strategies to develop critical thinking in nursing students

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• v.7(2); 2020 Mar

Critical thinking skills of nursing students: Observations of classroom instructional activities

Christian makafui boso.

1 Department of Nursing and Midwifery, Faculty of Medicine & Health Sciences, Stellenbosch University, Cape Town South Africa

2 School of Nursing and Midwifery, College of Health and Allied Sciences, University of Cape Coast, Cape Coast Ghana

Anita S. van der Merwe

Janet gross.

3 Peace Corps Liberia, Mother Patern College of Health Sciences, Stella Maris Polytechnic, Monrovia Liberia

Critical thinking (CT) is vital for nursing practice. Nursing schools should provide learning experiences that enable nursing students to acquire CT skills. Yet, these authors are not aware of any study that has directly observed instructional activities related to CT skills acquisition in the classroom environment. The aim of this study was to explore instructional activities in the classroom environment in relation to acquisition of CT skills of students.

Qualitative non‐participant observation.

Using a purposive sampling, 10 classroom teaching sessions were observed and mediating factors of CT skills acquisition of students noted. Data were analysed thematically. Data were collected from October–December 2017. 

Three key themes of instructional activities relating to acquisition of CT skills of students emerged, namely educators’ behaviour, students’ characteristics and university‐wide factors/administrative support. Class sizes ranged from 34–162 students with an average of 95.

1. INTRODUCTION

The ever‐changing and complex healthcare environment requires that nurses acquire critical thinking (CT) skills to meet the complex challenges of the environment (Von Colln‐Appling & Giuliano, 2017 ). Nurses should be able to select and use data for effective clinical judgements to promote good health outcomes (Nelson, 2017 ; Von Colln‐Appling & Giuliano, 2017 ). Consequently, nursing schools must offer learning experiences that assist students to think critically about complex issues instead of just merely becoming receptacles for information (Toofany, 2008 ; Von Colln‐Appling & Giuliano, 2017 ). It is the duty of nurse educators to help students to acquire CT skills (Nelson, 2017 ; Von Colln‐Appling & Giuliano, 2017 ).

Attempts have been made to conceptualize CT to guide the facilitation of CT skills of students. Worth noting are Dwyer, Hogan, and Stewart ( 2014 ) and Duron, Limbach, and Waugh’s ( 2006 ) frameworks, which could be relevant in the classroom setting. Focusing on learning outcomes, Dwyer et al. ( 2014 ) posited that long‐term memory and comprehension are foundational processes for CT application. The framework incorporates both reflective judgement and self‐regulatory functions of metacognition as a requirement for CT. Self‐regulation refers to an individual's ability, willingness and the perceived need to think critically when solving specific problems. Therefore, factors that influence the interrelationship between short‐term and long‐term memory (the bedrock of CT), comprehension, reflective judgement and self‐regulation functions of metacognition will influence CT skills of the students. On the other, Duron et al.’s model focused on practical instructional activities needed to guide students in acquiring CT skills. The five‐step framework requires that educators: (a) determine learning objectives; (b) teach through questioning; (c) practice before assessing; (d) review, refine and improve; and (e) provide feedback and assessment of learning.

Nursing literature is replete with studies demonstrating that adopting appropriate teaching methods/strategies, such as active learning, improves the CT scores of students. Examples of such approaches include problem‐based learning (Jones, 2008 ; Jun, Lee, Park, Chang, & Kim, 2013 ), concept mapping (Wheeler & Collins, 2003 ) and simulation (Sullivan‐Mann, Perron, & Fellner, 2009 ). Furthermore, based on a systematic review, Chan ( 2013 ) suggested three strategies to facilitate CT skills of nursing students, which include appropriate questioning strategy, reflective writing on learning experiences and discussion of case study.

The classroom environment provides a vital opportunity for educators to create the necessary milieu to encourage students to develop their CT skills. It is therefore required that negative factors to the development of CT are minimized or removed and those factors that enhance the development of CT skills are accentuated. However, these factors that influence CT have received less attention in nursing education (Raymond, Profetto‐McGrath, Myrick, & Strean, 2018 ). Furthermore, no direct observations have been made to identify specific factors influencing CT in the classroom setting.

Studies such as those of Mangena and Chabeli ( 2005 ) and Shell ( 2001 ) assessed factors that inhibit CT acquisition of nursing students. Mangena and Chabeli's study focused on educators and students’ perspectives. They found that educators’ lack of knowledge of CT teaching methods and evaluation, negative attitudes of educators, student selection and educational background, socialization, culture and language inhibited the development of CT skills of students. Shell also found negative student factors, demand to cover content and time constraints both on class time and on educators’ development that hindered CT skills development of students.

Raymond and Profetto‐McGrath ( 2005 ) also identified internal and external factors of educators that had an impact on their CT. These factors included physical and mental well‐being, the view of leadership on CT and collegial relationships that existed in the educators’ environment. Similarly, Raymond et al. ( 2018 ) identified personal (elements/conditions originating from the educator), interpersonal (elements originating from the student–educator relationship) and broader environmental factors (conditions evident in the larger physical setting or political milieu) that influenced educators’ CT and influenced their abilities to role model CT skills.

The above authors focused on factors influencing CT from different perspectives. Shell ( 2001 ) and Mangena and Chabeli ( 2005 ) focused on barriers to student development of CT. Also, Shell examined educators’ perspectives. Mangena and Chabeli examined both educators’ and students’ views. Raymond and Profetto‐McGrath ( 2005 ) and Raymond et al. ( 2018 ) specifically focused on nurse educators' CT skills. None of the above studies directly observed classroom teaching though similar factors were identified.

2. BACKGROUND

The “greatest healthcare resource is the healthcare personnel, of which nurses are a primary component” (Talley, 2006 , p. 50). However, limited resources in nursing schools especially in developing countries where this study was undertaken (Talley, 2006 ) impede the experiences required for the students to develop CT skills. For example, studies have identified lack of qualified educators (Bell, Rominski, Bam, Donkor, & Lori, 2013 ; Salifu, Gross, Salifu, & Ninnoni, 2018 ) as well as infrastructural and logistical constraints (Talley, 2006 ), large class sizes and absenteeism (Wilmot, Kumfo, Danso‐Mensah, & Antwi‐Danso, 2013 ) as some of the challenges affecting nursing education. These challenges have led to the dominance of inappropriate teaching approaches (Boso & Gross, 2015 ; Wilmot et al., 2013 ).

Similarly, studies regarding CT have reported the negative influence of sociocultural norms such as the seniority tradition (Chan, 2013 ; Jenkins, 2011 ; Kawashima, 2003 ; Mangena & Chabeli, 2005 ). In such cultures, students are not encouraged to speak out openly (Chan, 2013 ). For example, an individual is not expected to disagree nor question an authority figure in public. In the context of this study, the seniority tradition could have been manifested in the classroom where the faculty is regarded as an authority whose ideas may be seen as sacrosanct by students. These authors argue that it is necessary to identify the factors through direct observation that might hinder or enhance the facilitation of CT of students in the classroom setting. Notwithstanding, the authors of this paper had not found any publication in the nursing literature where direct observation for CT teaching methods/strategies had been carried out in the classroom setting. Therefore, this study explored factors that might influence students’ ability to memorize and comprehend content towards CT skills acquisition. Also, educators’ instructional activities that either enhanced or inhibited students’ CT facilitation in the classroom context were explored.

3. THE AIM OF THE STUDY

The aim of this study was to explore instructional activities towards the development of CT skills of students in a classroom environment. This study was part of a larger research project aimed at developing a CT‐based curriculum framework of students.

4. RESEARCH DESIGN

Qualitative non‐participant observation design was used. This design was to allow for the observation of first‐hand (Patton, 2015 ) and unusual aspects (Creswell & Creswell, 2018 ) real‐time classroom practices whilst being present. Also, qualitative observation has been noted as a primary means of understanding the experiences of users (Reddacliff, 2017 ).

5.1. Setting

The study was conducted in classroom settings of an undergraduate nursing programme in a public university in Ghana. As a school in a developing country, there are constraints such as logistical inadequacies and lack of adequate qualified faculty, which could inhibit meaningful learning experience towards CT skills development of students existed. The classes are scheduled based on the demands of the various departments of the university. The university runs several programmes, and each programme is allocated with venues as demanded.

5.2. Sampling

Through a purposive method ten (10) teaching sessions from class levels 200 to 400 were observed from October to December 2017. Educators who had lectures within the period were approached face‐to‐face. Ten out of 16 educators agreed to participate. They provided informed consent. The 10 sessions provided rich data to be able to deduce current practices of instruction as occurring in the classroom environment. The main selection criterion was a full teaching session (1–3 hr) of B.Sc. nursing undergraduate programme taught by an educator in the selected nursing school.

5.3. Data collection and instrumentation

Data were collected between October and December 2017. The observations were from five level 200, three level 300 and two level 400 classes; six medical–surgical, one maternal health, one biomedical and two nursing fundamental/theoretical courses were taught. Two individuals—first author and an assistant, consistent with Winter and Munn‐Giddings’ ( 2001 ) recommendation for observation, observed the teaching sessions. A six‐item semi‐structured observation guide/protocol using Billing and Halstead's ( 2005 ) six steps of designing learning experiences for developing CT skills was employed for data collection. Billing and Halstead's six steps of designing experiences for developing CT skills were consistent with identifying factors that enhance or inhibit memory, comprehension, reflective judgement and instruction identical to Dwyer et al. ( 2014 ) and Duron et al.’s ( 2006 ) frameworks. The protocol was pre‐tested in a classroom at an analogous nursing school. Though the sixth step of Billing and Halstead's ( 2005 ) six steps of designing learning experiences for developing CT skills proposes both summative and formative assessments, in the context of this observation, only formative assessment methods used by the educators could be observed.

Billing and Halstead's six steps of designing experiences for developing CT skills are as follows. Step 1 involved determining the learning outcome for the specific class. These learning objectives should be explicitly clear to students and fit for purpose. Step 2 involved creating an anticipatory set. The educator's strategies that generate students’ interest in content, encourage their participation and create collegial environment for students were observed. Step 3 consisted of selecting teaching and learning strategies. Observation focused on identifying active learning methods of teaching against passive teaching methods. Also, whether the educator or students dominated the class was explored. Whether the nurse educator combined different teaching methods/strategies were explored. Step 4 considered implementation issues. Class size, involvement of students, classroom arrangement, use of teaching aids and materials and instructional media were observed. Step 5 involved the observation of how the learning experience was closed. This included how the educator summarized the lesson and related lessons to next class period. Step 6 involved how students’ learning experiences were evaluated. The educator's strategies for the assessment and evaluation of student learning experience during class period were observed.

The observers positioned themselves at the back of the classrooms throughout each period of teaching. Participants did not appear distracted or uncomfortable during the periods of observation. Thoughts and feeling of the observers relative to observed situations were captured as field notes. In order not to distract and cause discomfort to participants, the observers took minimal notes and expanded them immediately after the observations. Transcripts from the observations were compared and agreed on by the two observers. Differences were resolved through discussion. Also, the educators whose teaching sessions were observed were asked to provide feedback and revision made based on educators' comment(s). This was to minimize observers’ bias.

5.4. Data analysis

Bryman's ( 2010 ) four stages of qualitative analysis as described by Gibbs ( 2010 ) were used to analyse the data. The first author and an assistant described each observation. Later, the first author read the transcript at least four times to enable a meaningful content analysis. Data were coded, and themes and sub‐themes were derived. Subsequently, the second and third authors who are the supervisors of this research project cross‐checked the themes and sub‐themes with the observational transcripts for validation.

5.5. Ethical consideration

This study was approved as one part of a doctoral project by the Health Research Ethics Committee of Stellenbosch University (Ref. no S17/05/106) and the university where the study was done. Permission was also sought from the dean of the selected school. The first author visited the students at their various classrooms to explain the nature and purpose of the study to them. Likewise, the nurse educators were provided with information on the purpose and nature of the study. They were provided individually with informed consent forms for signing before data were collected. They were assured of their rights to opt out at any stage of the study. Confidentiality and anonymity were also assured. Individual participants were not identified with the data (during data collection, analysis and reporting).

Three overall themes were deduced from the classroom observation data, namely educators’ behaviour, students’ behaviour and university‐wide factors/administrative support. These themes related to the Dwyer et al. ( 2014 ) and Duron et al.’s ( 2006 ) frameworks of CT development. To reiterate, these factors could either enhance or inhibit memory (foundation of CT development), comprehension, reflective judgement and self‐regulatory functions of metacognition as a requirement for CT.

6.1. Theme I: Educators’ classroom behaviour

Educators’ behaviour includes actions and inactions of the educators that might either enhance or inhibit students’ positive learning experiences towards the acquisition of CT skills. Four sub‐themes under this theme were identified namely beginning and ending on time; creating a conducive and participatory environment; and teaching methods and styles and managing the class.

6.1.1. Subtheme A: Beginning and ending on time

Only one (observation 6) started on time. The lecturer was in the class before scheduled time waiting for students. However, nine of the classes started late. The lateness ranged from 10 min (observations 2 and 7) to 44 min (observation 3). In one case (observation 5), the lecturer was on time but students were not available because they were moving immediately from another lecture. In other words, the ending time from the other lecture overlapped with the starting time of the new lecture. In another case (observation 8), the lecturer was engaged in an analogous official duty and therefore reported late.

6.1.2. Subtheme B: Creating a conducive and participatory environment

Some attitudes demonstrated by the educators appeared to have encouraged collegiality. For example, one lecturer's statement, "no answer is wrong, it could only be a right answer to a different question" (observation 2) caused students to participate in the teaching/learning process, which is consistent with CT teaching strategies. Also, some lecturers demonstrated a good sense of humour that was appreciated by students. For example, in observation 3, the lecturer asked a question and after the question, jokingly said, "my question to those in spectacles", which generated laughter from the students. The same lecturer appeared receptive to students’ views—allowed students to disagree with his views and even thanked students for asking questions. These strategies also demonstrated modelling of open‐mindedness (an attribute of CT) on part of the educators.

Active participation in the teaching and learning process is required to facilitate CT skills of students. However, some actions taken by some lecturers appeared to have resulted in students not fully participating in the learning process. For example, students appeared tense or nervous after the lecturer made the statements that "they [students] must respect and not make offensive statements; some of you are still adolescents. You must respect, I have always told you" (observation 8). This statement was in reaction to a comment from a student that the lecturer found to be offensive.

6.1.3. Subtheme C: Teaching methods and styles

The most frequent teaching method used was student presentation. In one case (observation 6), students were given case studies from which they were requested to draw a plan of care. However, students themselves used lectures whilst presenting. General discussions followed students' presentations led by the lecturer. The presentation encouraged students to share their views freely. However, during student presentations, several students appeared disinterested and were passive in the process. Some presenters just read from the power point slides verbatim. In cases where lecturers taught, they often used the lecture method interspersed with periods of questions and answers (observations 2, 3, 4 and 8).

In one lecture (observation 3), the lecturer related lessons to real life situations (stories from the clinical settings) that appeared to have sustained the interest of the students. The lecturer also frequently moved up and down the aisles during the class session. These actions appeared to have caused students to be more attentive (which enhances memory) throughout the session.

6.1.4. Subtheme D: Managing the class

Management of the class appeared to be challenging to some lecturers. For example, in observation 10, the lecturer did not act even when students were engaged in distractive behaviours. Most students generally appeared interested in the lesson. However, several students appeared indifferent with what was happening, and some conversed throughout the session (observation 10).

6.2. Theme II Students' characteristics

Students’ characteristics refer to actions and inactions of the students during observations that might either enhance or inhibit students’ positive learning experiences towards the acquisition of CT skills. Two sub‐themes under this theme were identified, namely distractive student behaviour and punctuality.

6.2.1. Subtheme A: Distractive student behaviour

Attention/perception processing is needed to enhance short‐term memory, which leads to long‐term memory (Dwyer et al., 2014 ). In all classes observed, several students were engaged in distractive behaviours that might hinder memory, namely fidgeting with phones, beeping/ringing phones, petty chatting and whispering—especially those sitting at the back roll of the class. However, what appeared to be the source of most distractive behaviour—the mobile phone—was useful in helping students in some of the presentations. Students sitting in front appeared more attentive. Movement of lecturers up and down the aisles appeared to limit distractive behaviours.

6.2.2. Subtheme B: Punctuality

Students arrived to lectures late. For example, during observation 2, approximately 70 students were late, with some more than 1 hr late. Also, another class session began with 62 students and ended with 117 (about 55 students late). In another instance, at a pre‐scheduled time, only 29 students were present. One student came after about 1 hr 21 min (observation 5), whilst some students left before the classes concluded.

6.3. Theme III: University‐wide factors/administrative support

University‐wide factors/administrative support relate to administrative factors in the university or school that might either enhance or inhibit students’ positive learning experiences towards the acquisition of CT skills. Three sub‐themes under this theme were identified: class size; scheduling of classes; and classroom layout and equipment.

6.3.1. Subtheme A: Class size

Class sizes observed for the 10 sessions ranged from 34–162 with an average of 95 students. Most classes (7) were above 90 students.

6.3.2. Subtheme B: Scheduling of classes

Some students who were to have a lecture immediately after the session were packed at the entrance to the lecture hall whilst engaging in conversation apparently causing distraction (observation 4). Also, some lectures started immediately after a lecture had ended with no time to move from one lecture hall to another.

6.3.3. Subtheme C: Classroom layout and equipment

Classrooms’ arrangements/layouts are rectangular with desks and chair bolted down. Most ceiling mounted projectors in classrooms were dysfunctional forcing lecturers to use movable projectors which were placed too close to screens. This made power point font sizes small. Some screens were torn and dirty making projected content unclear (observation 3). Also, some public address systems were dysfunctional, and therefore, some students could not hear the lecturers. For example, during a lecture (observation 4) on three different occasions, students drew the attention of the lecturer to the fact that they could not hear him. At a point, rain stopped the lecture because students could not hear the lecturer.

7. DISCUSSION

Based on the observation of classroom environment in relation to instructional activities, several factors need to be considered to provide students with the desired learning experiences to the development of their CT skills. Educators’ positive behaviour which served as factors towards the enhancement of CT skills of students identified in this study is worth noting. These factors including educators’ good sense of humour and open‐mindedness appeared to inspire students to engage in the teaching–learning process were encouraging. The learning and learning process were also made entertaining. This finding is consistent with Ulloth's ( 2002 ) study which found humour to be useful in holding students’ attention, relieving anxiety, establishing rapport and making learning fun. Froneman, Du Plessis, and Koen's ( 2016 ) study on student–educator relationship identified similar characteristics needed for meaningful learning experiences of students. Similarly, other studies (Mangena & Chabeli, 2005 ; Raymond & Profetto‐McGrath, 2005 ; Raymond et al., 2018 ) buttress the need for nurse educators to create a conducive environment for students to develop CT skills.

Another finding worth highlighting in this study was negative educators’ factors such as being unfriendly in correcting students, using inappropriate teaching methods and poor class management skills. Similar factors were identified among educators in South Africa (Mangena & Chabeli, 2005 ) and Canada (Raymond & Profetto‐McGrath, 2005 ; Raymond et al., 2018 ). Mangena and Chabeli ( 2005 ) found that educators’ lack of knowledge, inappropriate teaching and assessment methods and educators’ negative attitude as barriers to the facilitation of CT skills of students.

A further noteworthy finding is the inappropriate implementation of CT teaching methods by educators. Notably, the incongruous implementation of students’ presentation and discussion methods need to be highlighted. This finding is similar to Boso and Gross' ( 2015 ) study among nurse educators in Ghana and inappropriate teaching and assessment methods identified in Mangena and Chabeli’s ( 2005 ) study.

Students’ lateness to lectures (lack of punctuality) identified in this study is worth highlighting. This finding indicates loss of valuable time which may be needed to engage with the content which may hinder the development of students’ CT skills. Also, students’ lateness to lectures appears to correspond with educators’ own late start to lectures. This appears to agree with Jack, Hamshire and Chambers' ( 2017 ) findings which highlight the influence of educator's behaviour on students. This is similar to Cruess, Cruess, and Steinert ( 2008 ) and Billings and Halstead's ( 2005 ) assertions about role modelling.

Another important finding of this study was students’ distractive behaviour. Some students engaging in distractive behaviours are not unexpected, but the degree and extent of these distractive behaviours were unanticipated. Shell ( 2001 ) identified students’ behaviour as the highest barrier to the development of CT skills of students. Also, this finding may be indicative of nurse educators’ apparent lack of appropriate classroom management skills required for meaningful learning experience of students. For example, as seen in this study, educator's movements up and down the aisles aided in the minimization of distractive behaviours of students.

The use of mobile phone during class time as an example of distractive behaviours is worth highlighting. These students may have been engaged on social media platforms such as WhatsApp, Facebook and Twitter during class sessions underscoring the penetration of social media into every facet of the students’ lives. The risk of the use of technology or social media has been noted (Ferguson, 2013 ). Inappropriate use of social media by students found in this study may highlight the absence of social media guidelines for students and educators. Peck ( 2014 ) suggests a purposeful use of social media to improve learning. Schools of higher learning have used social media to improve connectedness, increase access to academic libraries, create virtual classrooms and create student learning experiences to achieve desired academic outcomes (Peck, 2014 ). Evidence supports increased knowledge and flexibility of learning when technology is introduced into the classroom such as blended‐learning (Strickland, Gray, & Hill, 2012 ) and flipped‐classroom (Missildine, Fountain, Summers, & Gosselin, 2013 ) approaches. A purposeful use of social media should reflect the availability of social media guidelines/policy, which will likely minimize the risk or abuse of social media use.

Large class sizes were observed in this study. Pressure to increase student intake appears to overwhelm the school's capacity in terms of space and the number of qualified nurse educators at post (Bell et al., 2013 ; Hornsby, Osman, & Matos‐Ala, 2013 ). This is similar to Raymond and Profetto‐McGrath, ( 2005 ) and Raymond et al.’s ( 2018 ) studies that highlight environmental factors that influence facilitation of CT in a school. The large class sizes appear to influence teaching methods/strategies (Hornsby et al., 2013 ) that could be adopted by educators as identified in Gibbs, Lucas, and Spouse's ( 1997 ) study.

Another finding of this study was scheduling of classes. Classes were sometimes beginning immediately after another for the same students. This was partly accounting for late arrival of students to the next class. The late arrival of students to class may reduce their contact hours and may influence the introduction of the appropriate learning methods/strategies. Given that found time as a factor in CT development of students, reduced contact hours could inhibit the facilitation of CT of the students.

Issues relating to classroom features were observed in this study. These findings primarily relate to logistical and design issues. Logistical issues included dysfunctional ceiling mounted projectors, torn/dirty screens and inadequate public address systems. These logistical constraints may impede meaningful learning experience and consequently hinder the development of CT skills acquisition of students. This finding is consistent with other reports on challenges in the Ghanaian nursing educational system (Bell et al., 2013 ; Talley, 2006 ; Wilmot et al.,  2013 ). The traditional rectangular classroom physical layouts with desks and chairs bolted down is inconsistent with CT skills tenets which require that physical features of classrooms involve small or large circle arrangements to allow for students to make eye contact with each other and the educator to facilitate open dialogue (Billings & Halstead, 2005 ).

8. LIMITATIONS

Given that this was a direct non‐participatory observational study, some observations might have been missed by the researchers (Creswell & Poth, 2018 ; Patton, 2015 ), especially when an attempt to minimize interruption of the teaching process, the observers of this observational study positioned themselves at the back of the classroom throughout each session. Also, there could have been observer bias. As noted by Creswell and Poth, there could have been impression management and potential deception on the part of the participants, especially the educators which might have influenced the data obtained. Several observations (10) were purposefully conducted to minimize this potential Hawthorne effect. In addition, some accounts might have been misinterpreted. However, this was minimized to some extent by reviewing the accounts with participants involved in the study.

9. RECOMMENDATION

Based on this study, further studies are recommended. The exploration of the experiences of nursing students and educators of instructional practices towards the development of CT skills in Ghana is highly recommended. Both quantitative and qualitative studies on how social media or technology in general could be used to facilitate meaningful learning are recommended.

This study also has implications for nurse educators and nursing school authorities who need to create a conducive environment for students for CT skills of students. Nurse educators should examine their own instructional methods/strategies with the view to adopting appropriate CT methods. In this regard, educators should aim at making learning fun and enjoyable. Educators should see themselves as role models to students regarding the demonstration of CT skills. School authorities should institute continuous faculty development programmes to help educators update their teaching skills regarding CT skills of students. School managers should provide the needed logistics needed for meaningful learning and commensurate to learning space, available faculty and other resources.

10. CONCLUSIONS

This study sought to observe instructional practices that influence the acquisition of CT skills of students in a classroom environment. The findings suggest that the educators’ teaching strategies have influence on learning atmosphere for CT skills facilitation of students. Also, several inhibiting and enhancing factors relating to students, university‐wide/administrative support were identified. It is therefore important that inhibiting factors are minimized or removed and enhancing factors are maintained or accentuated to help students engage in meaningful and purposeful learning experience with the view of developing their CT skills. Particularly, the role of the educators must be stressed to ensure that a conducive and participatory environment is created for student learning.

CONFLICT OF INTEREST

We do not have any conflict of interest to report.

AUTHOR CONTRIBUTIONS

CMB, ASVDM and JG: Conceptualization and designing of the study. CMB: Data collection, analysing and drafting of the manuscript. ASVDM and JG: Study supervision and made critical revisions on the paper. All the authors made substantial contributions to the manuscript.

ACKNOWLEDGEMENTS

We wish to acknowledge Victor Angbah for assisting in data collection. We also express our gratitude to the study participants.

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The Value of Critical Thinking in Nursing

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

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

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

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

How Do Nurses Use Critical Thinking?

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

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

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

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

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

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

Top 5 Ways Nurses Can Improve Critical Thinking Skills

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

Case-Based Approach

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

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

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

Practice Self-Reflection

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

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

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

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

Develop a Questioning Mind

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

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

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

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

Practice Self-Awareness in the Moment

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

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

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

Use a Process

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

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

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

Common Critical Thinking Pitfalls in Nursing

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

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

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

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

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

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

An Essential Skill for All Nurses

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

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

Frequently Asked Questions About Critical Thinking in Nursing

How are critical thinking skills utilized in nursing practice.

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

How does nursing school develop critical thinking skills?

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

Do only nurse managers use critical thinking?

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

Meet Our Contributors

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

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

Jenna Liphart Rhoads, Ph.D., RN

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

Nicholas McGowan, BSN, RN, CCRN

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

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?

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• Volume 10, Issue 1
• Teaching strategies and outcome assessments targeting critical thinking in bachelor nursing students: a scoping review protocol
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• http://orcid.org/0000-0002-4086-0086 Frida Westerdahl 1 ,
• Elisabeth Carlson 1 ,
• Anne Wennick 1 ,
• Gunilla Borglin 1 , 2
• 1 Department of Care Science , Malmö University , Malmö , Sweden
• 2 Nursing Education , Lovisenberg Diaconal University College , Oslo , Norway
• Correspondence to Frida Westerdahl; frida.nygren{at}mau.se

Introduction Applying critical thinking is essential for nursing students both in an academic and clinical context. Particularly, as critical thinking is a vital part of nurses’ everyday problem-solving and decision-making processes. Therefore, regardless of the topic taught or the setting in which it is taught, it requires teaching strategies especially targeting students’ critical thinking skills and abilities. One challenge with the latter is the difficulties to assess and evaluate the impact of such teaching strategies on the students’ critical thinking disposition. Hence, our objective will be to review published literature on; existing teaching strategies and outcomes assessments targeting nursing students’ critical thinking skills and abilities.

Methods and analysis Our scoping review will be conducted in accordance with Arksey and O’Malley’s framework for scoping studies. Search strategies will be developed in cooperation with an experienced librarian, and adjusted to each individual database for example, CINAHL, PubMed, PsycINFO, ERIC and ERC. A preliminary search in CINAHL was conducted on the 17 th of July 2019. Peer-reviewed published studies conducted with a qualitative, quantitative or mixed method design and focussing our objectives, will be eligible for inclusion. Included studies will be quality assessed in accordance with their study design. Data will be charted using a standardised extraction form. The qualitative data will be presented through a thematic analyses, and the quantitative data by descriptive numerical analysis. Lastly, nurse educators and nursing students will be consulted for validation of the findings from the scoping review.

Ethics and dissemination Under the Swedish Ethical Review Act (2003:460) this study does not need ethical clearance by a Regional Ethical Review Authority as it not includes any primary empirical data on biological material or sensitive information. The findings will be used to inform the design of a future study aiming to develop an, and subsequently evaluate it, educational intervention targeting teaching strategies focussing on nursing students’ critical thinking skills and abilities.

• critical thinking abilities
• critical thinking skills
• descriptive numerical analysis
• nurse educators
• thematic analysis

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2019-033214

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Strengths and limitations of this study

To ensure rigour and transparency the upcoming scoping review will be based on (1) a solid methodological framework for scoping studies and (2) the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews checklist.

A minimum of two members of the review team will independently assess study eligibility.

Eligible studies will be quality assessed in accordance with their study design.

To achieve a comprehensive picture of the existing research qualitative, quantitative and mixed methods designs will be included in this scoping review.

One limitation might be the potential risk for publication bias since grey literature will not be included, as this will facilitate charting of teaching strategies and outcome assessments targeting critical thinking skills and abilities as described solely in published research.

Introduction

Applying critical thinking is essential for bachelor nursing students (hereafter nursing students); particularly, considering the complex care situations they regularly will find themselves in after graduation. 1 Care situations that among others require them to work in accordance with established standards 2 to be able to contribute to a safe, evidence based and optimal clinical practice. Given that nursing is based on scientific knowledge, critical thinking is the reasonable reflection to justify nursing actions based on evidence. Skills and abilities in critical thinking have consequently been found to predict nursing competence together with working years, position, title and educational level, that is, Bachelor or Master in Nursing. 3 Critical thinking is, therefore, a crucial component of every registered nurse’s daily activities, aiding problem-solving and decision-making processes. 4

According to Scheffer and Rubenfeld the ability to execute critical thinking in nursing could be seen from two perspectives; habits of the mind (cognition), and skills employed by the critical thinker. 5 Critical thinking can also be seen as a consecutive process including (i) gathering information, (ii) questioning, (iii) analysis and evaluation and (iv) problem-solving and application of theory, that is, the nursing process. 6 This consecutive process of critical thinking needs to be applied both in the clinical area and in the classroom. 7 However, to develop this ability among nursing students is a complex process. To apply critical thinking, the necessary skills and abilities need to be taught and developed during both the students’ clinical placements as well as during their theory courses throughout the nursing education. 4

One challenge with the concept of critical thinking, often highlighted in the literature, and despite its priority within the nursing education, is the interchangeable use of the concepts of critical thinking, clinical reasoning and clinical judgement. 7–9 Concepts that Victor-Chmil describe as; ‘they are not one and the same’ (p 34). It needs to be acknowledged, as the authors of this current protocol do, that critical thinking often is used as a broader term which includes the concepts of clinical reasoning and clinical judgement. 8 According to Alfaro-LeFevre clinical reasoning refers to the process used to solve clinical issues and clinical judgement refers to the outcome or conclusion of this process. 7 Therefore, regardless of the topic taught or the setting in which it is taught, requires teaching strategies especially targeting nursing students’ critical thinking skills and abilities. For these strategies to be favourable, it requires implementation throughout the nursing education, and thereby reflected in all parts of the nursing programmes’ learning objectives and curricula. 10 It has been outlined that teaching strategies such as, problem-based learning, concept-mapping, case-based learning interventions and reflective writing are often used in nursing programmes to support critical thinking. 6 10 11 However, another challenge with critical thinking, besides the interchangeable use of concepts, is the difficulty to assess and evaluate the impact of different teaching strategies on the students’ critical thinking disposition (ie, skills and abilities) as well as the assessment of the different components in the critical thinking process. 8 Previous reviews in the current research area have only included either experimental studies 12 or randomised clinical trials 13 measuring the effectiveness of teaching strategies. Further, other reviews have involved mixed populations including not only nursing students, but also working nurses and nursing managers 14 and midwifery students. 15 Since critical thinking is a vital part of registered nurses’ problem-solving and decision-making, this ability needs to be taught already during the nursing education. It is therefore necessary to focus the educational context of undergraduate nursing taking an extended approach on how teaching strategies targeting critical thinking are described, experienced and assessed. Hence, our overarching objective will be to review published literature on; existing teaching strategies and outcomes assessments targeting nursing students’ critical thinking skills and abilities.

Methods and analysis

The upcoming scoping review will address a broad topic (ie, teaching strategies targeting nursing students’ critical thinking skills and abilities, as well as outcome assessments of such skills and abilities), where a diverse range of study designs can be considered relevant in answering our additionally wide review questions. Our scoping review will therefore be designed in accordance with Arksey and O’Malley’s methodological framework for scoping studies. 16 However, our design will also be informed by other more recent methodological accounts. 17 18 The framework will enable us to identify existing gaps in the literature as well as to summarise, evaluate and disseminate the overall state of research activities within the field. 16 The Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews checklist (PRISMA-ScR) was used to prepare this protocol. 19 PRISMA-ScR will also form the base for the upcoming scoping review as standardised reporting guidelines can according to Colquhoun et al support the critical appraisals of published reviews by expanding on their transparency and reproducibility. 20

Stage 1: identifying the research question

The research questions for the upcoming scoping review aims for comprehensiveness, that is, they will be broad to cover the breadth of research evidence in our field of focus. As scoping is an iterative methodological process, 16 it is possible for us to decide to add supplementary questions based on the findings emerging during the review process. A modified 21 PICOS (Population, Intervention, Comparison, Outcome and Study Setting) framework will aid us in determining the appropriateness of the research questions, as well as guide us in our database searches ( table 1 ).

• View inline

Framework (PICOS) for determination of eligibility of review questions

Since the subsequent goal of the upcoming scoping review is to further the knowledge and understanding about how nurse educators via teaching strategies can target the development of nursing students’ critical thinking skills and abilities we will additionally engage in findings of relevance to this. The following tentative research questions were developed to capture the objectives of the upcoming study:

Which are the teaching strategies described in the literature as targeting critical thinking skills and abilities among nursing students?

How are these teaching strategies conceptualised, described and experienced by students and/or nurse educators for example, pros and cons?

Which outcomes are described in the literature as used to assess critical thinking skills and abilities?

Stage 2: identifying relevant studies

The upcoming scoping review will include primary studies utilising qualitative, quantitative and mixed methods, published in peer-reviewed journals. This strategy will support us to achieve a comprehensive picture of the existing research focussing peer-reviewed studies on teaching strategies targeting critical thinking skills and abilities among nursing students, as well as on existing research focussing on outcome assessments of such skills and abilities. No limits will be applied concerning publication year, since we aim at conducting a comprehensive overview of published studies. Studies will be excluded if the population is not identifiable, qualitative and quantitative data is not possible to extract in case of mixed method design or published in other languages than English. All reasons for exclusion will be documented.

In our upcoming scoping review the term ‘teaching strategies’ will be used. Thus, our focus is not the overall educational organisation of teaching (ie, educational strategies) or the students’ individual general learning process (ie, learning strategies). However, as we are aware of the commonly interchangeable use in the literature of the terms; teaching strategies, educational strategies and learning strategies, they will all be included in our searches. Here the term teaching strategies are operationalised in accordance with Banning, and as encompassing three different perspectives; (i) the didactic perspective, which is teacher centred and mainly involves lectures; (ii) the facilitative perspective, focussing on self-directed learning making the students articulate their knowledge and lastly (iii) the Socratic perspective which is emphasising student-centredness and use objective questioning from the teacher. 22

The following databases; CINAHL, PubMed, PsycInfo, ERIC and ERC will be used to search for eligible studies. These databases are chosen to cover a comprehensive sample of literature from healthcare science and education. A search strategy for each database will be developed by the review team with assistance from an experienced librarian. Our strategies will include both database specific heading that is, Medical Subject Headings, keywords and synonyms. All specific headings and key words will be combined using the Boolean operators OR as well as AND. To ensure comprehensiveness, included studies reference lists will be manually searched. As outlined by Arksey and O’Malley the search strategy should be an iterative process and the search terms could be adjusted while an increased familiarity with the literature is achieved. For this reason, a preliminary pilot search strategy will be applied to the databases and the first 100 search results will be reviewed by the review team to assess validity. 16 During the review team meetings, adjustments will be applied to the search strategy and search terms until full agreement is reached. Grey literature (ie, literature that is not formally published in sources such as journal articles or books) will not, as described elsewhere, be included in our upcoming scoping study. 23 This will support us to focus on and to chart how teaching strategies targeting skills and abilities such as critical thinking is described in published peer-reviewed research. A draft of a preliminary search in CINAHL conducted on the 17 th of July 2019 is attached in online supplementary file 1 .

Supplemental material

Stage 3: study selection.

The study selection will first consist of a title and abstract scan. If the title and abstract are in line with the scoping review’s objectives and questions to the literature or if the relevance of the study is unclear a full-text review will follow. Retrieved studies from each database are going to be divided equally among a minimum of two reviewers, who independently will conduct the selection process. 17 To facilitate the process, we are going to use the data programme Rayyan. The programme is a mobile and web application developed to facilitate the screening of title and/or abstract as well as the collaboration between the reviewers. 24 During the study selection process, the first reviewer (FW) will be responsible for regularly convoking the review team for discussions concerning uncertainties and to refine the study selection process. 17 Criteria for inclusion can also be applied ad hoc during the process when acquaintance with the field of research is increased. 16 If any disagreements on study inclusion occur, an additional reviewer will be consulted to determine the final inclusion. 17 The study selection process ( figure 1 ) will be accounted for by the PRISMA flow diagram. 25

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Overview study selection process.

Contrary to Arksey and O’Malley’s methodological framework, 16 studies eligible for inclusion in our scoping review are going to be quality assessed. The assessment of the included studies’ quality will allow us to identify where the research itself is of poor quality, that is, identifying gaps in the existing literature review. According to Grant and Booth the lack of quality assessments in scoping reviews are likely to limit the uptake of the findings. 26 Their sentiment is supported by both Levac, Colquhoun and O’Brien 17 and Daudt, van Mossel and Scott 18 who state that a quality assessment of included studies will likely result in findings more useful for practice. The quality assessment will be conducted by a minimum of two reviewers, who will use the relevant study design checklists from the Critical Appraisal Skills Programme (CASP). 27 As, CASP lack a checklist for mixed methods studies, the mixed method appraisal tool will be applied. 28 In the case of any ambiguity concerning a study’s quality assessment, an additional reviewer is going to be consulted. No exclusion of eligible studies will be made on behalf of the quality assessment as studies with limited quality nevertheless can provide a valid rationale as guidance as to where more research is required.

Stage 4: charting data

A data charting form would be developed, and piloted on the first 5 to 10 included studies in this review. The piloting will support the team to reach an agreement on extraction consistency. The latter is especially important, as the extraction will be conducted individually and independently by a minimum of two reviewers. 17 A systematic and analytical approach will be utilised to extract the relevant information of each included study. The variables and themes to be included in order to answer the review’s objective and questions to the literature will be established iteratively ( box 1 ). Thus, the data charting form will be updated throughout the review by one of the reviewers (FW) who will also hold regular discussion with the others in the review team. 17

Tentative data charting form

Author and date.

Study title.

Journal full reference.

Aim, objective and/or research questions.

Study and recruitment context (eg, in what country and where people were recruited).

Participant characteristics (eg, age, gender, education year/semester of study, course (ie, theoretical or clinical placement)).

Sampling method.

Number of study participants.

Study design.

Data collection (eg, what data collection methods were used?).

Data analysis (eg, how was the data analysed?).

Described ethical approval and/or considerations. 29

Described teaching strategies and/or interventions targeting review focus.

Described outcomes and assessments.

Most relevant findings.

Study quality appraisal. 27 28

Tentative ethical requirements influenced by Weingarten, Paul and Leibovici.

Was the study approved by a research ethical committee? (Yes/No)

Was informed consent obtained? (Yes/No)

Were adequate measurements taken to protect personal data? (Yes/No)

Is there a declaration on financial support? (Yes/No)

Is there a declaration on potential conflict of interest? (Yes/No)

Influenced by Weingarten, Paul and Leibovici’s substantial contribution to raise the ethical awareness in reviews, an ethical assess form ( box 2 ) was developed for the upcoming scoping review including five requirements. 29 Included studies valued by the review team as not adhering to the ethical requirements will be excluded at this stage of the scoping review process.

Stage 5: collating, summarising and reporting the results

In the fifth stage, an overview and narrative account of variables and information extracted in stage 4 will be presented, and as highlighted by Arksey and O’Malley no evidence grading will be executed. 16 Levac, Colquhoun and O’Brien 17 and Daudt, Van Mossel and Scott 18 suggest that the extracted qualitative data should be presented through thematic analysis, since no synthesis of data is required. 16 For this purpose, the thematic analysis by Braun and Clarke will be applied which is a flexible method suitable when the data is broad and allowing for a wide range of analytical options. 30 This cohere with the upcoming scoping review, which will include studies with a wide range of research questions and methods. Quantitative data will be reviewed through basic descriptive numerical analysis and presented in tables and charts to highlight the range of data. 16 If studies with a mixed method design are included in stage 3, the qualitative and quantitative data will be extracted and analysed separately. A minimum of two reviewers will be responsible for this stage of the scoping review process. During the process, meetings with the entire review team will be scheduled by the first reviewer (FW) to discuss and come to agreement concerning analysis and presentation of extracted data.

Stage 6: consultation stage

To validate the findings of this scoping study and make it more useful for practice the optional stage consultation will be applied. For this purpose, the findings from the scoping review will be presented to a group of educators and students connected to a nursing programme as a means to contribute with valuable insights on issues connected to the application and implementation of the findings.

Patient and public involvement

No patients have been involved in the design of this study. However, to conduct a study targeting teaching strategies for critical thinking in nursing education will eventually benefit patients since education is the foundation for raising future nurses and improve patient care.

Ethics and dissemination

Under the Swedish Ethical Review Act (2003:460) 31 this study does not need ethical clearance by a Regional Ethical Review Authority as it does not include any primary empirical data on biological material or sensitive information (eg, ethnicity, political or sexual orientation). However, the issue of ethical consideration in the execution of reviews is raised by Vergnes et al 32 as well as by Weingarten, Paul and Leibovici. 29 They state that without an ethical judgement of the included studies it could result in establishing clinical practise and guidelines based on studies with poor ethical quality and even unethical studies. It could further be seen as a way of increasing the awareness and necessity of high ethical standards in research. To meet these requirements one variable in the charting form will be ethical consideration and for that purpose a tentative checklist for ethical requirements was developed ( box 2 ). The checklist will be tested on a minimum of 10 publications, and revised accordingly if necessary.

The upcoming scoping review will contribute to the advancement of research concerning teaching strategies targeting nursing students’ skills and abilities in critical thinking and the outcome assessment of it. It will also provide an indication of the maturity of the literature by identifying research gaps. Gaining more knowledge of the targeted research area can act as a benchmark to implement new teaching strategies facilitating students’ critical thinking disposition within the nursing education. This will better prepare future nurses for the complex care situations they will approach. Our findings will be used to inform the design of a future study aiming to develop and evaluate an educational intervention targeting teaching strategies focussing on nursing students’ critical thinking skills and abilities. The upcoming scoping review will be published in a peer-reviewed journal. We expect to report in late spring 2020.

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Contributors FW, EC, AW and GB were responsible for the initial design of this study. FW conceptualised the review approach and led the writing of the manuscript. FW, EC, AW and GB contributed to the protocol’s development and approved the final version of this protocol. GB, EC and AW led the supervision of the manuscript preparation.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Patient consent for publication Not required.

Provenance and peer review Not commissioned; externally peer reviewed.

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