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Critical thinking in healthcare and education

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• Peer review
• Jonathan M Sharples , professor 1 ,
• Andrew D Oxman , research director 2 ,
• Kamal R Mahtani , clinical lecturer 3 ,
• Iain Chalmers , coordinator 4 ,
• Sandy Oliver , professor 1 ,
• Kevan Collins , chief executive 5 ,
• Astrid Austvoll-Dahlgren , senior researcher 2 ,
• Tammy Hoffmann , professor 6
• 1 EPPI-Centre, UCL Department of Social Science, London, UK
• 2 Global Health Unit, Norwegian Institute of Public Health, Oslo, Norway
• 3 Centre for Evidence-Based Medicine, Oxford University, Oxford, UK
• 4 James Lind Initiative, Oxford, UK
• 5 Education Endowment Foundation, London, UK
• 6 Centre for Research in Evidence-Based Practice, Bond University, Gold Coast, Australia
• Correspondence to: J M Sharples Jonathan.Sharples{at}eefoundation.org.uk

Critical thinking is just one skill crucial to evidence based practice in healthcare and education, write Jonathan Sharples and colleagues , who see exciting opportunities for cross sector collaboration

Imagine you are a primary care doctor. A patient comes into your office with acute, atypical chest pain. Immediately you consider the patient’s sex and age, and you begin to think about what questions to ask and what diagnoses and diagnostic tests to consider. You will also need to think about what treatments to consider and how to communicate with the patient and potentially with the patient’s family and other healthcare providers. Some of what you do will be done reflexively, with little explicit thought, but caring for most patients also requires you to think critically about what you are going to do.

Critical thinking, the ability to think clearly and rationally about what to do or what to believe, is essential for the practice of medicine. Few doctors are likely to argue with this. Yet, until recently, the UK regulator the General Medical Council and similar bodies in North America did not mention “critical thinking” anywhere in their standards for licensing and accreditation, 1 and critical thinking is not explicitly taught or assessed in most education programmes for health professionals. 2

Moreover, although more than 2800 articles indexed by PubMed have “critical thinking” in the title or abstract, most are about nursing. We argue that it is important for clinicians and patients to learn to think critically and that the teaching and learning of these skills should be considered explicitly. Given the shared interest in critical thinking with broader education, we also highlight why healthcare and education professionals and researchers need to work together to enable people to think critically about the health choices they make throughout life.

Essential skills for doctors and patients

Critical thinking is not a new concept in education: at the beginning of the last century the US educational reformer John Dewey identified the need to help students “to think well.” 3 Critical thinking encompasses a broad set of skills and dispositions, including cognitive skills (such as analysis, inference, and self regulation); approaches to specific questions or problems (orderliness, diligence, and reasonableness); and approaches to life in general (inquisitiveness, concern with being well informed, and open mindedness). 4

An increasing body of evidence highlights that developing critical thinking skills can benefit academic outcomes as well as wider reasoning and problem solving capabilities. 5 For example, the Thinking, Doing, Talking Science programme trains teachers in a repertoire of strategies that encourage pupils to use critical thinking skills in primary school science lessons. An independently conducted randomised trial of this approach found that it had a positive impact on pupils’ science attainment, with signs that it was particularly beneficial for pupils from poorer families. 6

In medicine, increasing attention has been paid to “critical appraisal” in the past 40 years. Critical appraisal is a subset of critical thinking that focuses on how to use research evidence to inform health decisions. 7 8 9 The need for critical appraisal in medicine was recognised at least 75 years ago, 10 and critical appraisal has been recognised for some decades as an essential competency for healthcare professionals. 11 The General Medical Council’s Good Medical Practice guidance includes the need for doctors to be able to “provide effective treatments based on the best available evidence.” 12

If patients and the public are to make well informed health choices, they must also be able to assess the reliability of health claims and information. This is something that most people struggle to do, and it is becoming increasingly important because patients are taking on a bigger role in managing their health and making healthcare decisions, 13 while needing to cope with more and more health information, much of which is not reliable. 14 15 16 17

Teaching critical thinking

Although critical thinking skills are given limited explicit attention in standards for medical education, they are included as a key competency in most frameworks for national curriculums for primary and secondary schools in many countries. 18 Nonetheless, much health and science education, and education generally, still tends towards rote learning rather than the promotion of critical thinking. 19 20 This matters because the ability to think critically is an essential life skill relevant to decision making in many circumstances. The capacity to think critically is, like a lot of learning, developed in school and the home: parental influence creates advantage for pupils who live in homes where they are encouraged to think and talk about what they are doing. This, importantly, goes beyond simply completing tasks to creating deeper understanding of learning processes. As such, the “critical thinking gap” between children from disadvantaged communities and their more advantaged peers requires attention as early as possible.

Although it is possible to teach critical thinking to adults, it is likely to be more productive if the grounds for this have been laid down in an educational environment early in life, starting in primary school. Erroneous beliefs, attitudes, and behaviours developed during childhood may be difficult to change later. 21 22 This also applies to medical education and to health professionals. It becomes increasingly difficult to teach these skills without a foundation to build on and adequate time to learn them.

Strategies for teaching students to think critically have been evaluated in health and medical education; in science, technology, engineering, and maths; and in other subjects. 23 These studies suggest that critical thinking skills can be taught and that in the absence of explicit teaching of critical thinking, important deficiencies emerge in the abilities of students to make sound judgments. In healthcare studies, many medical students score poorly on tests that measure the ability to think critically , and the ability to think critically is correlated with academic success. 24 25

Evaluations of strategies for teaching critical thinking in medicine have focused primarily on critical appraisal skills as part of evidence based healthcare. An overview of systematic reviews of these studies suggests that improving evidence based healthcare competencies is likely to require multifaceted, clinically integrated approaches that include assessment. 26

Cross sector collaboration

Informed Health Choices, an international project aiming to improve decision making, shows the opportunities and benefits of cross sector collaboration between education and health. 27 This project has brought together people working in education and healthcare to develop a curriculum and learning resources for critical thinking about any action that is claimed to improve health. It aims to develop, identify, and promote the use of effective learning resources, beginning at primary school, to help people to make well informed choices as patients and health professionals, and well informed decisions as citizens and policy makers.

The project has drawn on several approaches used in education, including the development of a “spiral curriculum,” measurement tools, and the design of learning resources. A spiral curriculum begins with determining what people should know and be able to do, and outlines where they should begin and how they should progress to reach these goals. The basic ideas are revisited repeatedly, building on them until the student has grasped a deep understanding of the concepts. 28 29 The project has also drawn on educational research and methods to develop reliable and valid tools for measuring the extent to which those goals have been achieved. 30 31 32 The development of learning resources to teach these skills has been informed by educational research, including educational psychology, motivational psychology, and research and methods for developing learning games. 33 34 35 It has also built on the traditions of clinical epidemiology and evidence based medicine to identify the key concepts required to assess health claims. 29

It is difficult to teach critical thinking abstractly, so focusing on health may have advantages beyond the public health benefits of increasing health literacy. 36 Nearly everyone is interested in health, including children, making it easy to engage learners. It is also immediately relevant to students. As reported by one 10 year old in a school that piloted primary school resources, this is about “things we might actually use instead of things we might use when we are all grown up and by then we’ll forget.” Although the current evaluation of the project is focusing on outcomes relating to appraisal of treatment claims, if the intervention shows promise the next step could be to explore how these skills translate to wider educational contexts and outcomes.

Beyond critical thinking

Exciting opportunities for cross sector collaboration are emerging between healthcare and education. Although critical thinking is a useful example of this, other themes cross the education and healthcare domains, including nutrition, exercise, educational neuroscience, learning disabilities and special education needs, and mental health.

In addition to shared topics, several common methodological and conceptual issues also provide opportunities for sharing ideas and innovations and learning from mistakes and successes. For example, the Education Endowment Foundation is the UK government’s What Works Centre for education, aiming to improve evidence based decision making. Discussions hosted by the foundation are exploring how methods to develop guidelines in healthcare can be adapted and applied in education and other sectors.

Similarly, the foundation’s universal use of independent evaluation for teaching and learning interventions is an approach that should be explored, adapted, and applied in healthcare. Since the development and evaluation of educational interventions are separated, evaluators have no vested interested in the results of the assessment, all results are published, and bias and spin in how results are analysed and presented are reduced. By contrast, industry sponsorship of drug and device studies consistently produces results that favour the manufacturer. 37

Another example of joint working between educators and health is the Best Evidence Medical Education Collaboration, an international collaboration focused on improving education of health professionals. 38 And in the UK, the Centre for Evidence Based Medicine coordinates Evidence in School Teaching (Einstein), a project that supports introducing evidence based medicine as part of wider science activities in schools. 39 It aims to engage students, teachers, and the public in evidence based medicine and develop critical thinking to assess health claims and make better choices.

Collaboration has also been important in the development of the Critical Thinking and Appraisal Resource Library (CARL), 40 a set of resources designed to help people understand fair comparisons of treatments. An important aim of CARL is to promote evaluation of these critical thinking resources and interventions, some of which are currently under way at the Education Endowment Foundation. On 22 May 2017, the foundation is also cohosting an event with the Royal College of Paediatrics and Child Health that will focus on their shared interest in critical thinking and appraisal skills.

Education and healthcare have overlapping interests. Doctors, teachers, researchers, patients, learners, and the public can all benefit from working together to help people to think critically about the choices they make. Events such as the global evidence summit in September 2017 ( https://globalevidencesummit.org ) can help bring people together and build on current international experience.

Contributors and sources: This article reflects conclusions from discussions during 2016 among education and health service researchers exploring opportunities for cross sector collaboration and learning. This group includes people with a longstanding interest in evidence informed policy and practice, with expertise in evaluation design, reviewing methodology, knowledge mobilisation, and critical thinking and appraisal.

Competing interests: We have read and understood BMJ policy on declaration of interests and declare that we have no competing interests.

Provenance and peer review: Not commissioned; externally peer reviewed.

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Cultivating Critical Thinking in Healthcare

Published: 06 January 2019

Critical thinking skills have been linked to improved patient outcomes, better quality patient care and improved safety outcomes in healthcare (Jacob et al. 2017).

Given this, it's necessary for educators in healthcare to stimulate and lead further dialogue about how these skills are taught , assessed and integrated into the design and development of staff and nurse education and training programs (Papp et al. 2014).

So, what exactly is critical thinking and how can healthcare educators cultivate it amongst their staff?

What is Critical Thinking?

In general terms, ‘ critical thinking ’ is often used, and perhaps confused, with problem-solving and clinical decision-making skills .

In practice, however, problem-solving tends to focus on the identification and resolution of a problem, whilst critical thinking goes beyond this to incorporate asking skilled questions and critiquing solutions .

Several formal definitions of critical thinking can be found in literature, but in the view of Kahlke and Eva (2018), most of these definitions have limitations. That said, Papp et al. (2014) offer a useful starting point, suggesting that critical thinking is:

‘The ability to apply higher order cognitive skills and the disposition to be deliberate about thinking that leads to action that is logical and appropriate.’

The Foundation for Critical Thinking (2017) expands on this and suggests that:

‘Critical thinking is that mode of thinking, about any subject, content, or problem, in which the thinker improves the quality of his or her thinking by skillfully analysing, assessing, and reconstructing it.’

They go on to suggest that critical thinking is:

• Self-directed
• Self-disciplined
• Self-monitored
• Self-corrective.

Key Qualities and Characteristics of a Critical Thinker

Given that critical thinking is a process that encompasses conceptualisation , application , analysis , synthesis , evaluation and reflection , what qualities should be expected from a critical thinker?

In answering this question, Fortepiani (2018) suggests that critical thinkers should be able to:

• Formulate clear and precise questions
• Gather, assess and interpret relevant information
• Reach relevant well-reasoned conclusions and solutions
• Think open-mindedly, recognising their own assumptions
• Communicate effectively with others on solutions to complex problems.

All of these qualities are important, however, good communication skills are generally considered to be the bedrock of critical thinking. Why? Because they help to create a dialogue that invites questions, reflections and an open-minded approach, as well as generating a positive learning environment needed to support all forms of communication.

Lippincott Solutions (2018) outlines a broad spectrum of characteristics attributed to strong critical thinkers. They include:

• Inquisitiveness with regard to a wide range of issues
• A concern to become and remain well-informed
• Alertness to opportunities to use critical thinking
• Self-confidence in one’s own abilities to reason
• Open mindedness regarding divergent world views
• Flexibility in considering alternatives and opinions
• Understanding the opinions of other people
• Fair-mindedness in appraising reasoning
• Honesty in facing one’s own biases, prejudices, stereotypes or egocentric tendencies
• A willingness to reconsider and revise views where honest reflection suggests that change is warranted.

Papp et al. (2014) also helpfully suggest that the following five milestones can be used as a guide to help develop competency in critical thinking:

Stage 1: Unreflective Thinker

At this stage, the unreflective thinker can’t examine their own actions and cognitive processes and is unaware of different approaches to thinking.

Stage 2: Beginning Critical Thinker

Here, the learner begins to think critically and starts to recognise cognitive differences in other people. However, external motivation  is needed to sustain reflection on the learners’ own thought processes.

Stage 3: Practicing Critical Thinker

By now, the learner is familiar with their own thinking processes and makes a conscious effort to practice critical thinking.

Stage 4: Advanced Critical Thinker

As an advanced critical thinker, the learner is able to identify different cognitive processes and consciously uses critical thinking skills.

Stage 5: Accomplished Critical Thinker

At this stage, the skilled critical thinker can take charge of their thinking and habitually monitors, revises and rethinks approaches for continual improvement of their cognitive strategies.

Facilitating Critical Thinking in Healthcare

A common challenge for many educators and facilitators in healthcare is encouraging students to move away from passive learning towards active learning situations that require critical thinking skills.

Just as there are similarities among the definitions of critical thinking across subject areas and levels, there are also several generally recognised hallmarks of teaching for critical thinking . These include:

• Promoting interaction among students as they learn
• Asking open ended questions that do not assume one right answer
• Allowing sufficient time to reflect on the questions asked or problems posed
• Teaching for transfer - helping learners to see how a newly acquired skill can apply to other situations and experiences.

(Lippincott Solutions 2018)

Snyder and Snyder (2008) also make the point that it’s helpful for educators and facilitators to be aware of any initial resistance that learners may have and try to guide them through the process. They should aim to create a learning environment where learners can feel comfortable thinking through an answer rather than simply having an answer given to them.

Examples include using peer coaching techniques , mentoring or preceptorship to engage students in active learning and critical thinking skills, or integrating project-based learning activities that require students to apply their knowledge in a realistic healthcare environment.

Carvalhoa et al. (2017) also advocate problem-based learning as a widely used and successful way of stimulating critical thinking skills in the learner. This view is echoed by Tsui-Mei (2015), who notes that critical thinking, systematic analysis and curiosity significantly improve after practice-based learning .

Integrating Critical Thinking Skills Into Curriculum Design

Most educators agree that critical thinking can’t easily be developed if the program curriculum is not designed to support it. This means that a deep understanding of the nature and value of critical thinking skills needs to be present from the outset of the curriculum design process , and not just bolted on as an afterthought.

In the view of Fortepiani (2018), critical thinking skills can be summarised by the statement that 'thinking is driven by questions', which means that teaching materials need to be designed in such a way as to encourage students to expand their learning by asking questions that generate further questions and stimulate the thinking process. Ideal questions are those that:

• Embrace complexity
• Challenge assumptions and points of view
• Question the source of information
• Explore variable interpretations and potential implications of information.

To put it another way, asking questions with limiting, thought-stopping answers inhibits the development of critical thinking. This means that educators must ideally be critical thinkers themselves .

Drawing these threads together, The Foundation for Critical Thinking (2017) offers us a simple reminder that even though it’s human nature to be ‘thinking’ most of the time, most thoughts, if not guided and structured, tend to be biased, distorted, partial, uninformed or even prejudiced.

They also note that the quality of work depends precisely on the quality of the practitioners’ thought processes. Given that practitioners are being asked to meet the challenge of ever more complex care, the importance of cultivating critical thinking skills, alongside advanced problem-solving skills , seems to be taking on new importance.

Additional Resources

• The Emotionally Intelligent Nurse | Ausmed Article
• Refining Competency-Based Assessment | Ausmed Article
• Socratic Questioning in Healthcare | Ausmed Article
• Carvalhoa, D P S R P et al. 2017, 'Strategies Used for the Promotion of Critical Thinking in Nursing Undergraduate Education: A Systematic Review', Nurse Education Today , vol. 57, pp. 103-10, viewed 7 December 2018, https://www.sciencedirect.com/science/article/abs/pii/S0260691717301715
• Fortepiani, L A 2017, 'Critical Thinking or Traditional Teaching For Health Professionals', PECOP Blog , 16 January, viewed 7 December 2018, https://blog.lifescitrc.org/pecop/2017/01/16/critical-thinking-or-traditional-teaching-for-health-professions/
• Jacob, E, Duffield, C & Jacob, D 2017, 'A Protocol For the Development of a Critical Thinking Assessment Tool for Nurses Using a Delphi Technique', Journal of Advanced Nursing, vol. 73, no. 8, pp. 1982-1988, viewed 7 December 2018, https://onlinelibrary.wiley.com/doi/10.1111/jan.13306
• Kahlke, R & Eva, K 2018, 'Constructing Critical Thinking in Health Professional Education', Perspectives on Medical Education , vol. 7, no. 3, pp. 156-165, viewed 7 December 2018, https://link.springer.com/article/10.1007/s40037-018-0415-z
• Lippincott Solutions 2018, 'Turning New Nurses Into Critical Thinkers', Lippincott Solutions , viewed 10 December 2018, https://www.wolterskluwer.com/en/expert-insights/turning-new-nurses-into-critical-thinkers
• Papp, K K 2014, 'Milestones of Critical Thinking: A Developmental Model for Medicine and Nursing', Academic Medicine , vol. 89, no. 5, pp. 715-720, https://journals.lww.com/academicmedicine/Fulltext/2014/05000/Milestones_of_Critical_Thinking___A_Developmental.14.aspx
• Snyder, L G & Snyder, M J 2008, 'Teaching Critical Thinking and Problem Solving Skills', The Delta Pi Epsilon Journal , vol. L, no. 2, pp. 90-99, viewed 7 December 2018, https://dme.childrenshospital.org/wp-content/uploads/2019/02/Optional-_Teaching-Critical-Thinking-and-Problem-Solving-Skills.pdf
• The Foundation for Critical Thinking 2017, Defining Critical Thinking , The Foundation for Critical Thinking, viewed 7 December 2018, https://www.criticalthinking.org/pages/our-conception-of-critical-thinking/411
• Tsui-Mei, H, Lee-Chun, H & Chen-Ju MSN, K 2015, 'How Mental Health Nurses Improve Their Critical Thinking Through Problem-Based Learning', Journal for Nurses in Professional Development , vol. 31, no. 3, pp. 170-175, viewed 7 December 2018, https://journals.lww.com/jnsdonline/Abstract/2015/05000/How_Mental_Health_Nurses_Improve_Their_Critical.8.aspx

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Nursing surveillance: a concept analysis May 18, 2022

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Differential diagnosis checklists reduce diagnostic error differentially: a randomised experiment. January 26, 2022

Think twice: effects on diagnostic accuracy of returning to the case to reflect upon the initial diagnosis. September 23, 2020

Associations between healthcare environment design and adverse events in intensive care unit. May 26, 2021

Barriers to accessing nighttime supervisors: a national survey of internal medicine residents. March 17, 2021

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Evaluating the relationship between health information technology and safer-prescribing in the long-term care setting: a systematic review. March 17, 2021

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The association between nurse staffing and omissions in nursing care: a systematic review. July 11, 2018

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Impact of unacceptable behaviour between healthcare workers on clinical performance and patient outcomes: a systematic review. February 16, 2022

Standardized assessment of medication reconciliation in post-acute care. April 27, 2022

Cognitive biases in surgery: systematic review. March 1, 2023

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Diagnostic errors in hospitalized adults who died or were transferred to intensive care. January 17, 2024

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Does a suggested diagnosis in a general practitioners' referral question impact diagnostic reasoning: an experimental study. April 27, 2022

WebM&M Cases

Analysis of the interprofessional clinical learning environment for quality improvement and patient safety from perspectives of interprofessional teams. March 16, 2022

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

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

What Is Critical Thinking In Nursing?

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.

More From Forbes

The indispensable role of critical thinking in healthcare leadership.

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Dr. Hudson Garrett is the President and Chief Executive Officer of Community Health Associates , which is a leader in healthcare consulting.

In the fast-paced and complex landscape of healthcare, where decisions can have life-altering consequences, the value of critical thinking cannot be overstated. Critical thinking is not just a skill; it's a mindset—an essential tool for healthcare leaders to navigate uncertainty, make informed decisions and drive positive outcomes.

Understanding Critical Thinking In Healthcare

Critical thinking involves the ability to analyze, evaluate and synthesize information to form reasoned judgments and make sound decisions. In healthcare, where challenges are multifaceted and solutions are rarely straightforward, critical thinking enables leaders to:

1. Assess complex situations: Healthcare leaders encounter a myriad of complex challenges, from patient care decisions to organizational strategy. Critical thinking allows them to dissect these challenges, consider various perspectives and identify underlying issues to develop effective solutions.

2. Make informed decisions: Informed decision-making is paramount in healthcare, where outcomes directly impact patient well-being. Critical thinking empowers leaders to weigh evidence, anticipate consequences and choose the most appropriate course of action based on the available information and best practices.

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3. Promote innovation: Innovation drives progress in healthcare, from medical breakthroughs to operational efficiencies. Critical thinking encourages leaders to question conventional practices, explore alternative approaches and embrace new technologies to improve patient care and organizational performance. An organization must be committed to ongoing innovation both in process and in leadership development. This approach prevents stagnation and encourages growth at truly remarkable levels.

Putting Critical Thinking Into Practice

As a healthcare leader, I have witnessed firsthand the transformative power of critical thinking in addressing complex challenges and driving meaningful change. Here are three examples of how I've applied critical thinking in leadership.

1. Optimizing resource allocation: In a previous role as a department head, I faced the challenge of optimizing resource allocation to meet patient demand while managing budget constraints. Through critical thinking, I conducted a comprehensive analysis of patient flow, staff productivity and resource utilization. By identifying inefficiencies and implementing targeted interventions, such as workflow redesign and staff training initiatives, we were able to improve patient access, reduce wait times and maximize the efficiency of our resources.

2. Implementing quality improvement initiatives: In response to an increase in hospital-acquired infections, I spearheaded a quality improvement initiative aimed at reducing infection rates and enhancing patient safety. Through critical thinking, I led a multidisciplinary team in conducting root cause analyses, identifying contributing factors and developing evidence-based interventions. We then implemented standardized protocols, enhanced staff education and implemented robust surveillance systems, which helped us achieve a significant reduction in infection rates and improved patient outcomes.

3. Navigating ethical dilemmas: Healthcare leaders often encounter ethical dilemmas that require careful consideration and ethical decision-making. In a challenging scenario involving end-of-life care decisions, I relied on critical thinking to navigate conflicting interests, respect patient autonomy and uphold ethical principles. By facilitating open communication, engaging with patients and families and consulting with ethics committees, we were able to reach a consensus on a care plan that honored the patient's wishes and provided compassionate end-of-life care.

Building Your Critical Thinking Skills

I believe critical thinking has become a lost art in a way across healthcare and that modern medicine has, in many aspects, become algorithm-driven. This can create challenges when the patient or situation at hand does not fully fit into the box as defined by the algorithm. The ability to think strategically through a challenge and then leverage solutions in today's dynamic healthcare climate can prove to be invaluable.

Here are a few tips that I have personally found highly effective at addressing complex challenges while using a critical thinking methodology.

1. Start with the end in mind and establish your goal.

2. Remember that you are only able to control your reaction; you cannot directly control the challenge itself in many circumstances.

3. Think outside the box, and don't put constraints on your brainstorming. This will allow your creative juices to flow, and you will not find yourself constrained by guidelines.

4. Engage your trusted network of advisors. You can find tremendous strengths when you band together and bring in different perspectives, expertise and thoughts.

5. Never make assumptions about a solution. Just because it didn't work in the past doesn't mean it can't work now. Timing is everything.

Critical thinking is a fundamental competency for healthcare leaders. It enables them to effectively navigate complexity, drive innovation and promote excellence in patient care. By fostering a culture of critical thinking within healthcare organizations and drawing from personal examples to illustrate its practical application, leaders can enhance their decision-making capabilities, drive positive outcomes and, ultimately, improve the delivery of healthcare services to those who need it most.

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Critical Thinking in Healthcare and Medicine: A Crucial Skill for Improved Outcomes

Critical thinking is a crucial skill for individuals working in various healthcare domains, such as doctors, nurses, lab assistants, and patients. It serves as the foundation for evidence-based practice in healthcare and education and is essential for making informed decisions while evaluating research findings, which may sometimes be mixed or even conflicting [ The BMJ ].

In healthcare and medicine, critical thinking facilitates a more in-depth understanding of patients’ situations, complex clinical scenarios, and the ability to integrate various sources of information to make informed decisions. Professionals with strong critical thinking skills can better evaluate options, weigh potential risks and benefits, and ultimately choose the most appropriate course of action for their patients [ NurseJournal ].

Developing critical thinking skills in the healthcare sector is vital not only for patient safety but also for the professional development and career advancement of clinical and administrative nursing leaders. Ensuring that these skills are continuously nurtured and improved is critical for the ongoing success of the healthcare industry and for delivering the highest quality of patient care [ PubMed ].

Critical Thinking in Healthcare and Medicine

Critical thinking in healthcare and medicine involves the application of evidence-based practices and analytical skills to make informed decisions about patient care. This process often requires healthcare professionals to reflect on their knowledge, collaborate with colleagues, and evaluate the validity of various sources of information, including medical research, clinical experience, and patient preferences.

An example of critical thinking in healthcare is when a primary care doctor encounters a patient with acute, atypical chest pain. The doctor must assess the patient’s condition, review their medical history, and consider possible diagnoses while ruling out other potential causes of the pain [source] . Applying critical thinking skills enables healthcare practitioners to provide safe and effective care that is tailored to the needs of each patient.

Developing critical thinking skills is vital for healthcare professionals, as they often face complex and unique cases, where the available evidence is uncertain or conflicting. The ability to question claims, evaluate sources, and make informed decisions based on evidence contributes to improved patient outcomes and the overall quality of care [source] .

Some key components of critical thinking in healthcare and medicine include:

• Applying clinical reasoning to diagnose and treat patients
• Assessing the reliability of medical research and information sources
• Identifying gaps in knowledge and seeking additional information as needed
• Collaborating with team members and integrating their perspectives into patient care
• Reflecting on performance and implementing strategies for continuous improvement

By fostering these critical thinking skills, healthcare professionals can navigate the complexities of their field, make better clinical decisions, and ultimately provide a higher standard of patient care.

The Role of Critical Thinking in Decision-Making

Critical thinking plays a pivotal role in healthcare and medicine, affecting every aspect of the decision-making process. In clinical practice, it serves a key function in assessing patients’ symptoms, interpreting diagnostic results, and choosing appropriate interventions. This cognitive skill involves questioning, analysis, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application, and creativity to guide professional judgments and actions ( source ).

In many medical situations, such as triage, critical thinking can be crucial to ensure appropriate prioritization of patients based on their medical needs. Healthcare professionals must quickly adapt and process an influx of information to efficiently make critical decisions ( Rasmussen University ). Some practical examples of critical thinking in decision-making include:

• Evaluating multiple treatment options and selecting the best course of action for a particular patient;
• Appraising and integrating relevant evidence from research into clinical practice;
• Asking meaningful questions that lead to useful answers and promote deeper understanding of complex medical issues ( NurseJournal ); and
• Identifying personal biases and potential barriers that could impair objective decision-making.

Furthermore, fostering critical thinking in medical education empowers healthcare professionals to make informed decisions, even in ambiguous or uncertain circumstances. Cross-sector collaboration between healthcare and education sectors can nurture and enhance the development of these essential skills, creating better-prepared providers ( The BMJ ).

Developing Critical Thinking Skills in Healthcare Professionals

Enhancing critical thinking abilities in healthcare professionals is crucial for promoting effective decision making, improving patient outcomes, and maintaining quality patient care. This can be achieved through various approaches, including education and training, mentoring, and continuing professional development.

Education and Training

Formal education and specialized training programs play a vital role in developing critical thinking skills among healthcare professionals. These programs should emphasize the importance of honing these skills as an essential component of their professional growth. Incorporating interactive learning methods, such as case studies, group discussions, and problem-solving exercises, can encourage participants to engage in reflective and analytical thinking. Courses on clinical reasoning and decision making can further strengthen these abilities.

Mentoring has been shown to be an effective method for fostering critical thinking skills in healthcare professionals. Experienced mentors can support and guide their mentees in developing the habits of mind associated with critical thinking, such as open-mindedness, intellectual curiosity, and reflection. The mentor-mentee relationship offers a platform for the exchange of ideas, constructive feedback, and experiential learning. By reflecting on real-life clinical scenarios with their mentors, mentees can hone their critical thinking skills to make better informed decisions in their practice.

Continuing Professional Development

Continuing Professional Development (CPD) is an integral component of maintaining and improving critical thinking skills in the healthcare setting. By participating in relevant workshops, seminars, and courses, healthcare professionals can stay up-to-date with the latest advances in their field and strengthen their decision-making abilities. Additionally, engaging in regular self-reflection and assessment allows them to identify areas for improvement and seek targeted education to further enhance their critical thinking skills.

To summarize, developing critical thinking skills in healthcare professionals is crucial in promoting optimal patient care, decision-making, and overall professional growth. Fostering these skills through education and training, mentoring, and continuing professional development ensures that healthcare providers remain effective, well-rounded professionals.

Critical Thinking Tools and Techniques

Critical thinking in healthcare and medicine is an essential skill for professionals to make well-informed decisions and provide quality care to patients. This process combines cognitive abilities with strategic skills to achieve specific objectives. This section will explore some common tools and techniques used to promote critical thinking in healthcare professionals.

1. Interpretation : Professionals should be able to understand and explain the meaning of various types of information, such as diagnostic results or patient medical histories. They need to interpret complex data and make sense of it to provide the best possible care. This skill is important for accurate diagnosis, efficient treatment, and effective communication with patients and colleagues (APA) .

2. Analysis : Critical thinking in healthcare requires professionals to assess the quality and relevance of information, such as research findings or clinical guidelines. By breaking down information into its constituent parts and evaluating its strengths and weaknesses, professionals can make informed decisions that are based on evidence and best practices (The BMJ) .

3. Evaluation : Healthcare professionals need to appraise the credibility, accuracy, and applicability of information. Evaluating the reliability of sources, such as the reputation of journals or the robustness of research, helps ensure that only high-quality, trustworthy information is used to guide clinical decisions (Nursing Clinical Practice, Education and Research) .

4. Inference : Drawing conclusions from available information is a crucial aspect of critical thinking in healthcare. Professionals must infer the best course of action, considering all relevant variables and factors, such as patient preferences, clinical guidelines, and ethical considerations. Inference requires professionals to weigh the potential benefits and harms and use their judgment to make sound decisions (Critical Thinking in Critical Care) .

5. Self-regulation : It is essential for healthcare professionals to monitor and adjust their thinking processes by maintaining an open-minded and reflective approach. Self-regulation involves the ability to identify biases and inconsistencies in one’s thinking, question assumptions, and adapt to new information or insights as they emerge (Scoping Review of Critical Thinking) .

Using these critical thinking tools and techniques, healthcare professionals can better navigate complex situations, problem-solve effectively, and ensure that they are providing the highest quality care to their patients.

Challenges in Implementing Critical Thinking in Healthcare

One of the major challenges in implementing critical thinking in healthcare is overcoming personal biases. These biases can sometimes lead healthcare professionals to make incorrect inferences or judgments, which ultimately affects patient care. In nursing, for example, personal biases are regarded as one of the most common pitfalls to critical thinking ( NurseJournal ).

Another challenge is the risk of conflicting metrics. Healthcare professionals often need to balance various metrics and targets to provide the best possible care to patients. Sometimes, success in one area may come at the expense of another, making it difficult to find a balance conducive to critical thinking ( International Journal for Quality in Health Care ).

Moreover, healthcare professionals must also deal with disconnected metrics. Staff members may face multiple targets and metrics that appear unrelated or difficult to comprehend, making it harder for them to incorporate critical thinking into their decision-making processes ( International Journal for Quality in Health Care ).

In terms of education, there is an ongoing need to identify the most effective strategies for teaching critical thinking in healthcare. A scoping review of critical thinking literature in healthcare education highlights the broad range of methods used to teach critical thinking, as well as the variability in research methodologies ( PubMed ). This suggests a need for further research and consensus to develop the most effective critical thinking educational methods for healthcare professionals.

The Impact of Critical Thinking on Patient Outcomes

Critical thinking is essential in healthcare as it enables healthcare professionals to make well-informed decisions, ultimately leading to improved patient outcomes. This higher-order thinking skill involves the application of knowledge and experience to identify patient problems and direct clinical judgments and actions that result in positive outcomes (NCBI) .

One of the ways critical thinking can positively impact patient outcomes is through accurate problem identification. This skill can help healthcare professionals correctly diagnose patients’ issues, resulting in a more efficient and effective care plan (ScienceDirect) .

Another impact of critical thinking on patient outcomes is seen through proper planning and administration of care. A healthcare professional who utilizes critical thinking skills can carefully examine all aspects of patient care and make informed decisions that minimize harm and improve outcomes (ScienceDirect) .

Furthermore, critical thinking skills can also enhance communication and collaboration among healthcare professionals. This can lead to more effective teamwork and coordinated care, ultimately benefiting the patient and improving their overall experience in the healthcare system.

In summary, incorporating critical thinking skills into healthcare practice can play a significant role in improving patient outcomes. Accurate problem identification, effective planning, and administration of care, coupled with better communication and collaboration among professionals, all contribute to enhancing the quality of care delivered to patients.

Future Perspectives

As the healthcare industry continues to evolve, the importance of critical thinking skills in medical practice is becoming increasingly evident. The ability to critically evaluate evidence, diagnose complex problems, and develop effective solutions will be paramount for healthcare providers as they face new challenges and adapt to novel technologies.

One of the exciting prospects for the future of critical thinking in healthcare is cross-sector collaboration. Professionals from various disciplines, such as medicine, nursing, psychology, and education, have the opportunity to work together to gain new insights and develop innovative approaches to patient care. This collaboration could lead to significant advancements in both healthcare practice and medical education, as described in The BMJ .

Furthermore, the integration of new technologies like artificial intelligence (AI) and machine learning will necessitate a greater emphasis on critical thinking. Healthcare practitioners will need to adapt and learn how to effectively use these tools while maintaining their ability to think critically about diagnoses and treatment plans.

Medical education must also evolve to reflect the shifting landscape of healthcare. Educators should prioritize the development of critical thinking skills in their curricula, alongside clinical competencies and lifelong learning. This entails incorporating teaching strategies that foster problem-solving, evidence-based decision making, and collaboration, as highlighted in The BMJ .

In summary, the future of critical thinking in healthcare and medicine holds promise for enhancing patient care and improving medical education. By fostering a culture of collaboration and embracing new technologies, healthcare professionals can leverage their critical thinking skills to navigate complex challenges and drive innovation in their field.

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• v.8(4); 2021 Jul

Factors associated with the critical thinking ability of professional nurses: A cross‐sectional study

Tuan van nguyen.

1 Faculty of Nursing and Medical Technology, Can Tho University of Medicine and Pharmacy, Can Tho Vietnam

2 School of Nursing, College of Medicine, Chang Gung University, Taoyuan Taiwan

Hsueh‐Erh Liu

3 Department of Rheumatology, Chang Gung Memorial Hospital, Linkou Taiwan

4 Department of Nursing, College of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan

Associated Data

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

To measure the level of critical thinking among Vietnamese professional nurses and to identify the related factors.

A cross‐sectional design was used.

The total sample included 420 professional nurses. Data were collected from July to September 2019 in three public hospitals located in Southwestern Vietnam. The level of critical thinking was measured using the Vietnamese version of the Nursing Critical Thinking in Clinical Practice Questionnaire. The data were analysed using the independent Student's t tests, ANOVA, Pearson's correlation and regression analysis.

Most of the participants had a low (48.3%) or moderate (45.5%) level of critical thinking. Age, gender, ethnicity, education level, health condition, duration of working as a nurse, duration of working in the current hospital, having heard the term “critical thinking” and work position had an impact on the critical thinking ability. Work position and gender explained 11% of the total variance in critical thinking ability.

1. INTRODUCTION

Critical thinking is defined as the cognitive process of reasoning that involves trying to minimize errors and to maximize positive outcomes while attempting to make a decision during patient care (Zuriguel‐Pérez et al.,  2015 ). The importance of critical thinking in nursing practice has been identified in the literature (Chang et al.,  2011 ; Ludin,  2018 ; Mahmoud & Mohamed,  2017 ; Yurdanur,  2016 ; Zuriguel‐Pérez et al.,  2015 ). The current nursing environment has become more complex and demanding, especially regarding the acuity and safety of patients and the rapid turnover rate of hospitalization. If professional nurses want to provide high‐quality care, critical thinking is required (Berkow et al.,  2011 ; Brunt,  2005 ; Fero et al.,  2009 ; Zuriguel‐Pérez et al.,  2015 ). Nurses are often the first‐line professionals to observe and provide direct care for patients. Therefore, critical thinking is a necessary skill for them to be able to analyse clinical situations in order to make fast and correct decisions (Lee et al.,  2017 ). More importantly, critical thinking can also improve patient outcomes by preventing habitual thinking that may lead to incorrect medication or procedures (Fesler‐Birch,  2005 ). The critical thinking ability of nurses can have an impact on the patient's safety, and it is a priority in educational programs for healthcare providers (Berkow et al.,  2011 ; Buerhaus et al.,  2006 ). We can identify those with poor critical thinking and provide in‐service education. Although critical thinking has been shown that is influenced by the experience and knowledge acquired during clinical practice (Zuriguel‐Pérez et al.,  2015 ), other personal information needs to be considered to clarifying. Therefore, it is essential to measure the levels of critical thinking and to identify the work‐related and personal‐related factors that influence the critical thinking of nurses.

2. BACKGROUND

The literature has identified that there is a relationship between leadership and positive patient outcomes, such as fewer medication errors and nosocomial infections, lower patient mortality and higher patient satisfaction (Van Dyk et al.,  2016 ; Wong,  2015 ). Alongside leadership, critical thinking is an important factor that supports the management. They can apply critical thinking skills in decision‐making and problem‐solving, and they can develop strategies that help staff nurses to improve their critical thinking ability (Van Dyk et al.,  2016 ; Wong,  2015 ; Zuriguel‐Pérez et al., 2018 ). Thus, the ability to think critically is necessary for nurses because it will help them to effectively make decisions and to solve problems in practice.

Although the importance of critical thinking in nursing practice has been identified, a limited number of studies have been conducted in this population. Particularly, few hospitals have evaluated the critical thinking skills of nurses before employment or during the clinical competency evaluation (Lang et al.,  2013 ). By reviewing 90 articles to assess the current state of the scientific knowledge regarding critical thinking in nursing, Zuriguel‐Pérez et al., ( 2015 ) found that only 16 studies used working nurses as participants. Furthermore, Zuriguel‐Pérez et al., ( 2018 ) reported that few studies have explored the critical thinking ability of nurse managers (NMs). Moreover, several studies have identified that working nurses have a low (Lang et al.,  2013 ; Yurdanur,  2016 ) or moderate level of critical thinking (Chang et al.,  2011 ; Lang et al.,  2013 ; Zuriguel‐Pérez et al., 2018 ). To the researchers’ knowledge, no studies have investigated this issue in Vietnam.

In order to improve the quality and safety of patient care, various types of professional nurses have been established, such as Registered Nurses (RNs), NMs and administrative assistants (AAs). RNs provide direct care to the patients, NMs are responsible for forwarding management and delivering expert clinical care for patients, and AAs are an integral part of maintaining the quality of patient care. The AAs perform administrative tasks (e.g. filing, taking meeting minutes and distributing them and undertaking regular reports) that help NMs to spend more time assisting staff nurses and taking care of patients (Locke et al.,  2011 ). Therefore, RNs, NMs and AAs need to cooperate to help patients to regain their health.

In Vietnam, professional nurses work in three different positions, which are NMs, general nurses (GNs) and AAs (Ministry of Health,  1997 ). Specifically, NMs are recognized as head nurses in Western countries, and their responsibilities are in charge of organizing and implementing comprehensive patient care and conduct a variety of administrative work (e.g. planning and assigning work to nurses, planning the acquisition of tools and consumables, checking care sheets, recording daily labour). GNs are similar to RNs in Western countries, and they provide direct and comprehensive care to patients. AAs perform administrative tasks (e.g. keeping records about the hospitalized and discharged patients, preserving medical records, managing daily medications). They also participate in patients care if necessary (Ministry of Health,  1997 , 2011 ). Although the roles of these three types of professional nurses are different, their final goal is the same to provide holistic care for patients. With the cooperation and effort of these three types of professional nurses, patients can recover. Therefore, more surveys are needed that examine these participants’ level of critical thinking and the associated work‐related factors.

Previous studies have also found that several personal‐related factors are associated with the nurses' critical thinking ability, which are age, gender, ethnicity, education qualification, working experience and shift work (Chang et al.,  2011 ; Feng et al.,  2010 ; Howenstein et al.,  1996 ; Lang et al.,  2013 ; Ludin,  2018 ; Mahmoud & Mohamed,  2017 ; Ryan & Tatum,  2012 ; Wangensteen et al.,  2010 ; Yildirim et al.,  2012 ; Yurdanur,  2016 ; Zuriguel‐Pérez et al., 2018 ). However, the relationships between the critical thinking ability and these variables are inconsistent. For example, age and critical thinking have been found to be positively correlated (Chang et al.,  2011 ; Ludin,  2018 ; Zuriguel‐Pérez et al., 2018 ), negatively correlated (Howenstein et al.,  1996 ) and not related (Lang et al.,  2013 ; Mahmoud & Mohamed,  2017 ; Yurdanur,  2016 ). Gender and critical thinking have been reported with a statistically significant relationship (Liu et al.,  2019 ; Ludin,  2018 ) and no relationship (Mahmoud & Mohamed,  2017 ; Wangensteen et al.,  2010 ). Level of education and critical thinking have been found in a positive association (Chang et al.,  2011 ; Ludin,  2018 ) and not association (Lang et al.,  2013 ; Mahmoud & Mohamed,  2017 ). Year of experiences and critical thinking have been shown to be positively correlated (Chang et al.,  2011 ; Ludin,  2018 ), negatively correlated (Howenstein et al.,  1996 ) and not related (Lang et al.,  2013 ; Mahmoud & Mohamed,  2017 ). Those inconsistent findings indicated the relationships between the personal‐characteristics and the critical thinking ability of professional nurses need further exploration. Therefore, this study aimed to examine the level of critical thinking of professional nurses and to explore the work‐related and personal‐related factors. This is the first study to investigate this issue in Vietnam. The results of the current study will make a significant contribution to the literature because it will provide thorough descriptions of the critical thinking of professional nurses and its associated factors. Furthermore, the findings may be used as a baseline for nurse managers and nurse educators to propose further strategies to improve this ability in professional nurses.

3.1. Research design

A cross‐sectional design was used. The Strengthening the Reporting of Observational Studies in Epidemiology guidelines were applied in this report (Von Elm et al.,  2014 ).

3.2. Setting and sampling

Data collection was carried out from July to September 2019 in three representative and major public hospitals located in the Southwestern region of Vietnam. These hospitals have the same organizational structure, role of treating, operation of professional nursing and provide similar quality of health care to people around that area. The total numbers of professional in these three hospitals nurses were around 1,200. Besides, our study has two steps. The first step was to translate the English version of the Nursing Critical Thinking in Clinical Practice Questionnaire (N‐CT‐4 Practice) into the Vietnamese version. In that step, we used data as a pilot study to estimate the sample size in the second step, which was reported here. Sample size calculation was done by the formula: n  = 1.96 2  × p × (1‐p)/0.05 2 , where p  = .46 came from the poor level of critical thinking among nurses in the first step and 0.05 indicated the acceptable margin of error (5.0%); 382 participants were required by this formula. An additional 10% of participants were done to adjust for potential failures such as withdrawals or missing data (Suresh & Chandrashekara,  2012 ). Therefore, in total, 420 participants were required for this study. Convenience sampling was conducted to recruit the sample. The inclusion criteria were the nurses' employed full‐time employment in the study hospitals. Participants who participated in step 1 or being absent during the data collection such as sick leave or delivering a baby were excluded. Participants were grouped in each hospital and received an envelope with all questionnaires. Then, researchers explained the research's purpose, benefits and risks to the potential participants and the procedure for ensuring confidentiality, and the voluntary nature of the participation. The informed consent form was signed immediately after they agreed to participate in this study. Then, the participants were required to complete the questionnaires in 20 to 30 min and to return them to the data collector.

3.3. Data assessment

3.3.1. sample characteristics.

This instrument collected data about the personal information and occupational variables. The personal information included age, gender, marital status, ethnicity, religion, education level and self‐rated health conditions. The occupational variables were the duration of working as a nurse, the duration of working in the current hospital, the duration of working in the specific position, having heard the term “critical thinking” or not, previous exposure to critical thinking training or education or not, and type of work position.

3.3.2. Vietnamese version of the Nursing Critical Thinking in Clinical Practice Questionnaire ((N‐CT‐4 Practice (V‐v))

The N‐CT‐4 Practice (V‐v) was used to measure the critical thinking ability of the professional nurses. The original instrument (N‐CT‐4 Practice) was established and classified based on the four dimensions of the 4‐circle critical thinking model of Alfaro‐LeFevre (Zuriguel‐Pérez et al., 2017 ). These four dimensions were personal; intellectual and cognitive; interpersonal and self‐management; and technical dimensions. The personal dimension has 39 items to assess the individual pattern of intellectual behaviours; the intellectual and cognitive dimension has 44 items to assesses the knowledge of activity comprehension connected to the nursing process and decision‐making. For the interpersonal and self‐management dimension, it has 20 items to analyse interpersonal abilities that allow for therapeutic communication with patients and health teams and to gain information that is associated with the patient in the clinical environment. The final one, the technical dimension, has 6 items to is concerned with knowledge and expertise in the procedures that are part of the discipline of nursing. This scale has 109 items that are rated using a four‐point Likert response format (1 = never or almost never, 2 = occasionally, 3 = often, and 4 = always or almost always), for example: “I recognize my own emotions.” (item 1); “I have the scientific knowledge required to carry out my professional practice.” (item 40); “I adapt information to the needs and capacities of the patient.” (item 84); “I possess skills in the use of information and communication technologies needed to produce optimal professional results.” (item 105). The total score is obtained from the sum of the 109 items. The scores range from 109–436, and they are categorized into a low level (score <329), moderate level (score between 329–395) and high level (score >395). The overall Cronbach's alpha was 0.96, and the intraclass correlation coefficient (ICC) was 0.77 (Zuriguel‐Pérez et al., 2017).

The N‐CT‐4 Practice (V‐v) was translated, and its psychometric properties were tested with 545 Vietnamese nurses. The results showed that the N‐CT‐4 Practice (V‐v) has acceptable reliability (Cronbach's alpha) and validity (content and construct validity). Particularly, the overall Cronbach's alpha was 0.98, with that of the four dimensions ranging from 0.86–0.97. The ICC was 0.81 over two weeks. The item content validity index was 1.0. Moreover, the goodness‐of‐fit indexes in a confirmatory factor analysis showed acceptable values, which were χ 2 / df  = 2.87, root mean square error of approximation (RMSEA) = 0.059, standardized root mean square residual (SRMR) = 0.063, comparative fit index (CFI) = 0.73 and Tucker Lewis index (TLI) = 0.72 (T. V. Nguyen & Liu,  2021 ). Therefore, the N‐CT‐4 Practice (V‐v) can be used to measure the critical thinking ability of Vietnamese professional nurses.

3.4. Ethical considerations

This study conformed with the ethical principles of the Declaration of Helsinki (Helsinki Declaration,  2013 ), and it was granted research ethics committee approval by the ethical review board of the first author's institution.

3.5. Data analysis

The data were analysed using SPSS for Windows version 23.0 (IBM Corp.), and both descriptive and inferential statistics were calculated. The level of significance for all analyses was set at < 0.05. First, descriptive statistics were employed to summarize the collected data. The continuous variables were described using the mean and standard deviation ( SD ), and the frequency and percentage (%) were used for the categorical variables. Next, independent Student's t tests, analysis of variance (with Scheffe's post hoc comparison) and Pearson's correlation analysis were conducted to explore the association between the critical thinking ability and the personal and occupational factors. Then, a multiple regression analysis using the stepwise method was performed to identify the predictors of critical thinking ability (Pallant,  2010 ).

4.1. Characteristics of the participants

A total of 420 participants completed the questionnaires; the characteristics of overall participants and subjects in each group are listed in Table  1 . Three groups of subjects were included, which were NMs (24.8%), GNs (49.8%) and AAs (25.4%), respectively. Regarding the personal variables, almost all participants were Vietnamese (96.7%), no religion (73.1%) and had good health condition (60%). Meanwhile, the comparison among each group showed that age ( F  = 9.89, p  < .001), gender (χ 2  = 6.48, p  < .05), marital status (χ 2  = 6.77, p  < .05) and education level (χ 2  = 147.38, p  < .001) had reached the statistical significance. Further analysis showed that the age of NMs was significantly older than subjects in both the GN and AA group, AA group had a higher ratio of that in the GN group, and the AA group had a higher ratio of married one than the GN group. For educational levels, subjects in the NM group had a higher ratio of bachelor and master degree, whereas the other two groups had a high ratio of diploma and associate degree.

Characteristics of the participants ( n  = 420)

Abbreviations: AA, Administrator assistant; CT , Critical thinking; GN, General nurse; NM, Nurses manager ; SD , standard deviation.

Chi‐square and one‐way ANOVA test; significant at * p  < .05; ** p  < .01; *** p  < .001.

Regarding work‐related factors, the characters of all participants and subjects in each group are also listed in Table  1 . The comparison of professional experience, such as duration of working as a nurse, duration of working in the current hospital, duration of working in this specific position and heard the terminology of "critical thinking" showed a significant statistical difference among the three groups ( p  < .001). They showed that NMs had a longer duration of working as a nurse (mean = 12.30, SD  = 7.12) and duration of working in the current hospital (mean = 11.6, SD  = 7.02) than the other two groups; GNs had the longest duration of working in the specific position (mean = 7.41, SD  = 6.21). More subjects in the NM group heard the terminology of "critical thinking" than subjects in the other two groups. However, none of the subjects had been exposed to critical thinking training or education. Furthermore, there was a positive correlation among age, the duration of working as a nurse, the duration of working in the current hospital and duration of working in a specific position ( r  = .78–.975, p  < .01).

4.2. Level of the critical thinking of the professional nurses

The mean of the total scores of the N‐CT‐4 Practice (V‐v) for all participants was 333.86 ± 40.22 (with the average score/item = 3.06 ± 0.37), the median score was 331 (interquartile range [IQR] = 311–359), and it ranged from 204–436, which indicates that they generally had a moderate level of critical thinking. Meanwhile, most of the participants reported a low (48.3%) or moderate (45.5%) level of critical thinking. Only 6.2% of the participants had a high level of critical thinking. Regarding the four dimensions of the N‐CT‐4 Practice (V‐v), the average sum score was 119.52 ± 14.19 (with the average score/item = 3.06 ± 0.36) in the personal dimension, 136.38 ± 17.62 (with the average score/item = 3.10 ± 0.40) in the intellectual and cognitive dimension, 68.71 ± 12.65 (with the average score/item = 3.44 ± 0.63) in the interpersonal and self‐management dimension and 18.09 ± 3.01 (with the average score/item = 3.01 ± 0.50) in the technical dimension.

4.3. Work‐related and personal‐related factors associated with critical thinking ability

There were statistically significant associations between the critical thinking ability and some work‐related factors, such as work position ( F  = 23.30, p  < .001), duration of working as a nurse ( r  = 0.15, p  < .01), duration of working in the current hospital ( r  = 0.13, p  < .05) and having heard the term "critical thinking" ( t  = −2.48, p  < .05; Table  2 ). The findings indicated that NMs had higher scores than GNs and AAs. Moreover, nurses who had worked for a longer duration as a nurse or worked longer in the current hospital had a higher critical thinking ability. Meanwhile, those who had not heard the term "critical thinking" had lower scores than participants who had heard this term.

Association between the participants’ characteristics and the critical thinking ability ( n  = 420)

The bolded values indicate the level of statistical significance (with p < .05; p < .01; or p < .001) between the independent and dependent variables.

Abbreviations: SD , standard deviation.

There were statistically significant associations between the critical thinking ability and some personal‐related factors, such as age ( r  = 0.12, p  < .05), gender ( t  = 2.32, p  < .05), ethnicity ( t  = 1.97, p  < .05), education level ( F  = 7.45, p  < .01) and health condition ( F  = 3.14, p  < .05; Table  2 ). The findings indicated that the older nurses reported a higher critical thinking ability, and male nurses had a higher score than female ones. Vietnamese participants had higher scores than participants with other ethnicities. Participants with a bachelor's/graduate degree level of education had higher scores than participants with a diploma and associate degree level of education. Those with very good health had a higher score than participants who rated their health as fair/bad/very bad.

All of the statistically significant variables identified in the univariate analysis were selected as independent variables to determine the predictors of critical thinking ability. For the regression analysis, the categorical variables were first coded as dummy variables. The factors of having never heard of “critical thinking,” being an NM being male, being Vietnamese, having a diploma degree and being in very good health were selected as the standard factors. The results of the stepwise multiple regression method showed that there were only two predictors, namely the variables of work position and gender. Working as an AA or GN or being female can predict the critical thinking ability, and they accounted for 11% of the total variance ( F  = 17.12, p  < .001). This indicates that the AAs and GNs had a lower level of critical thinking than the NMs. Besides, when compared with male nurses, the female nurses exhibited a lower level of critical thinking (Table  3 ).

Predictors of the critical thinking ability ( n  = 420)

5. DISCUSSION

This study showed that the critical thinking ability of most professional nurses was at a low or moderate level. This finding is consistent with previous studies (Chang et al.,  2011 ; Lang et al.,  2013 ; Zuriguel‐Pérez et al., 2018 ). Using the same tool, Zuriguel‐Pérez et al. ( 2018 ) found that the median score of the N‐CT‐4 Practice was 363 (IQR = 340–386) for clinical nurses in Spain. Our study found a slightly lower median score (331; IQR = 311–359) but it was still in a moderate level (range of score: 329–395). Although critical thinking is a relatively new issue in Vietnamese professional nurses, it is not a brand new concept. Certain elements have been included in the nursing curriculum and clinical practice (e.g. the nursing process, problem‐based learning, evidence‐based practice). Therefore, up to 66.7% of participants had never heard the term "critical thinking," but 45.5% still reported a moderate level when measured using the N‐CT‐4 Practice (V‐v).

In Vietnam, clinical professional nurses are categorized into NMs, GNs and AAs with different job descriptions. Critical thinking ability has been identified as an important component for the high quality of care around the world, except in Vietnam. In order to identify this ability, we collected data from 3 hospitals in one region and grouped these data for analysis. Based on the comparison among NMs, GNs and AAs, it was found that NMs had a higher level of critical thinking than GNs and AAs. This can be explained by the fact that NMs have a higher age, work experience and high educational qualification than the other two groups. This result partially supports the finding that NMs report a slightly higher level of critical thinking than RNs (Zuriguel‐Pérez et al., 2018 ). Critical thinking is a necessary skill for effective and efficient management. Evidently, at present, NMs with a high level of critical thinking create positive practice environments that can help the staff nurses to deliver high quality and safe patient care (Zori et al.,  2010 ). Therefore, all healthcare personnel needs to learn and apply critical thinking in order to conduct their work effectively and efficiently.

For clinical nurses, continuous in‐service education is very important to update their knowledge and skill of care. Literature found various factors associated with curriculum design and learning of critical thinking ability. Therefore, grouping subjects in the present study together in order to identify the related factors could help the development of further in‐service education of critical thinking ability effectively and efficiently. In this study, a statistically significant positive correlation was found between the critical thinking ability and age, the duration of working as a nurse and the duration of working in the current hospital. These findings are consistent with previous studies. For example, older nurses have a higher level of critical thinking than younger ones (Chang et al.,  2011 ; Chen et al.,  2019 ; Feng et al.,  2010 ; Ludin,  2018 ; Wangensteen et al.,  2010 ; Yurdanur,  2016 ; Zuriguel‐Pérez et al., 2018 ), and nurses with more experience report a better critical thinking ability than those with less experience (Chang et al.,  2011 ; Chen et al.,  2019 ; Feng et al.,  2010 ; Ludin,  2018 ). Older and experienced nurses are more mature in their way of thinking (Chen et al.,  2019 ; Ludin,  2018 ). Because there were statistically significant positive correlations among age, the duration of working as a nurse and the duration of working in the current hospital. This indicates that older nurses have a longer duration of working as a nurse or working in the current hospital so they have better critical thinking. However, the correlation between these factors and critical thinking in the current study is small; further explorations are suggested.

This study showed that there is a significant association between critical thinking ability and gender and ethnicity, which is also supported by the literature. Ludin ( 2018 ) found that female nurses reported a lower critical thinking ability than male nurses. Traditionally, females have generally had fewer opportunities to receive education and more difficulty asserting their rights during decision‐making than males in Vietnam (L. T. Nguyen et al.,  2017 ). Even today, the phenomenon of gender inequality still exists in certain areas in Vietnam. This traditional burden and the limited opportunities to practice in a clinical care setting might lower the levels of the female participants’ critical thinking. Ethnicity has a similar impact, as found in the present study. For example, it has been reported that Caucasian and Hispanic/Latino participants have a significantly higher critical thinking ability than African American participants (Lang et al.,  2013 ) and that Malaysian and Indian participants report different levels of critical thinking; nevertheless, only 0.9% of the participants were Indian (Ludin,  2018 ). However, in the present study, as almost all of the participants were Vietnamese (96.7%), the skewed distribution of the ethnicity might limit the generalizability of the results. In future studies, an equal distribution of ethnicity is strongly recommended.

This study also confirmed that those who had a bachelor's/graduate degree had a higher level of critical thinking than those who had a diploma or associate degree, even though the former had never heard the term "critical thinking." A vast amount of studies has found that education has a positive impact on the level of critical thinking (Chang et al.,  2011 ; Gloudemans et al.,  2013 ; Ludin,  2018 ; Yildirim et al.,  2012 ; Zuriguel‐Pérez et al., 2018 ). Meanwhile, this study found that participants who had heard the term "critical thinking" displayed a higher level of critical thinking than those who had not heard this term. Education might be the major reason for this variation. In the present study, only 40.7% of participants had a bachelor's/graduate degree. In order to promote their levels of critical thinking, it is necessary to arrange for them, to encourage them, to attend advanced education or to provide further content in the in‐service education.

In this study, participants with very good health had a higher level of critical thinking than participants who self‐rated their health as fair/bad/very bad. Health status does have an impact on work productivity, job performance, quality of care and extra learning (Letvak et al.,  2011 ). Thus, poor health limits their learning and critical thinking ability. This ability is an important predictor of real‐life outcomes (e.g. interpersonal, work, financial, health and education) (Butler et al.,  2017 ). Therefore, the causal effects between health and critical thinking ability need further exploration.

In the current study, only the female gender and the type of work position as an AA or GN were identified as predictors, and they explained only 11% of the total variance of critical thinking ability in the regression model. The uneven distribution of gender and work position might be the reason for the low variance. Even though the male was significantly less than the female, NM was fewer than GN and AA. More factors need to be included in further studies.

The limitations of this study include that it used a convenience sample from only three public hospitals located in the Southwestern part of Vietnam. This sample does not represent all professional nurses in Vietnam. The N‐CT‐4 Practice is the instrument with good psychometric properties specific for clinical practice and translated into English (Zuriguel‐Pérez et al., 2017), Persian (FallahNezhad & Ziaeirad,  2018 ) and Turkish (Urhan & Seren, 2019 ). Different points of the Likert response format were selected by tools to measure critical thinking ability. For example, the N‐CT‐4 Practice selected a four‐point Likert response and it was rated in frequency, such as 1 = never or almost never and 4 = always or almost always. However, a seven‐point Likert scale for the Critical Thinking Disposition Assessment (CTDA) was selected and rated in levels of agreement, such as 1 for very strongly disagree and 7 for very strongly agree (Cui et al.,  2021 ). Which response format can be more reprinting the characters of critical thinking ability? Further investigation is strongly suggested. Besides, the N‐CT‐4 Practice (V‐v) questionnaire has too many items that may lead to the boredom of the participants to answer and thus affect the accuracy of the results. Moreover, the collapsing of three distinctly separate groups of nurses into one group for most of the analyses lead to not showing differences in critical thinking and influencing factors among the three groups. These factors all limit the generalization of the present results. Based on these limitations, it is suggested that the use of nationwide systematic sampling and an international comparison are strongly suggested in further studies. Regarding the critical thinking questionnaire, it would be better to use the revised versions with fewer questions. Therefore, developmental and psychometric properties are suggested to shorten this questionnaire.

6. CONCLUSIONS

The results demonstrate that most of the professional nurses had a low or moderate critical thinking ability. Certain personal and occupational variables were significantly associated with the level of critical thinking. Being male or working as an NM were statistically significant predictors of critical thinking ability, and they explained only 11% of the total variance.

The findings of this study indicate that it is necessary to develop strategies to improve the critical thinking ability of professional nurses. The critical thinking ability has been confirmed to be an essential factor for high‐quality health care that focuses on the quality of patient care and patient safety. Besides, providing more opportunities to pursue advanced degrees or enhancing the provision of in‐service education in hospitals that involves classroom teaching or web‐based learning is strongly recommended for this specific group of nurses. Consequently, the quality of patient care could be improved.

CONFLICT OF INTEREST

The authors declare that they have no competing interests.

ACKNOWLEDGEMENTS

The authors would like to thank the expert panel, translators, research assistants, the hospitals and all of the clinical nurses who participated in this study. We are indebted to the study participants and would like to dedicate the research findings to improving the critical thinking ability of Vietnamese professional nurses in the future. No specific grant was received from funding agencies in the public, commercial, or not‐for‐profit sectors.

Van Nguyen T, Liu H‐E. Factors associated with the critical thinking ability of professional nurses: A cross‐sectional study . Nurs Open . 2021; 8 :1970–1980. 10.1002/nop2.875 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

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Cultivating STEM Leaders

Written by Tina Potterf

March 28, 2024

Dean’s Fellows, a new program in the College of Science and Engineering, builds leadership skills, critical thinking and connections across majors.

This past fall, the College of Science and Engineering launched a new program for first-year students, providing opportunities to build community and connections with peers while developing leadership skills in STEM fields. 

The Dean’s Fellows program is comprised of highly motivated students—there are 25 students in this first cohort—who come from a range of majors within the college and once selected as fellows will stay in the program through their senior, or fourth, year. The programming connected to the Dean’s Fellows pulls on a theme consistent with the university’s Reignited Strategic Directions. 

“In line with our mission to educate leaders for a just and humane world, these Dean’s Fellows are creative and aspiring leaders in STEM who are learning to tackle the challenges facing humanity,” says Dean Amit Shukla, PhD. “As part of their growth and education, the fellows are learning how Jesuit education serves humanity through innovation.”

This year’s theme, selected by the fellows the summer before the start of the program, actually combines two that undeniably intersect—racial equity and environmental sustainability. 

In the first year of the program, the fellows:

• Build anchoring connections with peers and a faculty expert around the theme.
• Take a course with other fellows related to the chosen theme and complete at least one co-curricular project, activity or event.
• Develop a deeper understanding of an interdisciplinary problem, question or theme while gaining individual support for career exploration and development.
• Help shape the program for future students.

The program is co-facilitated by Lyn Gualtieri, PhD, teaching professor in Civil and Environmental Engineering, and Brenda Bourns, PhD, teaching professor in Biology. 

Gualtieri and Bourns chose a local scientific topic—river restoration—for them to explore through the theme. 

“We decided to look at the Duwamish and Elwha rivers/watershed restoration from an interdisciplinary perspective because they both offer significant and interesting environmental and racial justice components,” says Gualtieri. “Both these waterways also have a significant human history component that ties in directly with their history and restoration.”

Part of the work involved having the fellows connect their research to answering the following questions: “What combination of factors both natural and manmade are necessary for healthy river restoration and How does this enhance the sustainability of natural and human communities?”

Their responses were factored into how they approach their interdisciplinary research projects that the fellows work on as part of a 1-credit course in the fall. By the end of the quarter the students, in teams, present their findings. 

“Every week we had faculty ‘coaches’ from different disciplines in S&E come in and give a talk about how that discipline is used to answer questions in river restoration. Students also conducted their own online research and had a chance to ask the faculty coaches questions,” explains Gualtieri. Disciplines represented by faculty were biology, chemistry, environmental science, civil engineering and computer science. 

Being part of the first cohort of Dean’s Fellows allows the students to grow together, tackle scientific problems with peers from different disciplines and explore the range of STEM fields. 

Says Gualtieri, “They effectively interrogated, researched and tied in the natural, human and built environment, a perfect example of where we think science is headed.”

As part of their coursework, the Dean’s Fellows wrote reflections on what they learned working as part of a team, along with acquiring skills on how to give an effective presentation. The fellows also were asked to be introspective, envisioning themselves as a leader in STEM.

The Dean’s Fellows program, says Gualtieri, aligns with the mission of SU to educate the whole person and for students to be critical thinkers and problem solvers. It’s also a great way for new student to explore their potential future paths in STEM. 

“I think this program is an effective way to show students that they don’t need to pick just one major or discipline to study. Our students are fortunate to have the opportunity to take this interdisciplinary course in their first quarter as trends in science move toward cross discipline solutions.”

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