critical thinking questions for nursing students

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.

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Developing Critical-Thinking Skills in Student Nurses

April 8, 2020

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

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

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

Characteristics of Critical Thinkers

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

Interpretation

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

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

Critical thinkers consider relevant information from evidence to draw conclusions.

Explanation

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

Self-regulation

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

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

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

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

Teaching Critical Thinking to Nurses

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

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

Promoting interactions

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

Asking open-ended questions

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

Providing time for students to reflect on questions

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

Teaching for skills to transfer

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

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

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

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

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

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

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

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

For more information, contact Duquesne University today.

Critical Thinking: A Vital Trait for Nurses: Minority Nurse

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

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

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

Turning New Nurses Into Critical Thinkers: Wolters Kluwer

02.01 Critical Thinking

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If you have gone to one day of nursing school you understand that “critical thinking” is a buzzword.

Nursing schools love to talk about critical thinking.

The job of a nurse is essentially to take millions of data points and be able to arrive at a correct decision based on that data.

This is no easy task and there are few jobs which require this on the scale of nursing or with human lives in the balance.

What is Critical Thinking?

Critical thinking is defined as: Clear, rational thinking involving critique. Its details vary amongst those who define it. According to Barry K. Beyer (1995), critical thinking means making clear, reasoned judgments. During the process of critical thinking, ideas should be reasoned, well thought out, and judged. The National Council for Excellence in Critical Thinking defines critical thinking as the intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action.  Source .

So, while you are familiar with making decisions on a daily basis, most daily decisions do not require critical thinking (what color of shirt should I wear, what should I eat for dinner, etc).

It is a skill that can grow and develop with time and as you enter nursing school you are not expected to be an expert in the skill.

However, what you should understand is that critical thinking involves a level of decision making far beyond normal day to day decision making. With critical thinking you are analyzing, conceptualizing, and digging deep into the questions presented.

When it comes to nursing, often times you are presented with real life or death situations. You are presented with saving one patient or determining what the most important solution is to a highly complex problem.

Those nurses who develop advanced critical thinking skills find increased success in their careers.

Critical Thinking in Nursing

So let’s talk about critical thinking and how it applies to everything we are talking about here.

The NCSBN website states the following: Since the practice of nursing requires you to apply knowledge, skills and abilities, the majority of questions on the NCLEX are written at the cognitive level of apply or higher. And these questions, by nature, require critical thinking.

Answering these correctly will require you to do something with what you have learned, to manipulate previously learned material in new ways or find connections between many facts.

Again, since the majority of NCLEX questions fall into this category, this is exactly the type of questions you need to practice answering!

There it is again . . . the BUZZ word (critical thinking) . . . but once again no tips or information on what that means or how to develop it is given.

So let’s dive in and provide you with a simple framework and method for developing critical thinking.

How to Critically Think in Nursing

While there are many frameworks and methods for developing critical thinking, here we will provide you with a basic 4 step method.

At the risk of sounding oversimplified, this simple method will allow you to cut through the clutter, think critically, and arrive at correct decisions in even the most complex of scenarios.

Essentially there are 4 steps to critical thinking . . . in nursing and in life . . . and developing the ability to critically think will work wonders in your life.

• Suspend ALL Judgement
• Collect ALL Information
• Balance ALL Information
• Make a Complete and Holistic Decision

Before diving into the four individual steps let’s point out the use of the word “ALL” in each of the steps.

This is important because few individuals can make decisions with this inclusive word. It literally means ALL. To make a complete and holistic decision based upon critical thinking you have to have and weight ALL information. Otherwise you are just making a regular old decision.

•   Suspend All Judgement

You have to start by suspending all judgement. In other words, if you walk into a patients room and see them tachycardic an amature decision would be to run and grab the metoprolol to try to drop the heart rate.

An advanced clinician will WAIT until they have more information . . . not leaving the patient untreated . . . but not jumping freakishly into the WRONG treatment because they learned that tachycardia is bad . . .

Suspending judgement means that you don’t make a decision based upon the first sign. You also don’t walk into any situation of NCLEX question with a decision already made. You will treat all facts as equal until you can gather the needed information.

Not suspending judgment leaves you open to make biased decisions. This is detrimental in medicine and nursing. This will also result in poor success on nursing exams and the NCLEX.

As you read through nursing questions you must force yourself to refrain from jumping to conclusions until you have read the question in full. Do not allow yourself to assume what the question is asking or what the patient outcome is until you have read the question in full.

Obviously this sounds simple, but it is this step that, if missed, will through more nursing students and nurses off.

• Collect All Information 

Now you must collect ALL information. This is clutch! Don’t make a decision until you have collected every piece of data that you need to collect . . . on a tachycardic patient you can check BP, temp, run an EKG, check urine output.

Think of this as data mining. You are looking to have every piece of information you can find to put the puzzle pieces together.

When it comes to taking nursing tests you only have one place that you can collect the information . . . and that is from the test question itself. Do not go looking outside of the question of infer any details that are not provided within the question.

One thing we have noticed students doing almost more than anything else on test questions is reading into them. Don’t do this. Gather all the information you can . . . and when it comes to NCLEX questions, the only place you can gather information is from the question itself.

• Balance All Information

Now, balance all information. This means take all the data that you have and start weighing it to find out what is pertinent and what you can ignore. If the temp is 98.9 . . . it’s probably not the cause. If the BP is 74/56 are we looking at a volume issue?

In this step you are deciding what is important and what isn’t. While a pressure ulcer is important, if the patient is actively having a heart attack . . . it just doesn’t matter. At least, not until we take care of the MOST important issue.

NCLEX style questions will be FULL of extra information, things that you just really do not need to know to make a decision on the patient.

The NCSBN (who administers the NCLEX) in an effort to simulate real life nursing writes questions that include both important information and details that you just simply don’t need to know. It is your job to sift through the data and determine what you actually need to know.

Balancing means giving each data point a level of importance for your given patient. Some pieces of information will score much higher than others.

At this point you must all consider the implications of the possible options. Look at the available options and think to yourself, “if I choose this option, what happens next?”. As it relates to nursing, ask yourself these questions:

“Does this achieve a desired patient outcome?”

“If I do this and then go home, what happens to my patient?”

Forcing yourself to consider the implications allows you to look beyond the information presented and consider the RESULTS of your choices. Critical thinking thrives on looking beyond the presented data.

• Make a Holistic Decision

Finally, make your decision . . . with all the data in and after looking over it all very closely you can begin to make your decision.

Your goal is to make the decision that best serves the patient and addresses their most immediate concerns.

Critical Thinking in Nursing and on the NCLEX®

Lastly, I just want to talk briefly about how this applies to NCLEX questions . . .

Here is an actual practice NCLEX question from our Nursing Practice Questions Program (or NPQ, as we like to call it)!

A 56-year-old male patient has been admitted to the cardiac unit with exacerbation of heart failure symptoms. The nurse has given him a nursing diagnosis of decreased cardiac output related to heart failure, as evidenced by a poor ejection fraction, weakness, edema, and decreased urinary output. Which of the following nursing interventions are most appropriate in this situation?

42% of the students that have taken this question have selected this answer:

Administer IV fluid boluses to increase urinary output

The problem with that answer is that it fails to weigh the most important issue facing this patient.

Test takers see urine output as low . . . and want to correct that quickly with fluids.

However, this is a CHFer . . . you can’t (shouldn’t) bolu especially during an exacerbation . . . you could send the patient into pulmonary edema and drastically impact their respiratory status.

So the lesson here. . . . in school, on the NCLEX, and on the clinical floor . . . slow down, stay calm and start thinking at an analysis level.

And I promise you this helps in “REAL” life too . . . not just in nursing. You will begin to be a tad more skeptical and deliberate with your decisions.

Here are a couple resources that will help you in the process of developing critical thinking.

• CriticalThiking.org
• US News 5 Tools
• Thinking Fast and Slow
• NPQ – Nursing Practice Questions

The process for developing critical thinking is slow and arduous. However, don’t be hard on yourself. According to  CriticalThiking.org  the vast majority of colleges are not appropriately incorporating critical thinking into the college classroom. This means that while you might not being taught the skill as you should . . . most people aren’t. Using the strategies outlined above will put you light years ahead of most.

The nurse that is able to follow these four steps is a tremendous asset on a clinical floor.

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Test taking for the nclex®.

The Test-Taking course is the best place to start when you’re trying to figure out how to navigate NCLEX®-Style questions. Nursing school presents a unique challenge when it comes to test-taking. You’re no longer just looking for the right answer - you’re now looking for the most right answer or multiple right answers. In this course, we break down how to understand what these questions are even asking you, and our best tips for how to answer them. We also provide some strategies for goal-setting, studying, and note-taking that are sure to set you up for success on your exams and on the NCLEX®.

• 19 Questions
• 11 Questions

Effective clinical learning for nursing students

Approaches that meet student and nurse needs..

• Direct care nurses serve as significant teachers and role models for nursing students in the clinical setting.
• Building critical thinking skills is one of the most important outcomes in the clinical setting for nursing students.
• Collaboration with nursing faculty during the clinical rotation can ease the burden on direct care nurses and facilitate a positive learning experience for the student.

The nursing profession continues to experience several challenges—some longstanding and exacerbated by the COVID-19 pandemic. The shortage of nurses at the bedside and reports of nurses planning to leave the profession soon place stress on the workforce and the healthcare system. The situation has put even more pressure on nursing schools to recruit and retain students who enter the workforce well-prepared for practice and capable of filling these vacancies. However, concerns exist surrounding students’ critical thinking skills and their readiness for a demanding career.

The challenge

A longstanding shortage of nursing school faculty and a reliance on new graduate nurses to serve as preceptors create challenges to properly preparing nursing students for a demanding role that requires excellent critical thinking skills.

What-Why-How? Improving Clinical Judgement

New nurses and clinical judgment

Nurse faculty shortage

Lack of interest and incentives lead to difficulty recruiting nurses from the bedside or practice to education. Many 4-year schools require a terminal degree to teach full-time in their undergraduate programs, but only 1% of nurses hold a PhD. In addition, according to the National Advisory Council on Nurse Education and Practice (NACNEP), the average doctorally prepared nurse faculty member is in their 50s, which means they may soon retire. The surge in doctor of nursing practice programs has helped to bridge this gap, but attracting advanced practice nurses to academia from their more lucrative practice roles continues to prove difficult.

Concerns about the practice readiness of new graduate nurses have existed for several years. Missed clinical experiences and virtual learning during the COVID-19 pandemic heightened those concerns. The National Council of State Boards of Nursing (NCSBN) addressed the calls from nurse employers to make progress in this area by revamping the NCLEX-RN and NCLEX-PN exams to create Next Generation NCLEX (NGN), which includes more clinical judgment and critical thinking items. Nurse educators are working hard to prepare students for both practice and the new exam items by incorporating more active learning into classroom, clinical, and lab activities and emphasizing the importance of clinical judgment skills.

In most areas of the country, clinical student experiences have returned to pre-pandemic arrangements. State boards of nursing mandate maximum faculty-to-student ratios for clinical experiences. Schools can choose to have faculty supervise fewer students than the maximum, but faculty and clinical site shortages may eliminate that option. In many cases, preceptor-style experiences (such as capstone or practicum courses) have higher faculty-to-student ratios, and preceptors may have to meet specific criteria, such as a certain amount of experience.

Nursing faculty who facilitate on-site learning and supervise and teach students during their clinical experiences face several challenges. Some faculty supervise students across multiple units because unit size can’t accommodate 8 to 10 students at one time. Faculty may or may not have access to the organization’s electronic health records or other healthcare information technology, such as medication dispensing cabinets or glucometers.

In such instances, direct care nurses play an important role in the student’s experience at the clinical site. Their familiarity with the unit, the patient population, and the organization’s technology facilitates learning.

Direct care nurses

Allowing nursing students into the hospital can improve the patient care experience and potentially recruit students to work at the organization in the future. However, precepting a student or new employee creates an extra burden on an already overextended bedside nurse. NACNEP identifies several challenges for obtaining qualified preceptors, including lack of incentives and limited preparation in clinical teaching and learning strategies. Many hospitals have nursing students on the same unit several days a week to accommodate multiple area schools. This means that staff nurses are expected to teach students on most of their workdays during a typical school semester.

Unit nurse experience creates another barrier to effective precepting of nursing students. A study by Thayer and colleagues reported that the median length of experience for inpatient nurses working a 12-hour shift was less than 3 years at an organization. Without a better alternative, new graduate nurses frequently teach nursing students, although they may still be in what Benner describes as the advanced beginner stage of their career (still learning how to organize care, prioritize, and make clinical judgments). It’s difficult for someone who’s still learning and experiencing situations for the first time to teach complex concepts.

A guide to effective clinical site teaching

The following strategies promote critical thinking in students and collaboration with nurse faculty to ease direct care nurses’ teaching workload. Not every strategy is appropriate for all student clinical experiences. Consider them as multiple potential approaches to help facilitate meaningful learning opportunities.

Set the tone

Nursing students frequently feel anxious about clinical experiences, especially if they’ve been told or perceive that they’re a burden or unwanted on the unit. When meeting the student for the first time, welcome them and communicate willingness to have them on the unit.

If you feel that you can’t take on a student for the day, speak to the nurse faculty member and charge nurse to explore other arrangements. Nurse faculty recognize that work or personal concerns may require you to decline precepting a student. Faculty members want to find the best situation for everyone. If the charge nurse or supervisor determines that the student still needs to work with you, talk to the nurse faculty about how they can help ease the burden and facilitate the student’s learning experience for the day.

Begin your time with the student by asking about their experience level and any objectives for the day. Understanding what the student can or can’t do will help you make the most out of the clinical experience. You’ll want to know the content they’re learning in class and connect them with a patient who brings those concepts to life. A student may have assignments to complete, but their focus should be on patient care. Help the student identify the busiest parts of the day and the best time to review the electronic health record and complete assignments.

If a situation requires your full attention and limits training opportunities, briefly explain to the student what will happen. If you have time, provide the student with tasks or specific objectives to note during the observation. Involve the nursing faculty member to help facilitate the learning experience and make it meaningful.

Be a professional role model

Students like to hear about the benefits and rewards of being a nurse, and about each nurse’s unique path. Students also enjoy learning about the “real world” from nurses, but keep in mind that they’re impressionable. Speaking negatively about the unit, patients, organization, or profession may discourage the student. If you must deviate from standard care, such as performing a skill differently than it’s traditionally taught in school, provide the rationale or hospital policy behind the decision.

Feel free to discuss the student’s nursing school experience but don’t diminish the value of their education or assigned work. Keep in mind that school assignments, such as nursing care plans or concept maps, aren’t taught for job training but to deliberately and systematically promote critical thinking. These assignments allow a student to reflect on how a patient’s pathophysiology and nursing assessment and interventions relate to one another.

Reinforce how concepts students learn in school provide valuable knowledge in various settings. For example, if the student is on a medical-surgical unit but says that they want to work in obstetrics, engage the student by pointing out links between the two areas, such as managing diabetes and coagulation disorders. Provide encouragement and excitement about the student’s interest in joining the profession at a time of great need.

Build assessment skills

Explain to students your approach to performing assessments and organizing patient care. Most students learn comprehensive head-to-toe assessments but, in the clinical setting, need to focus on the most relevant assessments. To promote critical thinking, ask the student what data they should focus on gathering based on the patient’s condition. Many students focus on the psychomotor aspect of assessment (performing the assessment correctly); ask them about the subjective data they should gather.

Allow the student to perform an assessment and then compare findings. For example, a student may know that a patient’s lung sounds are abnormal but not remember what the sound is called or what it means. Provide them with the correct terminology to help connect the dots. Discuss with the student when reassessments are warranted. If appropriate, allow a student to reassess the patient (vital signs, output, pain, other physical findings) and then confirm their findings and discuss what any changes mean for the clinical situation. If you don’t have time for these types of discussions following a student’s patient assessment, ask nursing faculty to observe and discuss findings with the student.

Discuss care management

Take advantage of opportunities to discuss concepts such as prioritization, advocacy, delegation, collaboration, discharge planning, and other ways in which the nurse acts as a care manager. Pointing out what’s appropriate to delegate to unlicensed assistive personnel or a licensed practical nurse will prove valuable and help reinforce concepts frequently covered on the NGN exam.

Promote critical thinking

The NCBSN has introduced the Clinical Judgment Measurement Model (CJMM) as a framework for evaluating the NGN exam, which incorporates unfolding case studies that systematically address six steps: recognize cues, analyze cues, generate hypotheses, generate solutions, take action, and evaluate outcomes. Each candidate encounters three case studies, with six questions, one for each step of the CJMM. Nursing faculty incorporate this framework and language into the nursing curriculum to help students think systematically and critically and prepare them for the exam.

Nurses with practice experience use this type of framework to gather information, make judgments, and take action. As a nurse approaches Benner’s competent stage of nursing practice, this type of thinking becomes intuitive, and nurses may not even be aware of the conclusions they draw and decisions they make based on their clinical judgment skills. To help students understand why something is happening, they should continue to work through a process like this deliberately. For example, many students view medication administration as a simple task and may say in post-conference discussion, “All I did was give meds.” You perform many assessments and make various judgments while administering medications, but you may not think to discuss them with students. Asking questions of students while they’re performing what may seem like repetitive tasks can help prompt critical thinking. (See Critical questions .)

Critical questions

Enhance self-efficacy

Many nurses believe that the student must follow them to every patient. This can be overwhelming for the direct care nurse and a barrier to agreeing to work with students. Other approaches can better facilitate learning. Most students will complete an assignment focused on one or two patients. Encourage the student to spend time alone with those patients to perform a more comprehensive history and assessment, help patients with basic care, and provide education. Select a patient who might enjoy the extra attention to ensure a mutually beneficial experience.

Also, consider asking the student to find information using available resources. Such inquiry can benefit you and the student. For example, prompt a student to answer one or more critical thinking questions using their textbooks or resources available on the hospital’s intranet. If time prevents you from explaining complex topics or helping the student problem-solve, ask the student to take the information they find to their faculty member to review. Nurse faculty won’t be familiar with the specific details of all patients on the unit, so identify the most appropriate questions for the student to consider to help the nurse faculty facilitate learning.

Allowing the student time to find answers themselves builds self-efficacy and confidence and also relieves some of the stress and anxiety associated with being asked questions on the spot. This strategy also models the professional approach of using evidence-based resources to find information as needed in the clinical setting.

To ensure a positive learning experience and reduce anxiety, provide the student with ample time to prepare for performance-based skills. For example, identify an approximate time that medications will be administered to one patient and ask the student to independently look up the medication information by that time. This is more beneficial for the student than observing every patient’s medication administration or participating only in psychomotor tasks, such as scanning and giving injections. This also can free up your time by setting the expectation that the student will have the chance to prepare for and be directly involved in one medication pass.

Similarly, if an opportunity exists for practicing a psychomotor skill, such as inserting a urinary catheter or suctioning a tracheostomy, ask the student to review the procedure with their instructor using hospital policy and resources. If time doesn’t allow for a review, have the student observe to ensure provision of the best care and efficient use of time and resources.

Opportunities in education

Nurses who enjoy working with students or new staff members may want to consider academic roles. Many advanced nursing degrees, available in various formats, focus on education. For those who want to try teaching or have an interest in teaching only in the clinical setting, opportunities exist to work as adjunct faculty or to participate in hospital-based professional development activities. Adjunct faculty (part-time instructors) teach a variety of assignments and workloads, including in clinical, lab, or classroom settings. Many clinical adjunct faculty are nurses who also work in the organization with patients and may teach one group of students one day a week. Clinical and lab assignments vary from 4- or 6-hour experiences to 12-hour shifts.

According to NACNEP, most nursing programs require that adjunct faculty and clinical preceptors have the same or higher level of educational preparation as the program; for example, a nurse with a bachelor of science in nursing (BSN) may be able to teach clinicals for associate degree in nursing or BSN programs, depending on the state’s requirements and the school’s needs. Educational requirements to work in nursing programs vary by school. In some cases, adjunct faculty who don’t have a master’s degree may be supervised by full-time faculty with advanced degrees.

Benefits for adjunct faculty can include extra income, professional development, personal reward, tuition discounts or remissions, and giving back to the profession. Locate opportunities on nursing school websites or by talking to the nursing instructors or administrators in the local area.

Everyone benefits

Applying teaching approaches that benefit students and nurses can help ensure a positive clinical learning experience for everyone. When you graciously accept and teach students you help create positive encounters that enhance student critical thinking skill development, aid program retention, and support organizational recruitment.

Jennifer Miller is an assistant professor of nursing at the University of Louisville School of Nursing in Louisville, Kentucky .

American Nurse Journal. 2024; 19(4). Doi: 10.51256/ANJ042432

American Association of Colleges of Nursing. Nursing faculty shortage fact sheet. October 2022. aacnnursing.org/news-information/fact-sheets/nursing-faculty-shortage

Benner P. From Novice to Expert: Excellence and Power in Clin­i­cal Nursing Practice . Menlo Park, CA: Addison-Wesley; 1984.

National Advisory Council on Nurse Education and Practice. Preparing nurse faculty, and addressing the shortage of nurse faculty and clinical preceptors. January 2021. hrsa.gov/sites/default/files/hrsa/advisory-committees/nursing/reports/nacnep-17report-2021.pdf

National Council of State Boards of Nursing. Clinical Judgment Measurement Model. 2023. nclex.com/clinical-judgment-measurement-model.page

Thayer J, Zillmer J, Sandberg N, Miller AR, Nagel P, MacGibbon A. ‘The new nurse’ is the new normal. June 2, 2022. Epic Research. epicresearch.org/articles/the-new-nurse-is-the-new-normal

Key words: nursing students, nursing education, critical thinking, precepting

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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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Critical thinking definition

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

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

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

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

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

• Developing technical and problem-solving skills
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Is critical thinking useful in writing?

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

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