, whereas an unfolding case study purposefully leaves out information [ 13 ]. It has been shown that unfolding case study fosters critical thinking in students more effectively than traditional case studies [ 14 ]. Despite being regarded as an innovative and inexpensive teaching method, there is little research comparing unfolding case study with other simulation-based teaching methods. To address this knowledge gap, further study is necessary.

An umbrella review highlights that the existing literature on the learning outcomes of simulation-based education predominantly emphasizes knowledge and skills, while conferring limited focus on other core competencies, such as interprofessional collaboration and caring [ 15 ]. Therefore, future research should evaluate various learning outcome indicators.

This multicenter randomized controlled trial aimed to assess the effectiveness of high-fidelity simulation, computer-based simulation, high-fidelity simulation combined with computer-based simulation, and case study on nursing students’ knowledge, skill, interprofessional collaboration, critical thinking, caring, and interest in learning.

Study design

A multicenter randomized controlled trial was conducted between March 2022 and May 2023 in China. The study conforms to the CONSORT guidelines. This clinical trial was registered at the Chinese Clinical Trial Registry (clinical trial number: ChiCTR2400084880, date of the registration: 27/05/2024).

Participants and setting

Participants were recruited from five universities in China, two of which were private and three of which were public. Among the five universities, four were equipped with two high-fidelity simulation laboratories. Specifically, three universities had laboratories simulating intensive care unit wards and delivery rooms, while the remaining university had two laboratories simulating general wards. Additionally, one university possessed a high-fidelity simulation laboratory specifically designed to simulate a general ward setting. Three universities utilized Laerdal patient simulators in their laboratories, while the other two universities employed Gaumard patient simulators.

A recruitment poster with the time and location of the project promotion was posted on the school bulletin board. The research team provided a briefing to students at the designated time and location indicated on the poster, affording them the opportunity to inquire about and enhance their understanding of the project.

The study mandated that participants fulfill the following criteria: 1) enroll in a nursing undergraduate program; 2) have full-time student status; 3) complete courses in Anatomy and Physiology, Pathophysiology, Pharmacology, Health Assessment, Basic Nursing, and Medical and Surgical Nursing (Respiratory System); 4) have proficiency in reading and writing Chinese; and 5) participate voluntarily. Those who met the following criteria were excluded: 1) had a degree or diploma and 2) took the course again.

The sample size was calculated through the use of G*Power 3.1, which was based on F tests (ANOVA: Repeated measures, between factors). Several assumptions were taken into consideration, including a 5% level of significance, 80% power, four groups, three measurements, and a 0.50 correlation between pre- and postintervention time points. Compared to other teaching methods, high-fidelity simulation exhibited a medium effect size (d = 0.49 for knowledge, d = 0.50 for performance) [ 16 ]. The calculation employed a conservative approach, accommodating a small yet clinically significant effect size (0.25), thereby bolstering the reliability and validity of the findings. Based on these assumptions, the total sample size required was determined to be 124, with each group requiring 31 participants.

Randomization and blinding

Due to inconsistent teaching schedules at the five universities involved in the study, the participants were divided into four groups at each institution: the high-fidelity simulation group, the computer-based simulation group, the high-fidelity simulation combined with computer-based simulation group, and the case study group. Participant grouping was carried out by study team members who were not involved in the intervention or evaluation. The participants were each assigned a random nonduplicate number between zero and 100 using Microsoft Excel. The random numbers/participants were divided into four groups based on quartiles: the lower quarter, the lower quarter to a half, the half to three-fourths, and the upper quarter were assigned to the high-fidelity simulation group, the computer-based simulation group, the high-fidelity simulation combined with computer-based simulation group, and the case study group, respectively. It was not possible to implement participant blinding because the four teaching methods differed significantly, while effect evaluation and data analysis were conducted in a blinded manner. Each participant was assigned a unique identifier to maintain anonymity throughout the study.

Baseline test

Baseline testing started after participant recruitment had ended, so the timing of the study varied between universities. The baseline test items were the same for all participants and included general characteristics, knowledge, skills, interprofessional collaboration, critical thinking, caring, and interest in learning. The evaluation of skills was conducted by trained assessors, whereas a non-face-to-face online survey was utilized for the assessment of others.

Intervention

The four groups were taught with three scenarios covering the three different cases, in the following order: asthma worsening, drug allergy, and ventricular fibrillation. These three cases represent commonly encountered scenarios necessitating emergency treatment. It is anticipated that by means of training, students can enhance their aptitude to effectively handle emergency situations within clinical settings. It is vital that the case used in simulation-based education is valid so that its effectiveness can be enhanced [ 17 ]. The cases used in this study were from vSim® for Nursing | Lippincott Nursing Education, which was developed by Wolters Kluwer Health (Lippincott), Laerdal Medical, and the National League for Nursing. Hence, the validity of the cases can be assured. Participants received all the materials, including learning outcomes, theoretical learning materials, and case materials (medical history and nursing document), at least one day before teaching. All the teachers in charge of teaching participated in the meeting to discuss the lesson plans to reach a consensus on the lesson plans. The lesson plans were written by three members of the research team and revised according to the feedback. Table 1 shows the teaching experience of each case in the different intervention groups. The instructors involved had at least five years of teaching experience and a master's degree or higher.

Posttest and follow-up test

The posttest was conducted within one week of the intervention using the same items as those used in the baseline test. The follow-up test was administered after three months of the intervention.

General characteristics

The general characteristics of the participants included gender, age, and previous semester grade.

This was measured by five multiple-choice items developed for this study. The items were derived from the National Nurse Licensing Examination [ 18 ]. The maximum score was five, with one awarded for each correct answer. The questionnaire exhibited high content validity (CVI = 1.00) and good reliability (Kuder-Richardson 20 = 0.746).

The Creighton Competency Evaluation Instrument (CCEI) is designed to assess clinical skills in a simulated environment by measuring 23 general nursing behaviors. This tool was originally developed by Todd et al. [ 19 ] and subsequently modified by Hayden et al. [ 20 ]. The Chinese version of the CCEI has good reliability (Cronbach’s α = 0.94) and validity (CVI = 0.98) [ 21 ]. The CCEI was scored by nurses with master’s degrees who were trained by the research team and blinded to the intervention information. A dedicated person was assigned to handle the rating for each university, and the raters did not rotate among the participants. The Kendall's W coefficient for the raters' measures was calculated to be 0.832, indicating a high level of interrater agreement and reliability. All participants were tested using a high-fidelity simulator, with each test lasting ten minutes. The skills test without debriefing employed a single-person format, and the nursing procedures did not rely on laboratory results, so the items "Delegates Appropriately," "Reflects on Clinical Experience," "Interprets Lab Results," and "Reflects on Potential Hazards and Errors" were excluded from the assessment. The total score ranged from 0–19 and a higher score indicated a higher level of skill.

• Interprofessional collaboration

The Assessment of the Interprofessional Team Collaboration Scale for Students (AITCS-II Student) was used to assess interprofessional collaboration. It consists of 17 items rated on a 5-point Likert scale (1 = never, 5 = always), for a total score ranging from 17 to 85 [ 22 ]. The Chinese version of the AITCS-II has good reliability (Cronbach’s α = 0.961) and validity [ 23 ].

• Critical thinking

Critical thinking was measured by Yoon's Critical Thinking Disposition Scale (YCTD). It is a five-point Likert scale with values ranging from 1 to 5, resulting in a total score ranging from 27 to 135 [ 24 ]. Higher scores on this scale indicate greater critical thinking ability. The YCTD has good reliability (Cronbach’s α = 0.948) and validity when applied to Chinese nursing students [ 25 ].

Caring was assessed using the Caring Dimensions Inventory (CDI), which employs a five-point Likert scale ranging from 25 to 125 [ 26 ]. Higher scores on the CDI indicate a greater level of caring. The Chinese version of the CDI exhibited good reliability (Cronbach’s α = 0.97) and validity [ 27 ].

• Interest in learning

The Study Interest Questionnaire (SIQ) was used to assess interest in learning. The SIQ is a four-point Likert scale ranging from 18 to 72, where a higher total score indicates a greater degree of interest in the field of study [ 28 ]. The SIQ has good reliability (Cronbach’s α = 0.90) and validity when applied to Chinese nursing students [ 29 ].

Ethical considerations

The institution of the first author granted ethical approval (ethical approval number: REC-2021.801). Written informed consent was obtained from all participants. Participants were permitted to withdraw for any reason at any time without penalty. Guidelines emphasizing safety measures and precautions during the intervention were provided to participants, and study coordinators closely monitored laboratory and simulation sessions to address concerns or potential harm promptly.

Data analysis

Descriptive statistics were used to describe the participant characteristics and baseline characteristics. Continuous variables are presented as the mean and standard deviation, while categorical variables are presented as frequencies and percentages. According to the Quantile–Quantile Plot, the data exhibited an approximately normal distribution. Furthermore, Levene's test indicated equal variances for the variables of knowledge, skill, interprofessional collaboration, critical thinking, caring, and interest in learning, with p-values of 0.171, 0.249, 0.986, 0.634, 0.992, and 0.407, respectively. The baseline characteristics of the four groups were compared using one-way analysis of variance. The indicators of knowledge, skill, interprofessional collaboration, critical thinking, caring, and interest in learning were assessed at baseline, immediately after the intervention, and three months postintervention. Changes in these indicators from baseline were calculated for both the postintervention and three-month follow-up periods. The changes among the four groups were compared using one-way analysis of variance. Cohen's d effect sizes were computed for the between-group comparisons (small effect size = 0.2; medium effect size = 0.5; large effect size = 0.8). Missing data were treated as missing without imputation. The data analysis was conducted using jamovi 2.3.28 ( https://www.jamovi.org/ ). Jamovi was developed on the foundation of the R programming language, and is recognized for its user-friendly interface. The threshold for statistical significance was established at a two-sided p  < 0.05.

Participants

A total of 270 participants were initially recruited from five universities for this study. However, an attrition rate of 11.5% was observed, resulting in 31 participants discontinuing their involvement. Consequently, the final analysis included data from 239 participants who successfully completed the intervention and remained in the study. Specifically, there were 58 participants in the high-fidelity simulation group, 67 in the computer-based simulation group, 57 in the high-fidelity simulation combined with computer-based simulation group, and 57 in the case study group (Fig.  1 ). The participant demographics and baseline characteristics are displayed in Table  2 , and no significant differences were observed in these variables.

Study subject disposition flow chart

Efficacy outcomes

All the intervention groups showed improvements in knowledge after the intervention, with the high-fidelity simulation group showing the greatest improvement (Fig.  2 ). However, there were no significant differences in knowledge improvement among the groups (p = 0.856). The computer-based simulation group and case study group experienced a decrease in knowledge compared to baseline three months after the intervention, while the other groups showed an increase in knowledge. The high-fidelity simulation combined with computer-based simulation group performed best (Fig.  3 ), but no significant differences were observed (p = 0.872). The effect sizes between groups were found to be small, both immediately after the intervention and at the three-month follow-up (Table  3 ).

Changes in all effectiveness outcomes at post intervention. Note: A  High-fidelity simulation group; B  Computer-based simulation group; C  High-fidelity simulation combined with computer-based simulation group; D  Case study group

Changes in all effectiveness outcomes at three months of intervention. Note: A  High-fidelity simulation group;  B  Computer-based simulation group;  C  High-fidelity simulation combined with computer-based simulation group;  D  Case study group

The different intervention groups showed improvements in skills after the intervention and three months after the intervention. The high-fidelity simulation combined with computer-based simulation group showed the greatest improvement after the intervention (Fig.  2 ), while the greatest improvement was observed in the high-fidelity simulation group three months after the intervention (Fig.  3 ). There was a significant difference in the improvement in skills among the different groups after the intervention ( p  = 0.020). Specifically, the improvement observed in the computer-based simulation group was significantly lower than that in both the high-fidelity simulation group ( p  = 0.048) and the high-fidelity simulation combined with computer-based simulation group ( p  = 0.020). However, three months after the intervention, there was no statistically significant difference in skill improvement among the groups ( p  = 0.139). Except for the between-group effect sizes of the high-fidelity simulation group compared to the computer-based simulation group (Cohen d = 0.51) and the computer-based simulation group compared to the high-fidelity simulation combined with computer-based simulation group (Cohen d = 0.56), the effects were found to be medium after the intervention, while the other between-group effect sizes were small both after the intervention and three months after the intervention (Table  3 ).

In all intervention groups except for the high-fidelity simulation group, interprofessional collaboration improved after the intervention and three months after the intervention, with the case study group (Figs. 2 and 3 ) demonstrating the greatest improvement. No significant difference was found between the intervention groups after or three months after the intervention in terms of changes in interprofessional collaboration. Both immediately following the intervention and three months later, the effect sizes between groups were small (Table  3 ).

After the intervention and three months after the intervention, the critical thinking of all the intervention groups improved. Among them, the high-fidelity simulation group improved the most after the intervention (Fig.  2 ), while the computer-based simulation group improved the most three months after the intervention (Fig.  3 ). However, no statistically significant differences were observed in the improvement of critical thinking across the different groups. The between-group effect sizes of each group were small both after the intervention and three months after the intervention (Table  3 ).

Caring improved following the intervention in all intervention groups, with the exception of the high-fidelity simulation group and case study group (Fig.  2 ). However, no significant difference was observed between the intervention groups in terms of changes ( p  = 0.865). A decrease in caring was observed three months after the intervention in all intervention groups, except for the case study group (Fig.  3 ). Nevertheless, no statistically significant difference was detected between the intervention groups in terms of changes (p = 0.607). Both immediately following the intervention and three months later, the effect sizes between groups were small (Table  3 ).

In terms of interest in learning, both the high-fidelity simulation group and the high-fidelity simulation combined with computer-based simulation group improved after the intervention or three months later. Among the groups, the high-fidelity simulation combined with computer-based simulation group improved the most after both the intervention and three months after the intervention (Figs. 2 and 3 ). However, no statistically significant difference was detected between the intervention groups in terms of changes either after the intervention (p = 0.144) or three months after the intervention (p = 0.875). Both immediately following the intervention and three months later, the effect sizes between groups were small (Table  3 ).

To our knowledge, this study is the first multicenter randomized controlled trial to explore the effects of different simulation teaching methods on nursing students' competence and the first study in which multiple different indicators were evaluated simultaneously. The indicators included both objectively assessed indicators of knowledge and skills and subjectively assessed indicators of interprofessional collaboration, critical thinking, caring, and interest in learning. This study assessed the immediate and long-term effects of the intervention by examining its immediate impact as well as its effects three months postintervention.

The results obtained from this study indicate that high-fidelity simulation, computer-based simulation, high-fidelity simulation combined with computer-based simulation, and case study could improve nursing students’ knowledge immediately after intervention. Furthermore, these four teaching methods exhibited comparable effectiveness in improving knowledge. The findings of this study contradict previous meta-analyses that showed that high-fidelity simulation improved nursing students' knowledge over other teaching techniques [ 2 ]. This discrepancy may be attributed to the inclusion of simulation teaching in the previous study alongside theoretical teaching [ 12 ], whereas the current study solely employed simulation teaching without incorporating theoretical instruction. Notably, three months following the intervention, computer-based simulation and case study did not result in knowledge retention. Conversely, high-fidelity simulation, particularly when combined with computer-based simulation, demonstrated knowledge retention, with the latter exhibiting superior performance in this regard. The realistic nature of the simulation provided students with a context in which to apply their knowledge, enhancing their understanding of key concepts [ 30 ]. High-fidelity simulation surpasses computer-based simulation and case study in terms of realism. When combined with computer-based simulation, this approach affords students the opportunity to practice their knowledge in a safe environment while also providing them with access to additional resources and learning opportunities [ 31 ]. Therefore, in this study, high-fidelity simulation combined with computer-based simulation proved to be the most effective at retaining knowledge.

Four simulation-based education strategies were found to be effective at acquiring and retaining skills by the students in this study. High-fidelity simulation combined with computer-based simulation was found to be more effective at acquiring skill than was using either method alone. This method combines the benefits of both teaching methods, providing students with a comprehensive learning experience that combines physical realism and virtual interactivity [ 32 ]. Hybrid simulation creates a seamless learning experience in which individuals can practice their skills in a simulated environment, receive immediate feedback, and then transfer those skills to real-world situations. This integration provides a seamless transition from theoretical knowledge to practical skills, making it easier for individuals to apply what they have learned and enhance their overall performance [ 33 ]. Hybrid simulation may seem to be an attractive option [ 34 ]; however, this study found that hybrid simulation had no advantage in terms of skill retention; rather, high-fidelity simulation performed best. More research is needed in the future to confirm the results of this study and the underlying reasons since previous studies have not compared hybrid simulation with high-fidelity simulation on skill retention.

The findings of this study reveal a noteworthy observation: interprofessional collaboration improved across all interventions, except for high-fidelity simulation. This finding diverges from prior studies that indicated high-fidelity simulation as a more effective method for enhancing students' interprofessional collaboration compared to traditional case study [ 35 ]. This discrepancy may be attributed to the use of an unfolding case study in the current study, wherein patient scenarios evolve unpredictably, thereby prompting students and team members to engage in heightened collaborative efforts to address evolving patient care challenges [ 36 ]. Interprofessional collaboration plays a crucial role in improving healthcare outcomes. Studies have shown that when healthcare professionals collaborate effectively, patients experience better outcomes, fewer errors, and shorter hospital stays [ 37 ]. While high-fidelity simulation has gained popularity as a training tool, according to the results of this study, its impact on interprofessional collaboration remains limited. There may be two reasons for this. First, high-fidelity simulation scenarios are often time constrained [ 38 ], which can hinder effective interprofessional collaboration. Each team member may prioritize their individual goals or tasks, making it difficult to achieve optimal teamwork and coordination. Second, interprofessional team members may not have worked together extensively, which can hinder their ability to collaborate effectively in a high-fidelity simulation setting. It takes time to build trust and rapport, which may not be readily available in a simulated environment [ 39 ]. Despite being assigned the roles of senior nurse or junior nurse, participants in the high-fidelity simulation group were provided with the opportunity to engage with peers at various levels and individuals from different professions, such as instructors assuming the role of doctors. However, the duration of the simulation section for this group was limited to only 10 min. In contrast, participants in the computer-based simulation group and case study group were allocated 30 min and 35 min, respectively. It is crucial for healthcare institutions and educators to critically evaluate their simulation-based training programs and incorporate key components that promote interprofessional collaboration [ 40 ].

This study revealed that four interventions effectively promoted students' critical thinking, and these effects lasted for three months after the interventions. Furthermore, high-fidelity simulation was most effective at improving critical thinking in the short term, whereas computer-based simulation was most effective at fostering long-term improvements. High-fidelity simulation involves creating a realistic and immersive environment that closely resembles a real-world scenario [ 41 ]. This approach affords individuals the opportunity to actively participate and immerse themselves in the simulated scenario, thereby enhancing their experiential understanding [ 3 ]. Computer-based simulation does not provide the same immediate and tangible experience as high-fidelity simulation. High-fidelity simulation commonly incorporates the utilization of medical devices and mannequins that closely resemble clinical scenarios, thereby affording students a more authentic and immersive learning encounter. Only 5% of students perceive computer-based simulation as a viable substitute for mannequin-based simulation within the curriculum [ 42 ]. As a result, high-fidelity simulation is highly effective in the short term, and a previous meta-analysis reported similar results [ 43 ]. However, computer-based simulation provides advantages for data collection and analysis that contribute to the long-term development of critical thinking skills. In the simulation, participants can record their actions, decisions, and results [ 3 ]. These data can be used to compare different strategies and approaches, allowing participants to reflect on their own critical thinking skills and identify areas for improvement. Furthermore, it is noteworthy that the four simulation teaching methods demonstrated the ability to enhance students' critical thinking. However, it is important to consider the substantial disparity in costs among these methods. Therefore, educators should carefully evaluate their available resources and opt for the most cost-effective approach to foster students' critical thinking.

This study found limited evidence that all four simulation teaching methods contribute to improve caring among students. High-fidelity simulation often focuses on technical skills rather than patient interaction or emotional sensitivity [ 44 , 45 ]. Moreover, research has demonstrated that using mannequins in high-fidelity simulation leads some students to perceive them as separate from real-life patients [ 45 ]. This perception reduces students' concern for the consequences of their actions during the simulation [ 45 ], hindering empathy development and limiting the cultivation of their caring abilities [ 46 ]. Unlike high-fidelity simulation, which provides tactile experiences and simulates real-life interactions, computer-based simulation is characterized by the absence of human connections. This lack of physical proximity can hinder the development of caring behaviors such as nonverbal communication, empathy, and sympathy [ 47 , 48 ]. Similarly, the absence of direct patient interaction is a notable drawback of case study. Although case study simulates complex patient care scenarios, they do not allow students to practice hands-on or experience caregiving emotions. Similarly, the absence of direct patient interactions in case study is a notable limitation. This lack of personal connection and guided practice may hinder the development of caring behaviors. By recognizing these limitations and seeking alternative instructional methods, educational institutions can strive to enhance students' caring skills and equip them with the qualities and behaviors necessary for providing compassionate and patient-centered care.

The findings of this study revealed that neither computer-based simulation nor case study improved students' interest in learning, whereas high-fidelity simulation combined with computer-based simulation was most effective. One possible explanation for the ineffectiveness of computer-based simulation and case study in promoting students' interest is that they may lack the authenticity and immersive nature of real-world experiences [ 47 , 48 ]. High-fidelity simulation, on the other hand, provides a more lifelike and interactive learning environment, which may enhance students' engagement, interest, and retention [ 49 ]. High-fidelity simulation combined with computer-based simulation allows students to interact with the simulation in a hands-on manner while also having access to additional resources and information through computer-based simulation [ 50 ]. This combination provides a well-rounded learning experience that can captivate students' attention and keep them engaged. Notably, these findings are exploratory and should be further explored and validated in future studies. Further research should aim to identify the reasons behind the lack of improvement in students' interest in learning when using computer-based simulation and case study alone. Additionally, the impact of different combinations of simulation techniques on students' interest in learning should be investigated to further refine instructional practices.

Limitations

This study provides valuable insights into the effectiveness of simulation-based education in improving nursing students' competences. However, it is essential to acknowledge and address the study's limitations. One of the limitations is the possible selection bias introduced by the recruiting process. It is possible that students who were more motivated or had a greater interest in simulation-based education may have been more likely to participate in the study. This bias may have influenced the outcomes and interpretation of the results. Additionally, the participants were primarily from one cultural background, which may limit the generalizability of the findings. Future studies should include participants from diverse backgrounds to enhance generalizability. Third, participants assigned to different intervention groups may engage in communication and information sharing, potentially leading to contamination effects. To mitigate this issue, future studies could employ cluster randomized controlled trials, which can effectively minimize the risk of contamination among participants. Finally, the follow-up period was relatively short, which limits the understanding of the long-term impact of simulation-based education on competence. Long-term follow-up studies are needed to evaluate the sustained effect of simulation-based education on competence. Future research should aim to address these limitations to further our understanding of the effects of simulation-based education on undergraduate nursing students' competences.

The four methods are effective at improving skills and critical thinking both immediately and over time. In addition to high-fidelity simulation, the other three methods promote interprofessional collaboration both immediately and long term. High-fidelity simulation combined with computer-based simulation is the most effective approach for enhancing interest in learning both immediately and long term. Undergraduate nursing students benefit equally from four methods in cultivating their knowledge, interprofessional collaboration, critical thinking, caring, and interest in learning both immediately and over time. High-fidelity simulation and high-fidelity simulation combined with computer-based simulation improve skill more effectively than computer-based simulation in the short term. Nursing educators can select the most suitable teaching method to achieve the intended learning outcomes depending on the specific circumstances.

Availability of data and materials

The data that support the findings of this study are available from the corresponding author, upon reasonable request.

Panda S, Dash M, John J, Rath K, Debata A, Swain D, et al. Challenges faced by student nurses and midwives in clinical learning environment – A systematic review and meta-synthesis. Nurse Educ Today. 2021;101: 104875. https://doi.org/10.1016/j.nedt.2021.104875 .

Article   PubMed   Google Scholar  

Li YY, Au ML, Tong LK, Ng WI, Wang SC. High-fidelity simulation in undergraduate nursing education: A meta-analysis. Nurse Educ Today. 2022;111: 105291. https://doi.org/10.1016/j.nedt.2022.105291 .

Tamilselvan C, Chua SM, Chew HSJ, Devi MK. Experiences of simulation-based learning among undergraduate nursing students: A systematic review and meta-synthesis. Nurse Educ Today. 2023;121: 105711. https://doi.org/10.1016/j.nedt.2023.105711 .

Mulyadi M, Tonapa SI, Rompas SSJ, Wang R-H, Lee B-O. Effects of simulation technology-based learning on nursing students’ learning outcomes: A systematic review and meta-analysis of experimental studies. Nurse Educ Today. 2021;107: 105127. https://doi.org/10.1016/j.nedt.2021.105127 .

Chernikova O, Heitzmann N, Stadler M, Holzberger D, Seidel T, Fischer F. Simulation-Based Learning in Higher Education: A Meta-Analysis. Rev Educ Res. 2020;90(4):499–541. https://doi.org/10.3102/0034654320933544 .

Article   Google Scholar  

Lioce L. Healthcare Simulation Dictionary. 2nd ed. Rockville: Agency for Healthcare Research and Quality; 2020.

Book   Google Scholar  

Kim J, Park J-H, Shin S. Effectiveness of simulation-based nursing education depending on fidelity: a meta-analysis. BMC Med Educ. 2016;16(1):152. https://doi.org/10.1186/s12909-016-0672-7 .

Article   PubMed   PubMed Central   Google Scholar  

Roberts E, Kaak V, Rolley J. Simulation to Replace Clinical Hours in Nursing: A Meta-narrative Review. Clin Simul Nurs. 2019;37:5–13. https://doi.org/10.1016/j.ecns.2019.07.003 .

Lapkin S, Levett-Jones T. A cost–utility analysis of medium vs. high-fidelity human patient simulation manikins in nursing education. J Clin Nurs. 2011;20(23–24):3543–52. https://doi.org/10.1111/j.1365-2702.2011.03843.x .

Dziuban C, Graham CR, Moskal PD, Norberg A, Sicilia N. Blended learning: the new normal and emerging technologies. Int J Educ Technol High Educ. 2018;15(1):3. https://doi.org/10.1186/s41239-017-0087-5 .

Goldsworthy S, Ferreira C, Shajani Z, Snell D, Perez G. Combining Virtual and High-fidelity Simulation to Foster Confidence and Competency in Postpartum Assessment Complications among Undergraduate Nursing Students. Clin Simul Nurs. 2022;66:18–24. https://doi.org/10.1016/j.ecns.2022.02.001 .

Kang KA, Kim SJ, Lee MN, Kim M, Kim S. Comparison of Learning Effects of Virtual Reality Simulation on Nursing Students Caring for Children with Asthma. Int J Enviro Res Public Health. 2020;17(22):8417. https://doi.org/10.3390/ijerph17228417 .

Ellis M, Hampton D, Makowski A, Falls C, Tovar E, Scott L, et al. Using unfolding case scenarios to promote clinical reasoning for nurse practitioner students. J Am Assoc Nurse Pract. 2023;35(1):55–62. https://doi.org/10.1097/jxx.0000000000000806 .

Englund H. Using unfolding case studies to develop critical thinking skills in baccalaureate nursing students: A pilot study. Nurse Educ Today. 2020;93: 104542. https://doi.org/10.1016/j.nedt.2020.104542 .

Wang X, Yang L, Hu S. Teaching nursing students: As an umbrella review of the effectiveness of using high-fidelity simulation. Nurse Educ Pract. 2024;77: 103969. https://doi.org/10.1016/j.nepr.2024.103969 .

La Carmen C, Angelo D, Valeria C, Ilaria F, Elona G, Cristina P, et al. Effects of high-fidelity simulation based on life-threatening clinical condition scenarios on learning outcomes of undergraduate and postgraduate nursing students: a systematic review and meta-analysis. BMJ Open. 2019;9(2): e025306. https://doi.org/10.1136/bmjopen-2018-025306 .

Au ML, Tong LK, Li YY, Ng WI, Wang SC. Impact of scenario validity and group size on learning outcomes in high-fidelity simulation: A systematics review and meta-analysis. Nurse Educ Today. 2023;121: 105705. https://doi.org/10.1016/j.nedt.2022.105705 .

Book ECfAtNNLE. 2022 National Nurse Licensing Examination Guided Simultaneous Practice Question Set. Beijing: People's Medical Publishing House Co. LTD; 2022.

Todd M, Manz JA, Hawkins KS, Parsons ME, Hercinger M. The Development of a Quantitative Evaluation Tool for Simulations in Nursing Education. Int J Nurs Educ Scholarsh. 2008;5(1). https://doi.org/10.2202/1548-923X.1705

Hayden J, Keegan M, Kardong-Edgren S, Smiley RA. Reliability and Validity Testing of the Creighton Competency Evaluation Instrument for Use in the NCSBN National Simulation Study. Nurs Educ Perspect. 2014;35(4):244–52. https://doi.org/10.5480/13-1130.1 .

Song X, Jin R. Chinese revised CCEI cross-cultural debugging and measurement features evaluation. Int J Nurs. 2018;37(19):2622–7. https://doi.org/10.3760/cma.j.issn.1637-4351.2019.19.009 .

Orchard C, Mahler C, Khalili H. Assessment of the Interprofessional Team Collaboration Scale for Students-AITCS-II (Student): Development and Testing. J Allied Health. 2021;50(1):E1–7.

PubMed   Google Scholar  

Shi Y, Zhu Z, Hu Y. The reliability and validity of the Chinese version of the Assessment of Interprofessional Team Collaboration in Student Learning Scale. Chinese J Nurs Educ. 2020;17(5):435–8. https://doi.org/10.3761/j.issn.1672-9234.2020.05.011 .

Shin H, Park CG, Kim H. Validation of Yoon’s Critical Thinking Disposition Instrument. Asian Nurs Res. 2015;9(4):342–8. https://doi.org/10.1016/j.anr.2015.10.004 .

Au ML, Li YY, Tong LK, Wang SC, Ng WI. Chinese version of Yoon Critical Thinking Disposition Instrument: validation using classical test theory and Rasch analysis. BMC Nurs. 2023;22(1):362. https://doi.org/10.1186/s12912-023-01519-y .

Watson R, Lea A. The caring dimensions inventory (CDI): content validity, reliability and scaling. J Adv Nurs. 1997;25(1):87–94. https://doi.org/10.1046/j.1365-2648.1997.1997025087.x .

Article   CAS   PubMed   Google Scholar  

Tong LK, Zhu MX, Wang SC, Cheong PL, Van IK. A Chinese Version of the Caring Dimensions Inventory: Reliability and Validity Assessment. Int J Environ Res Public Health. 2021;18(13):6834. https://doi.org/10.3390/ijerph18136834 .

Schiefele U, Krapp A, Wild KP, Winteler A. Der Fragebogen zum Studieninteresse (FSI). [The Study Interest Questionnaire (SIQ)]. Diagnostica. 1993;39(4):335–51.

Google Scholar  

Tong LK, Au ML, Li YY, Ng WI, Wang SC. The mediating effect of critical thinking between interest in learning and caring among nursing students: a cross-sectional study. BMC Nurs. 2023;22(1):30. https://doi.org/10.1186/s12912-023-01181-4 .

Graham AC, McAleer S. An overview of realist evaluation for simulation-based education. Adv Simul. 2018;3(1):13. https://doi.org/10.1186/s41077-018-0073-6 .

Sharoff L. Faculty’s Perception on Student Performance using vSim for Nursing® as a Teaching Strategy. Clin Simul Nurs. 2022;65:1–6. https://doi.org/10.1016/j.ecns.2021.12.007 .

Cole R, Flenady T, Heaton L. High Fidelity Simulation Modalities in Preregistration Nurse Education Programs: A Scoping Review. Clin Simul Nurs. 2023;80:64–86. https://doi.org/10.1016/j.ecns.2023.04.007 .

Park S, Hur HK, Chung C. Learning effects of virtual versus high-fidelity simulations in nursing students: a crossover comparison. BMC Nurs. 2022;21(1):100. https://doi.org/10.1186/s12912-022-00878-2 .

Goldsworthy S, Patterson JD, Dobbs M, Afzal A, Deboer S. How Does Simulation Impact Building Competency and Confidence in Recognition and Response to the Adult and Paediatric Deteriorating Patient Among Undergraduate Nursing Students? Clin Simul Nurs. 2019;28:25–32. https://doi.org/10.1016/j.ecns.2018.12.001 .

Tosterud R, Hedelin B, Hall-Lord ML. Nursing students’ perceptions of high- and low-fidelity simulation used as learning methods. Nurse Educ Pract. 2013;13(4):262–70. https://doi.org/10.1016/j.nepr.2013.02.002 .

Cheng C-Y, Hung C-C, Chen Y-J, Liou S-R, Chu T-P. Effects of an unfolding case study on clinical reasoning, self-directed learning, and team collaboration of undergraduate nursing students: A mixed methods study. Nurse Educ Today. 2024;137: 106168. https://doi.org/10.1016/j.nedt.2024.106168 .

Kaiser L, Conrad S, Neugebauer EAM, Pietsch B, Pieper D. Interprofessional collaboration and patient-reported outcomes in inpatient care: a systematic review. Syst Rev. 2022;11(1):169. https://doi.org/10.1186/s13643-022-02027-x .

Tong LK, Li YY, Au ML, Wang SC, Ng WI. High-fidelity simulation duration and learning outcomes among undergraduate nursing students: A systematic review and meta-analysis. Nurse Educ Today. 2022;116: 105435. https://doi.org/10.1016/j.nedt.2022.105435 .

Livne N. High-fidelity simulations offer a paradigm to develop personal and interprofessional competencies of health students: A review article. Int J Allied Health Sci Pract. 2019;17(2). https://doi.org/10.46743/1540-580X/2019.1835

Marion-Martins AD, Pinho DLM. Interprofessional simulation effects for healthcare students: A systematic review and meta-analysis. Nurse Educ Today. 2020;94: 104568. https://doi.org/10.1016/j.nedt.2020.104568 .

Macnamara AF, Bird K, Rigby A, Sathyapalan T, Hepburn D. High-fidelity simulation and virtual reality: an evaluation of medical students’ experiences. BMJ simulation & technology enhanced learning. 2021;7(6):528–35. https://doi.org/10.1136/bmjstel-2020-000625 .

Foronda CL, Swoboda SM, Henry MN, Kamau E, Sullivan N, Hudson KW. Student preferences and perceptions of learning from vSIM for Nursing™. Nurse Educ Pract. 2018;33:27–32. https://doi.org/10.1016/j.nepr.2018.08.003 .

Lei Y-Y, Zhu L, Sa YTR, Cui X-S. Effects of high-fidelity simulation teaching on nursing students’ knowledge, professional skills and clinical ability: A meta-analysis and systematic review. Nurse Educ Pract. 2022;60: 103306. https://doi.org/10.1016/j.nepr.2022.103306 .

Najjar RH, Lyman B, Miehl N. Nursing Students’ Experiences with High-Fidelity Simulation. Int J Nurs Educ Scholarsh. 2015;12(1):27–35. https://doi.org/10.1515/ijnes-2015-0010 .

Au ML, Lo MS, Cheong W, Wang SC, Van IK. Nursing students’ perception of high-fidelity simulation activity instead of clinical placement: A qualitative study. Nurse Educ Today. 2016;39:16–21. https://doi.org/10.1016/j.nedt.2016.01.015 .

Dean S, Williams C, Balnaves M. Practising on plastic people: Can I really care? Contemp Nurse. 2015;51(2–3):257–71. https://doi.org/10.1080/10376178.2016.1163231 .

Chang YM, Lai CL. Exploring the experiences of nursing students in using immersive virtual reality to learn nursing skills. Nurse Educ Today. 2021;97: 104670. https://doi.org/10.1016/j.nedt.2020.104670 .

Jeon J, Kim JH, Choi EH. Needs Assessment for a VR-Based Adult Nursing Simulation Training Program for Korean Nursing Students: A Qualitative Study Using Focus Group Interviews. Int J Environ Res Public Health. 2020;17(23):8880. https://doi.org/10.3390/ijerph17238880 .

Davis R. Nursing Student Experiences with High-Fidelity Simulation Education [Ed.D.]. Arizona: Grand Canyon University; 2021.

Saab MM, Landers M, Murphy D, O’Mahony B, Cooke E, O’Driscoll M, et al. Nursing students’ views of using virtual reality in healthcare: A qualitative study. J Clin Nurs. 2022;31(9–10):1228–42. https://doi.org/10.1111/jocn.15978 .

Download references

Acknowledgements

Not applicable.

This work was supported by a research grant from Higher Education Fund of Macao SAR Government (project number: HSS-KWNC-2021–01). This funding source had no role in the design of this study and will not have any role during its execution, analyses, interpretation of the data, or decision to submit results.

Author information

Authors and affiliations.

Kiang Wu Nursing College of Macau, Edifício do Instituto de Enfermagem Kiang Wu de Macau, Avenida do Hospital das Ilhas no.447, Coloane, RAEM, Macau SAR, China

Lai Kun Tong, Yue Yi Li, Mio Leng Au, Wai I. Ng & Si Chen Wang

School of Nursing, Yangzhou University, No.136, Jiangyang Middle Road, Hanjiang District, Yangzhou, Jiangsu Province, China

Yongbing Liu

School of Nursing, Guangzhou Xinhua University, 19 Huamei Road, Tianhe District, Guangzhou, Guangdong Province, China

School of Nursing, Guangzhou Medical University, Dongfeng West Road, Yuexiu District, Guangzhou, Guangdong Province, China

Liqiang Zhong

School of Nursing, Shenzhen University, No. 3688, Nanhai Road, Nanshan District, Shenzhen, Guangdong Province, China

Xichenhui Qiu

You can also search for this author in PubMed   Google Scholar

Contributions

Study conceptualization and planning were organized and performed by LKT, YYL, MLA, WIN, SCW, YBL, YS, LQZ, and XCHQ. Data collection, data analysis and data interpretation were performed by LKT, YYL, MLA, WIN, SCW, YBL, YS, LQZ, and XCHQ. LKT drafted the initial version of the manuscript. YYL, MLA, WIN, SCW, YBL, YS, LQZ, and XCHQ revised the manuscript for important intellectual content. All authors had full access to the data and have reviewed and approved the submitted version of the manuscript. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Corresponding author

Correspondence to Mio Leng Au .

Ethics declarations

Ethics approval and consent to participate.

This research was approved by the Research Management and Development Department of Kiang Wu Nursing College of Macau (No. REC-2021.801) and conducted according to the Declaration of Helsinki. It was a completely voluntary, anonymous, and unrewarded study. Written consent was obtained from all participants.

Consent for publication

Competing interests.

The authors declare no competing interests.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Tong, L.K., Li, Y.Y., Au, M.L. et al. The effects of simulation-based education on undergraduate nursing students' competences: a multicenter randomized controlled trial. BMC Nurs 23 , 400 (2024). https://doi.org/10.1186/s12912-024-02069-7

Download citation

Received : 21 March 2024

Accepted : 05 June 2024

Published : 17 June 2024

DOI : https://doi.org/10.1186/s12912-024-02069-7

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• High-fidelity simulation
• Computer-based simulation
• High-fidelity simulation combined with computer-based simulation

BMC Nursing

ISSN: 1472-6955

• General enquiries: [email protected]

Encouraging critical thinking in an era of AI paraphrasing

By completing this form, you agree to Turnitin's Privacy Policy . Turnitin uses the information you provide to contact you with relevant information. You may unsubscribe from these communications at any time.

In the age of digital transformation, where generative AI and AI paraphrasing are prevalent, the ability to think critically has never been more important.

Education is navigating a world increasingly influenced by artificial intelligence, and the way we process and interpret information is rapidly evolving. Critical thinking—the practice of analyzing and evaluating information to form a reasoned judgment—is a fundamental skill that empowers individuals to make informed decisions and solve complex problems.

Writing for Forbes, Ron Carucci notes that, “There’s a big difference between machine learning and ‘machine thinking’ … the minute we start looking at AI as machine thinking, we’re in trouble, because it means we’ve tried to outsource our own critical thinking and problem solving skills to a machine that is only replicating and regurgitating information it has gathered.” But AI paraphrasing tools are making it easier than ever to bypass this deeply important skill.

In this blog post, we’ll explore the importance of teaching critical thinking in an era dominated by AI, with strategies for educators to promote critical thinking and ethical AI use among students.

What is paraphrasing vs AI paraphrasing?

A key aspect of critical thinking in academic and professional writing is paraphrasing. Writers generally paraphrase to reference credible authors, which in turn, establishes their own credibility.

Traditional paraphrasing requires a deep understanding of the content at hand, plus an ability to express it in a new form without altering the original meaning. It’s an alternative to using a quote, when a writer wants to use their own words, their own voice, but someone else’s idea. When a writer paraphrases, they show that they understand the meaning of the text, and it’s a common technique used to present information more concisely or clearly while properly attributing the original source.

AI paraphrasing, on the other hand, refers to the process of using AI technology to rewrite text while retaining the original meaning, sometimes without proper attribution. These AI-powered tools analyze the input text and generate alternative versions that convey the same information using different words or sentence structures. When powered by Natural Language Processing (NLP), AI paraphrasing tools can be remarkably sophisticated (more so than traditional text spinners) which is cause for concern for academic integrity.

Why is fostering critical thinking essential amidst AI paraphrasing tools?

The internet provides a vast amount of information, often with varying degrees of reliability. It is our critical thinking skills that enable us to discern credible sources from unreliable ones , ensuring we only rely on accurate information. AI paraphrasing tools do not carry out this task for us, thus understanding their limitations is key to academic and research success.

While AI paraphrasing tools can produce text that is grammatically correct, in parallel, they can produce contextually inaccurate or misleading information. Critical thinking helps users recognize these limitations and verify the information provided by AI.

Moreover, an over-reliance on AI paraphrasing tools can impact original thought and creativity. Teaching critical thinking encourages intellectual independence among students, empowering them to form their own ideas and arguments rather than passively accepting AI-generated content as being factually correct.

The use of AI in content creation also raises ethical questions about plagiarism and intellectual property. Critical thinking fosters ethical awareness, helping individuals use AI responsibly and respect the original authorship of content.

What are the risks of over-reliance on AI paraphrasing tools?

As AI paraphrasing tools become increasingly sophisticated and accessible, it's tempting to use them as a crutch for generating content quickly, particularly during periods of academic pressure . While these tools offer convenience, over-reliance on them presents several significant risks to students, their institutions, and the wider society.

AI paraphrasing tools often work by reordering or substituting words and phrases to create new sentences. This can result in bland and uninspired content that lacks the unique voice and creativity of the original author. Over time, this dependency can stifle a writer's ability to produce original work and diminish their creative capabilities, resulting in the atrophy of essential skills such as critical analysis, vocabulary development, and grammatical precision.

For students and learners, the process of writing and paraphrasing by hand is an essential part of learning. It encourages deep engagement with the material and promotes a better understanding of the subject matter. By using AI to paraphrase, they miss out on the mental exercise of evaluating, analyzing, and synthesizing information. This can lead to a superficial understanding of the material, as users may accept AI-generated content without questioning its accuracy or depth.

AI paraphrasing tools are only as good as the data and algorithms behind them. If the original content contains errors or biases, these can be perpetuated and even amplified by paraphrasing tools. Students may unwittingly propagate misinformation or incorrect interpretations, leading to a cycle of inaccuracies that could result in awarding a degree or certificate to a student lacking crucial subject knowledge. This is particularly concerning when awarding high-stakes qualifications, such as law or medicine, raising ethical concerns. Students, for example, may use these tools to bypass the hard work of writing and learning, which can undermine the educational process and academic integrity standards of their institution.

To deter students from relying heavily on generative AI, educators can take steps to prepare their students for a world where generative AI and critical thinking coexist in harmony.

How can educators encourage critical thinking in an era of AI paraphrasing?

Critical thinking is a higher-order skill and arguably one of the most valuable in academia. It significantly impacts problem-solving and decision-making and is transferable across many disciplines and domains. Developing critical thinking takes practice, beginning at the earliest possible level and evolving to proficiency over time. Transferring critical thinking from one domain to another involves explicit and deliberate instruction.

While there is ongoing debate about whether critical thinking can be taught directly or merely encouraged, we believe it’s prudent to provide a set of tips designed to help students develop critical thinking skills.

Promote active learning and collaboration

Active learning—sometimes referred to as authentic learning —involves engaging students directly in the learning process, putting them at the center of the learning experience. To engage students in active learning, educators can encourage students to participate in discussions, debates, and problem-solving activities. These activities require students to analyze information, form arguments, and critically evaluate different perspectives. Techniques such as case studies, group projects, and hands-on experiments can also facilitate active learning.

A study by Deslauriers et al. ( 2019 ) sought to measure actual learning vs. feeling of learning in response to being actively engaged in the classroom. The results indicated that although students felt that they learned more in the traditional lecture setting—rendered by an inherent student bias against active learning—they actually learned more when taking part in active learning strategies.

Encourage questioning

Foster a classroom environment where questioning is not only allowed but encouraged. Teach students to ask probing questions about the material they read, write, and the outputs of any generative AI tools they may have adopted to produce their work. Questions that challenge assumptions, explore alternative viewpoints, and dig deeper into the subject matter can significantly enhance students’ critical thinking skills. Questions can also help you, as an educator, to uncover misconceptions among students, which provides a means of formative assessment data that can be leveraged to improve future teaching and learning.

Immerse students in project-based learning

Presenting students with real-world problems can enhance their critical thinking skills by providing a practical and engaging context for applying knowledge. Students are asked to identify, analyze, and prioritize multiple variables, helping them to develop well-reasoned, evidence-based solutions. Real-world problems are also inherently engaging and relevant, increasing student motivation and enthusiasm for learning.

By integrating project-based learning in the form of real-world problems into the curriculum, educators create a dynamic learning environment that teaches critical thinking and prepares students for the complexities of real-world situations. Zhang and Ma ( 2023 ) found that “project-based learning significantly improved students’ learning outcomes and positively contributed to academic achievement, affective attitudes, and thinking skills, especially academic achievement.”

Integrate AI as supplementary aids

AI writing doesn’t have to mean academic misconduct. With practical strategies for embracing the challenge and also the potential that comes along with AI technology and writing, teachers can use AI as supplementary aids to enhance critical thinking and writing skills rather than replacements for traditional learning. For instance, students can use generative AI and AI paraphrasing tools to understand complex texts better, but they should also be encouraged to analyze and critique the AI's output. Writing for the Times Higher Education, science faculty member at Colorado State University, Urbi Ghosh , notes that, “AI technology helps to connect ideas, merging them to create stronger concepts and produce a wide range of ideas quickly.”

Can AI paraphrasing tools be used while upholding academic integrity?

While the use of AI paraphrasing tools poses challenges to academic integrity, there are situations where they can be employed ethically. For instance, these tools can be valuable aids for students and researchers in rephrasing complex ideas or improving the readability of their writing. When used appropriately, AI paraphrasing can complement original thought and enhance the overall quality of academic work.

However, it's crucial for users to understand the limitations and risks associated with AI paraphrasing. Simply relying on automated tools without a deep understanding of the content can lead to unintentional plagiarism or distortion of the original ideas. Therefore, it's essential for individuals to use AI paraphrasing tools responsibly, ensuring that they maintain transparency about the sources they are paraphrasing and accurately attribute ideas to their original authors .

Educators play a vital role in guiding students on the ethical use of AI paraphrasing and promoting a culture of academic integrity. By providing clear guidelines, offering resources for proper paraphrasing techniques , and encouraging critical thinking skills, educators can empower students to use AI paraphrasing tools effectively while upholding academic standards.

Overview: Encouraging critical thinking in an era of AI paraphrasing

In an era where generative AI can effortlessly generate text and AI paraphrasing tools can manipulate it, reinforcing the importance of critical thinking has become more crucial than ever in the education space.

Critical thinking is a cornerstone of effective decision-making, problem-solving, and ethical conduct and equips individuals with the ability to discern credible sources from unreliable ones, have a deeper understanding of complex information, and maintain intellectual independence. These skills are indispensable for ensuring the accuracy, originality, and integrity of our work. And educators play a pivotal role in this dynamic.

By promoting AI as a responsible learning resource rather than a crutch, teachers can cultivate an environment that prioritizes and develops critical thinking in the digital world. This not only prepares students for academic success but also for the complexities of real-world challenges, including their next steps into the workforce.

COVID-19 and TDR

• Standing Committee
• Joint Coordinating Board
• Scientific and Technical Advisory Committee
• Scientific Working Groups

• Malaria research
• Tuberculosis research
• Vector-borne diseases
• Neglected tropical diseases research 

Implementation research training materials

• Massive open online course (MOOC) on implementation research
• Postgraduate training scheme  
• Regional training centres
• Clinical Research Leadership fellowship programme

TDR Global profiles

• Women in science
• TDR impact research grants scheme
• Gender and infectious disease research
• Knowledge management
• SORT IT operational research and training

All feature stories

All Publications

TDR Strategy 2024-29

Global Health Matters podcast »

Grants and other funding opportunities

eTDR portal

Our partnerships

ESSENCE on Health Research

Social Innovation in Health Initiative

The Access and Delivery Partnership

Indonesian university boosts Asia’s public health programmes through research training

Growing up in Bangladesh where several infectious diseases transmitted by helminths (worms) take a large health toll, Tilak Chandra Nath has always been fascinated with the challenges of addressing diseases of poverty.

After graduating as a biologist, Ezra Valido’s interest in infectious diseases took him to work in a rural, poor community in the eastern Philippines, where he headed public health programmes on tuberculosis, measles, dengue and chikungunya.

Valido’s community was devastated in 2013 by Typhoon Haiyan, one of the most powerful tropical cyclones ever recorded. From that, he gained experience working in the aftermath of a disaster, including how to prevent waterborne diseases and sanitation-related illnesses.

As a TDR-supported fellow, also at UGM in 2017, Valido’s research project focused on how willing people were to take doses of the dengue vaccine in poor communities in the Philippines’ Quezon City. His initial plan was to focus on how the vaccines were rolled out. But this had to be shelved after community and media outrage based on misinformation about the vaccine led the government to cancel its vaccination plans.

TDR’s postgraduate training programme on implementation research

Both Nath and Valido were part of a special postgraduate training programme focused on implementation research, based at UGM’s Faculty of Medicine, Public Health and Nursing, located in Yogyakarta. 

The programme, involving students from both WHO’s South-East Asia and Western Pacific Regions, is supported by TDR, a global programme for research on diseases of poverty ,   hosted by the World Health Organization (WHO) in Geneva, and co-sponsored by the United Nations Children’s Fund (UNICEF), the United Nations Development Programme (UNDP), WHO and the World Bank.

UGM is part of TDR’s global postgraduate training scheme network , developed over the past eight years to boost the skills of future research leaders.  

The initiative focuses on building students’ skills in implementation research, a fast-growing field that supports the identification of system bottlenecks to delivering health services and approaches to addressing them. It is particularly useful in low- and middle–income countries where many health interventions do not reach those who need them the most.

One of the two partner institutions in Asia Pacific is UGM, where the initiative is co-ordinated by Professor Yodi Mahendradhata, Dean of Research and Development at the Faculty of Medicine, Public Health and Nursing. 

Involved from the start

Mahendradhata is proud of the fact that UGM was involved from the start - back in 2015 – in  TDR’s fellowship scheme as well as in the parallel development of course content for implementation research. So he feels considerable ownership over how it has evolved.

“It wasn’t just about receiving the tools and the toolkits, but being involved very early on in the development of the implementation research course, and that is what we particularly appreciate from TDR,” said Mahendradhata. “We learned a lot from participating in the development process, and that gives us a sense of ownership.”

His university has also developed and piloted lessons on implementation research as a part of a TDR-supported Massive Open Online Course (MOOC) , enabling researchers in places like Nepal and Myanmar to participate in virtual training, with UGM as the hub.

Critical and relevant

Valido is sanguine about how he had to shift the focus of his research on a new dengue vaccine from examining the standard parameters of mass rollout to focusing on the vaccine’s  acceptability in one city, Quezon, the biggest city in the Philippines.

Sanofi Pasteur’s Dengvaxia vaccine was approved in the Philippines in December 2015 , and the government started to roll it out to primary school children in 2016. However, in late 2017, Sanofi issued a statement reporting that, in rare cases, the vaccine could increase the risk of severe dengue illness in children who had never had the disease if they contracted the virus after being vaccinated. A public outcry followed , and the health department suspended the vaccine programme soon afterwards.

“While we were conducting the research, an update on the vaccine information caused a media frenzy which eventually led to its suspension and eventual cancellation,” he says. “We had to change the research and eventually looked at the change in the acceptability of the vaccine pre- and post-controversy.”

“The programme teaches you to be critical and relevant, and I had to change my research to remain relevant,” Valido says.“At the time, the Philippines was the only country implementing mass dengue vaccination in schools.”

Dengvaxia has since been approved in a number of countries, including the US – but only for people clinically proven to have had dengue in the past.

Valido enjoyed the opportunity to dissect the Filippino government’s plans for the vaccine’s implementation, focusing on “strategic actions, context and health system thinking.” 

New insights into managing parasitic diseases

Meanwhile, Nath’s research into parasitic diseases gave him new insights into how they can be both managed and prevented.

“In developed countries, most parasitic diseases have been either eradicated or controlled, but the scenario is quite different in lower-income countries, where many diseases remain a serious constraint to public health safety,” says Nath.

“Through the TDR training programme,” he says, “I learned to investigate the problems in preventing these diseases in greater detail and pave the way to find an implementable solution for policy-makers to mitigate the burden.”

Preparing for the future

Following his studies at UGM, Nath continued his research training, completing a PhD in Medicine from the Chungbuk National University, in Korea, in the area of One Health.  He is now an Associate Professor in the Department of Parasitology at Sylhet Agricultural University in Bangladesh.

 In a sense he has come full-circle - bringing knowledge amassed through years of study abroad back to his home country to ponder issues that he wondered about since his youth.  

“I am now actively engaged with helminthiasis elimination and biobanking of parasites projects,” says Nath, who is currently also the director of Bangladesh’s Parasite Resource Bank, where he is investigating the interactions between human, animal, and environmental parasites, following the One Health approach. 

Meanwhile, Valido is working on the biomedical aspects of infectious diseases as a post-doctoral researcher at Swiss Paraplegic Research, where he is exploring the interaction of microbiomes and the spinal cord. He started this work while completing his PhD in Health Sciences at the University of Lucerne in Switzerland. 

Few scientists understand the biomedical aspects of infectious diseases and “the complexity of public health designs to improve health programmes, guide health policies and identify key health infrastructure,” Valido observes. The TDR training helped him to build that interdisciplinary skill set.

This is the first article in a series on TDR’s research capacity strengthening programme - building skills of public health researchers, implementers, health practitioners and policy-makers in the fast-developing field of implementation research for improving uptake of effective health interventions.

TDR’s postgraduate training scheme

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• My Bibliography
• Collections
• Citation manager

Save citation to file

Email citation, add to collections.

• Create a new collection
• Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

• Search in PubMed
• Search in NLM Catalog
• Add to Search

Can internship programs affect nursing students' critical thinking disposition, caring behaviors, and professional commitment?

Affiliations.

• 1 Reproductive and Family Health Research Center, Kerman University of Medical Sciences, Kerman, Iran.
• 2 Nursing Research Center, Kerman University of Medical Sciences, Kerman, Iran.
• 3 Health in Disasters and Emergencies Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran.
• 4 Nursing Research Center, Kerman University of Medical Sciences, Kerman, Iran. [email protected].
• PMID: 38902770
• DOI: 10.1186/s12912-024-02089-3

Background: Nursing students are given opportunities to develop critical thinking disposition, caring behaviors, and professional commitment through clinical training. Therefore, nurse educators should move away from traditional methods toward new ones, such as internship programs in clinical training. This study assessed the effect of nursing internship programs on senior undergraduate nursing students' critical thinking disposition, caring behaviors, and professional commitment.

Methods: This quasi-experimental study was conducted using a pretest-posttest design but with no control group. The study sample included 46 senior students enrolled in nursing internship programs. A demographic questionnaire, the Critical Thinking Disposition Inventory (CTDI), the Caring Assessment Report Evaluation (Care-Q), and the Nursing Professional Commitment Scale (NPCS) were used to collect data before and five months after the nursing internship programs were implemented.

Results: The study findings revealed that the senior nursing students' caring behaviors improved, but the total scores of critical thinking disposition and professional commitment did not change significantly after the nursing internship programs (p > 0.05).

Conclusion: According to the results, nurse educators are recommended to adopt strategies to improve the effectiveness of internship programs on critical thinking disposition and professional commitment among senior undergraduate nursing students.

Keywords: Caring behaviors; Critical thinking disposition; Internship programs; Nursing students; Professional commitment.

© 2024. The Author(s).

PubMed Disclaimer

• Jamshidi N, Molazem Z, Sharif F, Torabizadeh C, Najafi Kalyani M. The challenges of nursing students in the clinical learning environment: A qualitative study. The Scientific World Journal 2016, 2016.
• Seobuk-gu C-S. The relationship between problem solving ability, professional self concept, and critical thinking disposition of nursing students. Int J Bio-Science bio-technology. 2014;6(5):131–42.
• de Oliveira LB, de Araújo Püschel VA, Díaz LJR. The effectiveness of teaching strategies for the development of critical thinking in nursing undergraduate students: a systematic review protocol. JBI Database Syst Reviews Implement Rep. 2015;13(2):26–36. - DOI
• Benner P, Hughes RG, Sutphen M. Clinical reasoning, decisionmaking, and action: thinking critically and clinically. Patient safety and quality: an evidence-based handbook for nurses. Agency for Healthcare Research and Quality (US); 2008.
• Nieto AM, Saiz C. Critical thinking: a question of aptitude and attitude? Inquiry: Crit Think Disciplines. 2010;25(2):19–26.
• Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Lippincott Open Access
• PMC10241415

Capturing New Nurses' Experiences and Supporting Critical Thinking

This study analyzed the contents of critical reflective journals written by new nurses during their orientations using a text network. This study aimed to find ways to reduce turnover and improve clinical field adaptability among new nurses. The authors analyzed the content of reflective journals written by 143 new nurses from March 2020 to January 2021. Text network analysis was performed using the NetMiner 4.4.3 program. After data preprocessing, frequency of occurrence, degree centrality, closeness centrality, betweenness centrality, and eigenvector community were analyzed. In total, 453 words were extracted and refined, and words with high simple frequency and centrality were “incompetence,” “preparation,” “explanation,” “injection,” “time,” “examination,” and “first try.” “Medication” had the highest frequency of occurrence, and “incompetence” was the most important keyword in the centrality analysis. In addition, component analysis and eigenvector community analysis revealed three sub-theme groups: (1) basic nursing skills required for new nurses, (2) insufficient competency, and (3) explanation of nursing work. Significantly, this study is the first to use the text network method to analyze the subjective experiences of the critical reflective journals of new nurses. In conclusion, changes are needed to improve the education system for new nurses and promote efficient sharing of nursing tasks.

“New nurses” are nurses who work in hospitals within their first year of acquiring a nursing license. New nurses experience several challenges while adapting to the clinical environment because they often identify patient problems and make high-quality clinical decisions in rapidly changing clinical settings. Critical thinking ability is essential to overcoming difficulties in meeting these demands. 1 In particular, critical thinking ability positively affects clinical decisions through communication and may help new nurses adapt to their working environment. 2 However, new nurses tend to have lower critical thinking abilities than tenured nurses and require time to develop clinical competencies. 3 Because inadequate critical thinking skills may make it difficult for new nurses to provide optimal nursing care and thus may negatively affect patient safety, 3 new nurses must develop strong critical thinking skills.

Furthermore, critical thinking is a reflective thinking process that enables one to decide what to believe and what to do, 4 and reflection is essential to enhance critical thinking ability. 5 Reflective journaling is an approach to internalizing learned knowledge through reflective thinking and objectifying activities, 6 which in turn may strengthen critical thinking and clinical decision-making abilities. 3 Reflective thinking connects new knowledge with existing knowledge, enables abstract thinking, and enables individuals to use specific solution-oriented strategies based on their knowledge and experiences in response to new problems. 7 In the context of nursing education, reflective journaling crucially allows learners to observe their emotional and psychological states. 8 For new nurses, the process of transitioning from being a nursing student to working as a nurse may be confusing and difficult, and reflective journaling during this period may improve clinical decision-making skills, relieve the challenges associated with the transition process, and promote communication with preceptors and nursing managers. 9 , 10

Reflective journaling is a clinically viable educational method for the self-analysis of clinical decision making in residency programs for new nurses. 11 In particular, reflective journaling is a useful educational method for strengthening clinical adaptation capacity in new nurses. 8 – 10 Analyzing the content of these journals can reveal how best to shape pedagogy to strengthen the competencies of new nurses.

Many studies have been conducted to help new nurses adapt and decrease their turnover. These studies include research on the factors affecting the retention intention and turnover of new nurses, 12 , 13 qualitative research on the practical adaptation experience of new nurses, and literature reviews on new nurse education programs. 14 , 15 However, no study has yet analyzed the reflective journals written by new nurses; therefore, it is necessary to review these journals, which offer insights into the actual experiences of new nurses. Other disciplines, such as pedagogy, have applied text network analysis (TNA) for more objective document research by linking content analysis and social network analysis. 16 The TNA method is an analysis technique that interprets a phenomenon using a network that displays the relationships between the words appearing in the text as “links.” Notably, TNA is a useful analysis method to identify the relationship between core keywords and other keywords. 17 In addition, this method can enhance knowledge of related phenomena through quantitatively examining the words appearing in text and identifying words that co-occur with other specific words. 18 Recently, in the field of nursing, studies have used network analyses to uncover research trends and knowledge structures, 19 , 20 including by analyzing the contents of the practices of nursing students. 21

In response to the gap in the literature, the authors sought to uncover the clinical experiences of new nurses during the orientation period by analyzing their critical reflective journals using the TNA method. In particular, the authors examined the relationships between keywords and main words and experiences. This study's specific objectives were as follows:

• To extract keywords based on their frequency and identify core keywords.
• To identify core topic and sub-theme groups.

Research Design

In this quantitative content analysis study, the authors applied the TNA method to identify the core keywords from new nurses' critical reflective journals on their clinical experiences during their orientation period.

Research Sample and Data Collection

The authors analyzed the critical reflective journals written by 143 new nurses who joined a university hospital located in an urban area of Korea from March 2020 to January 2021. The nurses recorded their experiences in the critical reflective journals six times during the orientation period (8 weeks). The nurses were instructed to record, in the form of narration, the most memorable aspects of their nursing interactions with patients and list their performance strengths and shortcomings in each situation. The journal structure was configured to assist them in establishing and writing goals, as well as with developing plans to improve their shortcomings. The researcher obtained the nurses' consent to participate in the study after detailing the purpose and method of writing critical reflective journals for 30 minutes during the common orientation period. New nurses were introduced to critical thinking as a very important and necessary process for improving clinical judgment. In addition, clinical nurse educators prompted new nurses to reflect on the situations they experienced in the field when writing in their journals; in particular, they asked the nurses to contextualize these situations and consider alternative ways they may have solved problems they encountered in the field. The researchers explained to the new nurses that the journals would only be used to analyze basic data to uncover how best to help new nurses adapt to the field. Next, new nurses who voluntarily agreed to participate were provided with a journal before being assigned to a department. Research participants were notified they could withdraw from the study at any time, and they were asked to contact the clinical nurse educators with any difficulties or questions related to journaling. After orientation, the nursing education team collected the journals.

Data Analysis

In the analysis of the collected data, the main semantic structure was visualized as a sociogram through preprocessing and network analysis. Analysis was performed using NetMiner 4.4.3 (Cyram Co. Ltd., Gyeonggi-do, Korea).

Preprocessing Stages

The journals were transcribed to Microsoft Office Excel (Microsoft Inc., Redmond, WA, USA) and converted into databases. Four researchers divided the reflective journals, copied them, and then went through the process of reconfirming each other's work. The data were extracted from long texts and included only nouns identified using the morpheme analysis function of NetMiner 4.4.3. Using the NetMiner's “import unstructured text” menu, the database data were read and morphemes were extracted. A thesaurus was created to unify words with similar meanings. While examining the extracted morphemes, meaningful morphemes were extracted using the thesaurus, defined words, and excluded words, and word purification was performed using the extraction results.

The thesaurus grouped words (phrases) with similar meanings, and the researcher designated the representative words for each group. 22 In Korean alphabet (Hangeul), words with the same meaning are often presented differently, 23 so the authors paid attention to the selection of representative words and their registration in the thesaurus. For example, “alcohol cotton” was made to represent “alcohol swab,” “disinfection cotton,” “cotton,” and “alcohol.” Phrases consisting of two or more words were also added to the dictionary to establish that the multiple words comprising the phrase should be read as a unit. 24 For example, the words “intravenous” and “injection” were registered within the dictionary as comprising “intravenous injection.” The dictionary of excluded words went through a refining process to exclude stop words, such as pronouns and adverbs without important meanings. The process of word refinement involved several rounds of consultation between joint researchers to reduce subjective bias. In addition, “frequency of appearance” refers to the number of times a keyword appears in an entire document. In order to exclude commonly used words that appear frequently in all documents, words with a term frequency–inverse document frequency (TF-IDF) value of 0.5 or less were excluded by referring to previous studies. 25 The frequency of words appearing in one document is called “term frequency,” and the number of documents in which a word appears is called “document frequency.” “Inverse document frequency” is the logarithmic expression of the inverse of document frequency. A high term frequency value may be recognized as a keyword due to a high frequency in one document, but if the term frequency value is equally high in other documents, it is considered a commonly used word in several documents, even if it may not be necessarily a keyword. Therefore, it should be excluded when extracting keywords by calculating inverse document frequency values of words. For this purpose, TF-IDF, which represents the importance of any word in a particular document, is obtained by multiplying term frequency and inverse document frequency, and used for word extraction. The larger the TF-IDF value, the higher the importance of any word in the document. 26 In this study, five words with a TF-IDF value of 0.5 or less (eg, “teacher,” “patient,” “work,” “think,” and “confirm”) were included in the dictionary of excluded words.

Finally, 274 thesaurus, 301 defined words, and 1759 excluded words were registered in the user dictionary. As a result, a total of 453 words were extracted in the critical reflective journals written by the new nurses. In this study, the top 30 keywords' frequency of appearance was analyzed based on refined words to extract keywords. To intuitively represent keywords, frequency of appearance was generated by using NetMiner 4.4.3.

Process of Network Formation

The network formation process generated a keyword co-occurrence matrix to reflect that the two keywords appeared next to each other in one sentence or were located among the other keywords. 27 Repeated co-occurrence can be interpreted as forming a semantic structure between the words. The higher the degree of connection, the more co-occurrence exists across different types of keywords, which yields a semantic structure in various contexts. In the one-mode matrix of the “keyword × keyword” relationship, the degree value was 1 to 48, 70.4% (1649) for less than 1 and 85.4% (1999) for less than 2.

To grasp the main phenomenon in network analysis, only keywords with an appropriate level of connection are included, but the reference value for the connection degree is not presented, 28 and the study result is determined considering ease of interpretation and network visualization. 27 In this study, a one-mode matrix composed of 401 keywords with a connection degree of two or higher was generated and used for network analysis.

Network Statistical Analysis and Visualization

Statistical analysis was performed and visualized using a one-mode network to discover the core keywords in the journals.

The centrality of the network was analyzed for degree centrality, closeness centrality, and betweenness centrality, which are indicators of centrality, and the average and concentration of each centrality were confirmed. Centrality indicators show that words with high centrality are considered core keywords to the extent that words in the network are centered. 29 The value of the centrality indicator exists between 0 and 1; the larger the value, the higher the centrality of the word. 28 The average centrality indicator refers to the center value of the entire network centrality indicator, and centralization represents the degree to which a network is structurally concentrated or distributed across a specific word. Thus, an intensive link flow in a small number of words indicates that the network is highly concentrated. 29

Degree centrality refers to the degree of connection between nodes (in this study, keywords used in the analysis) in the network; this indicates co-occurrence between words and indicates the number of connections between nodes. 28 Keywords with high connection centrality are often connected to other keywords, which means that they are important keywords. Closeness centrality refers to the degree to which a node is located close to another node in the network. 28 Keywords with high proximity centrality may be interpreted as keywords that play a central role in the network while reaching other keywords the fastest. Betweenness centrality refers to the degree to which other nodes and intermediaries play a role in the network. 28 Keywords with high mediation betweenness centrality serve as bridges that interconnect sub-keywords between networks. The top 30 words with high degree centrality, closeness centrality, and betweenness centrality were visualized as sociograms. The larger the node size, the larger the centrality index, and the thicker the link, the higher the co-occurrence frequency.

Sub-theme Analysis

To identify the sub-theme groups, the authors first extracted the largest component based on cohesion in the NetMiner program and then performed an eigenvector community analysis. A component is a group in which keywords are connected without being broken. Communities refer to subgroups with relatively low modularity, high connection density inside the group, and relatively low connection density outside the group within the component structure. The modularity value is used to determine the optimality of the community structure; eigenvector community modularity can have a value between negative (−) infinity and “1”—the larger the value, the better the modularity. 30

Ethical Considerations

This study was approved by the institutional review board (CNUH-2020-247) of the university hospital located in an urban area of Korea to protect the participants, where the current study was conducted. Participants were informed about the purpose of the study, their rights to anonymity and confidentiality, and their freedom to withdraw from the study. Written informed consent was obtained from those who wished to participate in the study.

Keywords of the Critical Reflective Journal of New Nurses

The top 30 keywords by simple frequency, degree centrality, closeness centrality, and betweenness centrality were identified as core keywords in the journals (Table ​ (Table1). 1 ). The simple frequency appeared in following order: “medication,” “intravenous (IV) cannulation,” “preparation,” “incompetence,” and “explanation.” In this study, the means of the degree centrality, closeness centrality, and betweenness centrality of the word networks were 0.216, 0.501, and 0.037, respectively, and the concentrations were 24.9%, 30.2%, and 14.0%, respectively. Regarding degree centrality, “incompetence,” “explanation,” “preparation,” “medication,” and “properly” were the most important keywords. Regarding closeness centrality, “incompetence,” “preparation,” “explanation,” and “time” were the most important keywords. Regarding betweenness centrality, “incompetence,” “preparation,” “first try,” “understand,” and “explanation” were the most important keywords. In the analysis of the most memorable events during the orientation period for new nurses, words such as “incompetence,” “preparation,” “explanation,” and “injection” were high in both frequency and centrality. Regarding the simple frequency, “medication” was the most frequent keyword. Regarding the centrality analysis, “incompetence” was the most important keyword.

Top 30 Keywords That Emerged From the Reflective Journal of New Nurses

Visualizing the Main Semantic Structure

Figure ​ Figure1 1 presents a sociogram, a graph consisting of nodes and links, of the top 30 keywords. The size of a node indicates the degree centrality, and the thickness of a link indicates the strength of the connection, that is, the frequency of co-occurrence. The researchers examined the semantic structure by focusing on five core topics: “medication,” which is strongly tied with “study,” “explanation,” “examination,” and “remember”; “preparation,” which is part of a semantic structure with “injection,” “operation,” “medication,” “time,” and “fluid”; “time,” which is strongly tied with “nursing” and “performance”; and “explanation,” which is part of a semantic structure with “caregiver,” “incompetence,” and “nursing.” Finally, “IV cannulation,” “fluid,” and “organization” formed the semantic structures; “first try,” “IV cannulation,” “admission,” and “night” appeared as meaningful structures; and “properly” and “explanation,” “need,” and “study” appeared as meaningful structures.

Keyword network analysis of the reflective journal of new nurses.

Regarding degree centrality and closeness centrality, “night,” “operation,” “condition,” and “suction” showed low degree centrality and centered on “incompetent,” which demonstrated the highest centrality. Regarding betweenness centrality, “night,” “blood glucose management,” “fluid,” “condition,” “operation,” and “suction” showed low betweenness centrality and centered on “incompetent,” which again demonstrated the highest centrality.

Sub-thematic Groups

The component analysis and eigenvector community analysis based on cohesion in the keyword network yielded three sub-thematic groups with an optimal modularity of 0.257 identified with sociograms (Figure ​ (Figure2). 2 ). Group 1 was classified into “medication,” “preparation,” “IV cannulation,” “first try,” “administration,” “injection,” “examination,” “blood glucose management,” “operation,” “fluid,” “blood sampling,” “blood,” “night,” and “caregiver.” Group 2 was classified into “incompetence,” “time,” “nursing,” “properly,” “electronic medical record (EMR),” “understand,” “study,” “organization,” “performance,” “condition,” and “suction.” Group 3 was classified into “explanation,” “need,” “remember,” “situation,” and “admission.” The research topic groups were named based on the contexts in which the keywords of each subgroup were used. The three sub-themes were (1) basic nursing skills required for new nurses, (2) insufficient competency, and (3) explanation of nursing work.

Visualization of subgroup analysis from the reflective journal of new nurses.

This study sought to understand the work experiences of new nurses by using a TNA method to analyze the contents of the critical reflective journals they wrote during their orientation (the first 8 weeks after they began working in the hospital). The main semantic structure specifically showed the context of the core topic.

More specifically, the frequency and centrality analyses confirmed that, in terms of working directly with patients, the new nurses had the most difficulty with tasks related to medication. The contents of the analysis suggest that a new nurse must prepare drugs for patients and explain the medication to the patient while administering the drug through injection. The new nurses described their experiences with this process in their journals as follows: “When I went to the patient to inject the drugs, the patient asked a question about why the drug was being used, but I did not explain the reason properly” and “I don't know how to explain the efficacy and side effects of various types of drugs administered to patients.” These excerpts suggest that new nurses lack knowledge about medications and experience job stress and low confidence; if these problems are not resolved, they may lead to job turnover. 31 New nurses must learn to administer medications; this is a core basic nursing skill in nursing colleges. A practical training room in the hospital is necessary to provide systematic and sufficient opportunities for repeated practice to improve the confidence of new nurses in their core basic nursing skills and reduce work stress. 32

This study uncovered the following main semantic structures. First, new nurses experience a lack of clinical knowledge about medication and feel a need to study on their own. In addition, a lack of drug-related knowledge caused new nurses to feel burdened when teaching a patient or their caregivers about a medication before administering it. Additionally, new nurses felt that they should remember what they learned on their own and in clinical practice from their preceptors. They also felt the need to learn and study the drugs used in many tests. Medication errors are an important factor in patient safety and are the most frequent medical accidents. 33 Administering the correct drug to the correct patient, providing information about the drug to the patient, and confirming and reporting the side effects of a drug is necessary to reduce medication errors; therefore, it is crucial to emphasize this in nursing programs. 33 Because this study found that new nurses experienced many difficulties with medication, it is necessary to establish a protocol for clinical practice and improve systematic education through simulation. 34

Second, this study confirmed that new nurses must prepare to successfully give injections, oral medications, and fluids and to facilitate operations (eg, preparing dressing materials). 35 In addition, new nurses were frequently pressed for time while taking care of patients. The results were similar to those from a study in which new nurses reported that the confidence level for the item “I can completely care for a patient within the allotted time” was low at 20%–50%. 36 New nurses often work overtime at hospitals; for example, some nurses go to work 2 hours early and complete their records after work because they do not have enough time to complete their duties within their scheduled hours. 37 This suggests that nursing tasks should be more appropriately distributed. 36

Third, new nurses need skills to explain their care to patients or caregivers while working. Accordingly, new nurses need to have strong relationship and communication skills. 38 The journals revealed that new nurses feel their work requires them to be able to properly explain different elements of care to patients and their caregivers; however, they often felt that they did not have the knowledge or skills necessary to carry out this duty. Moreover, the new nurses themselves felt they needed to study to ensure that they were not ignorant in ways that may harm the patient. Therefore, a system should be established to help new nurses strengthen their skills by actively utilizing support resources at the hospital level; notably, this may reduce turnover. Along these lines, a simulation program related to communication should be used during orientation to increase the communication abilities of new nurses. 39

Fourth, new nurses reported difficulties with IV cannulation and their first inpatient admissions. They felt pressured to complete an IV cannulation for the first time and struggled to connect and arrange various fluids. Simulations that teach new nurses how to administer intravenous injections should be included in orientations in response to this trend. Most wards in this research institute use functional nursing, with different numbers of people per service. Therefore, new nurses completed different tasks during day and evening shifts, such as IV cannulation, injection, and vital sign and blood glucose testing during the former and overseeing patients, checking prescriptions, and entering records during the latter. Accordingly, they reported that night work was very complicated and that they felt that they were lacking in their skills to complete it successfully. Previous studies reported that new nurses in Korea experienced excessive workload, communication difficulties, and low confidence in their work, suggesting that active intervention is needed to improve clinical adaptation in new nurses. 36 Therefore, there is a need to develop various programs, such as communication programs and basic nursing skill simulations, for new nurses.

Finally, based on the analysis of the three sub-thematic groups, the first subject group was “basic nursing skills required for new nurses.” The ability to perform basic nursing skills is an essential element for new nurses to adapt to practice: when nursing skills are lacking, they experience overload in the clinical field; this leads to increased stress, which increases the resignation rate. 40 In 2019, Korean institutions began to ensure they were offering clinical nurse educator systems and training programs to reduce the resignation rate of new nurses by improving their competency. 41 Programs that intensively train new nurses in basic nursing skills at the initial stage of their employment are essential in hospitals to help new nurses adapt to practice. The second thematic group was “insufficient competency.” New nurses start clinical work with insufficient clinical experience and competency; experience difficulties in providing and selecting appropriate treatments for patients; and must cope with overload, which increases their role burden. 37 Therefore, it is necessary to reduce the amount of work assigned to new nurses and to develop educational programs that can identify problems by presenting various situations that can help them understand their work. The third topic group was “explanation of nursing work.” New nurses most frequently deal with patients and caregivers and thus feel pressured to properly explain things to them (eg, why patients are hospitalized, what medications they are receiving); this feeds their desire to remember what they have learned. In addition, new nurses often complain of communication difficulties 38 ; accordingly, clinical communication programs should be developed to overcome this problem.

Unlike previous studies, this study analyzed the experiences of new nurses by applying TNA to the critical reflective journals they wrote during orientation. However, the information was only collected over the course of a year, which limits the generalizability of the research results. In addition, the fact that the nursing manager reports and provides feedback on the journals may have limited direct expression. To overcome these limitations, a program for the in-depth analysis of new nurses' experiences should be implemented in the future. Ultimately, this study sets the foundation for further analysis of the experiences of new nurses by being the first to use a TNA to effectively explore the subjective experiences of new nurses.

This study applied a TNA to identify, group, and analyze core keywords in the critical reflective journals new nurses wrote during their orientation at tertiary general hospitals in Korea. New nurses' most memorable events during orientation were reflected by high-frequency and high-centrality words, such as “incompetence,” “preparation,” “explanation,” and “injection.”

This study's results can guide best practice for improving the field adaptability of new nurses and reducing their turnover rate. Currently, nursing students in Korea nursing mainly complete observation-oriented practicums; this increases the burden on their basic nursing skills. Being compelled to perform extensive duties beyond their competencies is causing exhaustion among new nurses. To mitigate these issues, changes should be made to the new nurse education system to better prepare new nurses and nursing duties should be more efficiently distributed.

This study was financially supported from Back Ui Association, Chonnam National University Hospital (2021).

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

Ethical Approval: The study was approved by the Chonnam National University Hospital Institutional Review Board (approval number: CNUH-2020-247).

Hye Won Jeong: https://orcid.org/0000-0001-5664-8672

Shin Hye Ahn: https://orcid.org/0000-0002-1403-2711