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Critical thinking of nursing students in clinical teaching: an integrative

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Article in Revista de Enfermagem Referência · June 2017

DOI: 10.12707/RIV16029

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 ISSNe: 2182.2883 | ISSNp: 0874.0283
Available: https://doi.org/10.12707/RIV16029
REVIEW PAPER
ARTIGO DE REVISÃO

Critical thinking of nursing students in clinical teaching:

an integrative review
Pensamento crítico dos estudantes de enfermagem em ensino clínico: uma revisão
integrativa
Pensamiento crítico de los estudiantes de enfermería en la enseñanza clínica:
una revisión integradora
Tiago André dos Santos Martins Peixoto*; Nuno Miguel dos Santos Martins Peixoto**

Abstract
Theoretical Framework: Future nurses need to be prepared to develop critical thinking skills due to the diversity and com-
plexity in clinical practice.
Objectives: To explore the current state of scientific knowledge on nursing students’ critical thinking, namely in clinical
teaching settings.
Methodolog y: An integrative literature review was conducted in 3 online databases, according to the recommendations of
the Joanna Briggs Institute for scoping reviews.
Results: Of a total of 277 articles published between January 2010 and November 2015, 28 were included in this review.
Critical thinking is a complex process involving intellectual ability, ability to combine experience, knowledge, and reasoning,
and an attitudinal component. Some educational strategies effectively promote the development of these skills in nursing
students.
Conclusion: Enabling environments should be created to stimulate students’ reflection, creativity, and confidence, as well as
to develop and implement innovative strategies that promote critical thinking skills.

Keywords: nursing; students, nursing; education, nursing; clinical clerkship; thinking

Resumo Resumen
Enquadramento: Face à diversidade e complexidade da práti- Marco contextual: Frente a la diversidad y complejidad de
ca é essencial preparar os futuros enfermeiros para desenvol- la práctica es esencial preparar a los futuros enfermeros para
ver habilidades de pensamento crítico. desarrollar habilidades de pensamiento crítico.
Objetivos: Explorar o estado atual do conhecimento científi- Objetivos: Explorar el estado actual del conocimiento científi-
co sobre o pensamento crítico em estudantes de enfermagem,
nomeadamente no contexto do ensino clínico. co sobre el pensamiento crítico en estudiantes de enfermería,
Metodologia: Revisão integrativa da literatura em 3 bases de en concreto en el contexto de la enseñanza clínica.
dados eletrónicas, de acordo com as recomendações do Joan- Metodología: Revisión integradora de la literatura en 3 bases
na Briggs Institute para a realização de uma scoping review. de datos electrónicas, de acuerdo con las recomendaciones
Resultados: De um total de 277 artigos publicados entre ja- del Joanna Briggs Institute para la realización de un estudio
neiro de 2010 e novembro de 2015, 28 foram incluídos nesta de evaluación scoping review.
revisão. O pensamento crítico é um processo complexo que Resultados: De un total de 277 artículos publicados entre
envolve habilidade intelectual, capacidade para conjugar a ex- enero de 2010 y noviembre de 2015, se incluyeron 28 en esta
periencia, o conhecimento e o raciocínio e uma componente revisión. El pensamiento crítico es un proceso complejo que
atitudinal. Existem estratégias educativas que promovem eficaz- implica habilidad intelectual, capacidad para conjugar la ex-
mente o desenvolvimento desta capacidade nos estudantes de
enfermagem. periencia, el conocimiento y el raciocinio, y un componente
Conclusão: É importante criar ambientes propícios para actitudinal. Existen estrategias educativas que promueven efi-
estimular a reflexão, a criatividade e a confiança dos estudantes cazmente el desarrollo de esta capacidad en los estudiantes
e desenvolver e implementarem estratégias inovadoras que de enfermería.
promovam as habilidades dos mesmos para pensar criticamente. Conclusión: Es importante crear ambientes propicios para
estimular la reflexión, la creatividad y la confianza de los estu-
Palavras-chave: enfermagem; estudantes de enfermagem; edu- diantes, así como desarrollar y aplicar estrategias innovadoras
cação em enfermagem; estágio clínico; pensamento que promuevan las habilidades de los mismos para pensar
críticamente.

Palabras clave: enfermería; estudiantes de enfermeira; educa-

*MSc., Nurse Specialist in Medical-Surgical Nursing, Doctoral student, Universidade Católi- cíon en enfermeira; prácticas clínicas; pensamiento
ca Portuguesa [[email protected]]. Contribution to the article: literature
search; data collection and treatment, data analysis and discussion, and article writing. Ad-
dress for correspondence: Rua Diogo Botelho 1327, 4169-005 Porto
**MSc., Nurse Specialist in Medical-Surgical Nursing, Doctoral student, Universidade Cató- Received for publication: 12.04.16
lica Portuguesa [[email protected]]. Contribution to the article: literature
search; data collection and treatment; data analysis and discussion. Accepted for publication: 30.06.16

Revista de Enfermagem Referência Série IV - n.º 13 - ABR./MAI./JUN. 2017

pp. 125-138
Introduction psychology, and education (Lewis & Smith,
1993). Although there is no universally ac-
Over the past 30 years, health organizations cepted definition of critical thinking, critical
have gone through multiple changes con- thinking seems to be widely defined as the
cerning the demands related to care delivery intentional and self-regulatory judgment
because of the rapid technological develop- that results in the interpretation, analysis,
ment and production and dissemination of evaluation, and inference of a particular as-
scientific knowledge. In this complex and pect of reality; it includes an explanation of
changeable care environment, nursing pro- the evidential, conceptual, methodological,
fessionals need to think permanently and and criteriological considerations on which
develop skills that will enable them to solve judgment is based; and it does not admit
current or potential problems through an statements without recognizing legitimacy,
effective clinical judgment and an effective in which the more trained these skills are,
decision-making (Higgs & Jones, 2000). the higher is the likelihood of a desirable
The increasing problematization of criti- outcome (Alfaro-LeFevre, 1999; Facione,
cal thinking in nursing has been driven by 1990).
the response to the constant changes in the The classical The Delphi Report by Facione
healthcare environment to which nurses (1990) and published by the American Phil-
should be aware of. At the beginning of the osophical Association describes the ideal crit-
1990s, this issue was already a concern for ical thinker as the individual who is usually
nursing teachers, as can be seen in Schank’s inquisitive, well-informed, open-minded,
Wanted: nurses with critical thinking skills flexible, fair-minded in evaluation, honest
(1990) which was published in The Journal in facing personal biases, cautious in mak-
of Continuing Education in Nursing. ing judgements, willing to reconsider, clear
In recent years, the need to prepare future about issues, orderly in complex matters,
nurses to acquire and master thinking skills diligent in seeking relevant information, rea-
has been identified based on the fact that rea- sonable in the selection of criteria, focused
soning and criticism, when inserted into the in inquiry, and persistent in seeking results
thinking process, are key thinking tools for which are as precise as the subject and the
understanding reality and adjusting knowl- circumstances of inquiry permit.
edge. Enders, Brito, and Monteiro (2004) Critical thinking in nursing can be defined
advocate the acquisition of critical thinking as the process of intentional and reflective
skills in nursing for three reasons. First, nurs- judgment about nursing problems, where the
es’ need to use independent judgment, that focus is on clinical decision-making, in order
is, intervene based on a rational assessment to provide safe and effective care (Watson &
of the situation rather than on a prejudiced Glaser, 1991). In the development of critical
assessment or unquestioning submission to thinking skills, clinical teaching is particu-
the impositions of other professionals and larly important because it is the place where
institutions. Second, the liberation of the in- students not only make the initial contact
dividual, in which professionals move away with clinical practice, but also begin the pro-
from the control of unjustified beliefs and cess of professional socialization, and because
attitudes and act in accordance with their it is rich in unpredictability and requires the
own ideas, while always taking the ideas of mobilization of theoretical knowledge to the
others into consideration. Third, the need to practical reality (Abreu, 2003, 2007).
develop rationality in the clinical and scien- In 1992, the National League for Nursing in
tific judgment inherent to the nursing pro- the United States announced that all nursing
cess for the patient’s benefit. curricula should stimulate critical thinking
Critical thinking has been addressed by sev- and, in 1997, the Royal College of Nursing
eral schools of thought, namely philosophy, in Australia stated that the quality of nurs-

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Revista de Enfermagem Referência - IV - n.º 13 -2017 an integrative review

126
ing practice depends on nurses’ educational text): What is known in the scientific liter-
preparation to critically analyze and modify ature about the critical thinking of nursing
nursing interventions. students in clinical teaching?
This review aims at exploring the current The goals, inclusion criteria, and methods
state of scientific knowledge related to nurs- established for this review were specified and
ing students’ critical thinking and describ- documented in a protocol, which was previ-
ing this evidence by developing a conceptual ously drawn up but not published.
map on how nursing students develop their
critical thinking during clinical practice, Methodological procedures of integrative
with an emphasis on critical thinking pro- review
motion strategies. Such data are relevant be- We performed a literature review on the crit-
cause they may contribute towards the anal- ical thinking of nursing students in clinical
ysis, assessment, reflection, and research on teaching and its underlying concepts follow-
nursing students’ teaching-learning process. ing the guidelines of the JBI methodology
In accordance with the recommendations of for scoping reviews (2015).
the Joanna Briggs Institute (JBI) for scop- The inclusion criteria of articles are shown
ing reviews (JBI, 2015), the formulation of in Table 1 and were defined according to the
the research question was based on the PCC population, context, type of study, language
mnemonic (Population, Concept, and Con- and date of publication.

Table 1
Inclusion criteria of the studies

Population Concepts Context

Studies including adults (aged > 18) Studies addressing critical thinking: Studies addressing clinical teaching:
Thinking Clinical practice
Studies including 1st-cycle nursing students Critical thinking Clinical teaching
Students, nursing Judgment Clinical placement
Decision making Clinical learning
Problem solving
No geographic or ethnic limitations

Types of study
All primary and secondary, quantitative or qualitative studies
Language of publication
Studies published in Portuguese or English

Date of publication
Studies published between 1 January 2010 and 30 November 2015

The identification of articles to be includ- tified the major keywords and search terms
ed in this literature review went through a used, in order to create the Boolean expres-
thorough and systematic selection process. sions for the search.
Initially, we performed exploratory searches Thus, the scientific articles included in
in the selected online databases, using some this review were selected through a search
of the above-mentioned keywords in order conducted in three online databases with
to provide a better framework to the topic important data on the topic (MEDLINE
of nursing students’ critical thinking. Sub- with full text®, CINAHL plus with full
sequently, and after reading and analyzing text®, and Cochrane Library Plus®) using
the most relevant scientific articles, we iden- three Boolean expressions that combine free

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127
terms with indexed terms (Medical subject With the purpose of incorporating gray lit-
headings or Headings), combined with the erature in the analysis and discussion of the
Boolean operators “OR” and “AND” and topic, it is important to mention that, in
the tool “*”. addition to the scientific articles identified
The search strategy (Boolean search expres- through the above-mentioned search, other
sion and activated filters) used in the online studies that met the inclusion criteria were
database searching is shown below: added from other free searches. Then, dupli-
MEDLINE with full text® - ((MH “Stu- cate records were excluded.
dents, Nursing”) AND ((MH “Thinking”) OR Although the search was conducted in Eng-
(“Critical Think*”) OR (MH “Judgment”) lish, scientific articles written in English or
OR (MH “Decision Making”) OR (MH Portuguese could be included.
“Problem Solving”) OR (MH “Problem-Based Studies published between 1 January 2010
Learning”) AND ((MH “Education, Nursing”) and 30 November 2015 (when the search
OR (Clinica* Practice) OR (MH “Teaching”) was conducted) were eligible for inclusion.
OR (Clinical Teaching) OR (Clinica* Placement) No restrictions were made concerning the
OR (Clinica* Learning))); Activated filter: Lim- type of study.
iters: Full-text; Publication date: 2010/01/01-
2015/11/30; Expanders: Also search in full
text; Search modes: Boolean/Expression; Lan- Results and interpretation
guage: Portuguese and English.
CINAHL plus with full text® - (((MH “Stu- Of the 277 articles identified, 25 were ex-
dents, Nursing, Baccalaureate”) OR (MH cluded for being duplicates. The process of
“Students, Nursing”) OR (MH “Students, article selection started with the application
Nursing, Practical”)) AND ((MH “Criti- of two screening tests. The first test - Screen-
cal Thinking”) OR (MH “Decision Making, ing Test I - was applied to 252 studies. After
Clinical”) OR (MH “Thinking”)) AND ((MH this test, which consisted of the analysis of
“Education, Nursing”) OR (MH “Teaching the title and abstract of each article eligible
Methods, Clinical”) OR (MH “Clinical Com- for inclusion in this review, 181 studies were
petence”) OR (Clinica* Practice) OR (Clinica* excluded. The second test - Screening Test
Teaching) OR (Clinica* Placement) OR (MH II - was applied to the 71 remaining articles.
“Student Placement”) OR (Clinica* Learn- This test consisted of the full-text reading of
ing) OR (MH “Learning Environment, Clin- each article and analysis of the population,
ical”))); Activated filter: Limiters: Full-text; concepts, and contexts which were previous-
Publication date: 2010/01/01-2015/11/30; ly set for this review, and resulted in the ex-
Expanders: Also search in full text; Search clusion of 43 articles.
modes: Boolean/Expression; Language: Por- The reasons for exclusion included: the ob-
tuguese and English. jective of the study was different from the
Cochrane Library Plus® - ((“Students, Nurs- topic of this review (23), the issue of critical
ing”) AND ((“Critical Thinking”) OR (“De- thinking was presented as a secondary or ad-
cision Making”) OR (“Problem Solving”)) ditional topic and provided little informa-
AND ((“Clinica* Practice”) OR (“Student tion for the discussion (5), the study did not
Placement”) OR (“Clinica* Competence”) OR meet the inclusion criteria (8), the subject
(“Clinica* Placement”) OR (“Clinica* Learn- of the study was different from the subject
ing”))); Activated filter: Limiters: Full-text; of the review (7). Finally, we included 28
Publication date: 2010/01/01-2015/11/30. studies in this review.

Critical thinking of nursing students in clinical teaching:

Revista de Enfermagem Referência - IV - n.º 13 -2017 an integrative review

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 Identification
No. of records identified through
database searching (n = 270) No. of additional records identified
MEDLINE: 152 CINAHL: 107 through other sources
Cochrane: 11 (n = 7)

Screening No. of duplicate records excluded

(n = 25)

No. of records screened No. of articles excluded based on title and

(n = 252) abstract (n = 181)
Eligibility

No. of full-text articles assessed No. of full text articles excluded (n = 43)
for eligibility (n = 71)

Reasons for exclusion:

No. of studies included in this The purpose of the study was different
Included

review (n = 28) from the purpose of the review (n = 23)

Topic was presented as being secondary
(n = 5)
Did not meet inclusion criteria (n = 8)
The subject of the study was different
from the subject of the review (n = 7)

Figure 1. Process of identification of studies - PRISMA Diagram flow.

The articles included in this review were Brazil, Canada, United Kingdom, Sweden,
analyzed in two phases. In the first phase, a Spain, Turkey, and Singapore.
descriptive analysis was performed concern- With regard to the study methodology,
ing the productivity characteristics (number namely the type of study of the articles in-
of publications per year and country where cluded in this review, the studies of analysis
the study was conducted) and the method- were the most common (11, of which four
ological characteristics (type of study design; were literature reviews), followed by qualita-
sample type and size; and study objectives) tive (six) and descriptive (five) studies on the
of the studies. In the second phase, a content topic of critical thinking among nursing stu-
analysis was performed to the studies, which dents. On the other hand, experimental stud-
was divided into two key areas: the conceptu- ies (two), quasi-experimental studies (two),
alization of critical thinking, and strategies for and mixed-method studies (two) were less
promoting critical thinking. common.
In what concerns the distribution of studies by With regard to the type of sample, 18 studies
year of publication, of the 28 articles included (64.3%) used exclusively undergraduate nurs-
in this review, most of the relevant studies were ing students; six studies had no sample (jus-
published in 2010 (nine), six were published tified by the research design); one study used
in 2013, six in 2014, three in 2011, and only baccalaureate and accelerated second-degree
one study was published in 2015. nursing students; another one used senior
With regard to the country of publication of nursing students; another one used students
the included studies, 12 relevant studies on and teachers of the nursing undergraduate
this topic were published in the United States degree; and, finally, another one used under-
of America, three studies were published graduate students of different health areas,
in Portugal, two studies were published in including the nursing undergraduate degree.
Korea, China, and Iran, and one study was As to the size of the sample, nine of the 28
published in each of the following countries: studies had a sample composed of more than

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50 participants, five studies had a sample analysis and assessment of critical thinking,
composed of 20 to 50 participants, and three 11 on the skills and dispositions for critical
studies had a sample composed of less than 20 thinking, seven on the context that influences
participants. critical thinking, three on the relationship be-
As for the objectives of the studies included tween critical thinking and the nursing pro-
in this review (Table 2), 15 articles focused cess, three on the conceptualization of critical
on the analysis and assessment of strategies thinking and, finally, three on the factors that
for promoting critical thinking, 11 on the interfere with critical thinking.

Table 2
Studies included in this review and their main objectives
Study Main objective
S1
Mun, M. S. (2010). An analysis of narratives to identify
To identify the critical thinking contexts that nurs-
critical thinking contexts in psychiatric clinical practice.
ing students face in psychiatric clinical practices.
International Journal of Nursing Practice, 16(1), 75-80. doi:
10.1111/j.1440-172X.2009.01803.x
S2
Vivien, W. X., Tham, L. K., Lau, S. T., Mei, T.-T., & Kiat, T.
K. (2010). An exploration of the critical thinking disposi- To explore and analyze seven aspects of the critical
tions of students and their relationship with the preference thinking disposition.
for simulation as a learning style. Singapore Nursing Jour-
nal, 37(2), 25-33.
S3
Atay, S., & Karabacak, U. (2012). Care plans using concept
To analyze the effects of care plans prepared using
maps and their effects on the critical thinking dispo-
concept maps on the critical thinking dispositions
sitions of nursing students. International Journal of
of students.
Nursing Practice, 18(3), 233-239. doi: 10.1111/j.1440-
172X.2012.02034.x
S4 To compare the communication and critical think-
Raurell-Torredà, M., Olivet-Pujol, J., Romero-Collado, À., ing skills of nursing students in the control group
Malagon-Aguilera, M. C., Patiño-Masó, J., & Baltasar- with those of students in the intervention group,
-Bagué, A. (2015). Case-based learning and simulation: and to compare the communication and critical
Useful tools to enhance nurses’ education?: Nonrandom- thinking skills of nursing students with those of
ized controlled trial. Journal of Nursing Scholarship, 47(1), nurses with clinical experience in continuing profes-
34-42. doi: 10.1111/jnu.12113 sional education.
S5
Mann, J. (2010). Promoting curriculum choices: Critical think- To evaluate the effectiveness of an educational strat-
ing and clinical judgment skill development in baccalaureate egy (grand rounds) to develop critical thinking and
nursing students (Master’s dissertation). Retrieved from clinical judgment skills in nursing students.
https://kuscholarworks.ku.edu/handle/1808/6742
S6
Salsali, M., Tajvidi, M., & Ghiyasvandian, S. (2013). Critical
thinking dispositions of nursing students in Asian and To compare nursing students’ critical thinking dis-
non-Asian countries: A literature review. Global Journal positions in Asian and non-Asian countries.
of Health Science, 5(6), 172-178. doi: 10.5539/gjhs.
v5n6p172
S7
To determine if health students’ critical-thinking
Brudvig, T., Dirkes, A., Dutta, P., & Rane, K. (2013). Criti-
skills change as a result of participating in a health
cal thinking skills in health care professional students: A
care professional education program, and to assess
systematic review. Journal of Physical Therapy Education,
the quality of the evidence evaluating this change.
27(3), 12-25.

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Revista de Enfermagem Referência - IV - n.º 13 -2017 an integrative review

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S8
Fero, L., O’Donnell, J., Zullo, T., Dabbs, A., Kitutu, J.,
Samosky, J., & Hoffman, L. (2010). Critical thinking To examine the relationship between critical think-
skills in nursing students: Comparison of simula- ing skills and performance in simulated clinical
tion-based performance with metrics. Journal of Advanced scenarios.
Nursing, 66(10), 2182–2193. doi: 10.1111/j.1365-
2648.2010.05385.x
S9
Newton, S., & Moore, G. (2013). Critical thinking skills of To describe baccalaureate and accelerated second-de-
basic baccalaureate and accelerated second-degree nursing gree nursing students’ critical thinking skills and
students. Nursing Education Perspectives, 34(3), 154-158. analyze the educational implications.
doi: 10.5480/1536-5026-34.3.154
S10
To describe students’ perceived levels of confidence
Marchigiano, G., Eduljee, N., & Harvey, K. (2011). Devel-
for using thinking skills when creating a care plan
oping critical thinking skills from clinical assignments: A
and a narrative, and to determine whether students
pilot study on nursing students’ self-reported perceptions.
noted any difference between the two formats in
Journal Of Nursing Management, 19(1), 143-152. doi:
relation to promoting critical thinking skills.
10.1111/j.1365-2834.2010.01191.x
S11
Morey, D. (2012). Development and evaluation of web-based
To evaluate the effectiveness of animated peda-
animated pedagogical agents for facilitating critical think-
gogical agents on critical thinking among nursing
ing in nursing. Nursing Education Perspectives, 33(2),
students.
116-120. doi: 10.5480/1536-5026-33.2.116
S12
Gazarian, P. (2010). Digital stories: Incorporating narrative To describe the use of digital narratives as a strategy
pedagogy. The Journal Of Nursing Education, 49(5), 287- to enhance critical thinking skills in nursing stu-
290. doi: 10.3928/01484834-20100115-07 dents.
S13
Head, B., & Bays, C. (2010). Engaging nursing students To describe how senior nursing students partnered
and community partners in the development of decision with community health professionals to develop
cases. Journal Of Nursing Education, 49(6), 346-350. doi: and use case studies in teaching activities with other
10.3928/01484834-20100217-06 students.
S14
Forsgren, S., Christensen, T., & Hedemalm, A. (2014). Eval-
To understand nursing students’ experiences of case-
uation of the case method in nursing education. Nurse
based learning as an educational tool in order to find
Education In Practice, 14(2), 164-169. doi: 10.1016/j.
out if it supports their learning.
nepr.2013.08.003
S15
To explore students’ attitudes towards prob-
Chan, Z. (2013). Exploring creativity and critical thinking in
lem-based learning, creativity, and critical thinking,
traditional and innovative problem-based learning groups.
and the relevance to nursing education in clinical
Journal of Clinical Nursing, 22(15-16), 2298-2307. doi:
practice.
10.1111/jocn.12186
S16
Tschannen, D., & Aebersold, M. (2010). Improving student
To analyze the effectiveness of a pilot project in
critical thinking skills through a root cause analysis pilot
improving critical thinking skills.
project. Journal of Nursing Education, 49(8), 475-478. doi:
10.3928/01484834-20100524-02
S17
Lisko, S., & O’Dell, V. (2010). Integration of theory and prac- To discuss the integration of Kolb’s theory of experi-
tice: Experiential learning theory and nursing education. ential learning based on the practical integration of
Nursing Education Perspectives, 31(2), 106-108. a model aimed to provide critical thinking skills for
nursing students,

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S18
Lechasseur, K., Lazure, G., & Guilbert, L. (2011). Knowl- To describe the mobilization of knowledge within
edge mobilized by a critical thinking process deployed by the critical thinking process deployed by female
nursing students in practical care situations: A qualitative undergraduate nursing students in practical care
study. Journal of Advanced Nursing, 67(9), 1930-1940. situations.
doi: 10.1111/j.1365-2648.2011.05637.x
S19
Whiffin, C., & Hasselder, A. (2013). Making the link be- To analyze how the critical appraisal of research can
tween critical appraisal, thinking, and analysis. British be an opportunity for students to develop transfer-
Journal of Nursing, 22(14), 831-835. doi: 10.12968/ able critical thinking skills.
bjon.2013.22.14.831
S20
Ahn, S., & Yeom, H. (2014). Moral sensitivity and critical
To examine the level of moral sensitivity and critical
thinking disposition of nursing students in Korea. Inter-
thinking disposition among nursing students.
national Journal of Nursing Practice, 20(5), 482-489. doi:
10.1111/ijn.12185
S21
Tajvidi, M., Ghiyasvandin, S., & Salsali, M. (2014). Probing
To analyze and clarify the concept of critical think-
concept of critical thinking in nursing education in Iran:
ing in nursing education in Iran.
A concept analysis. Asian Nursing Research, 8(2), 158-164.
doi: 10.1016/j.anr.2014.02.005
S22
Romeo, E. (2010). Quantitative research on critical thinking To review and analyze quantitative research findings
and predicting nursing students’ NCLEX-RN perfor- relevant to the measurement of nursing students’
mance. Journal of Nursing Education, 49(7), 378-386. doi: critical thinking skills.
10.3928/01484834-20100331-05
S23
Kong, L., Qin, B., Zhou, Y., Mou, S., & Gao, H. (2014). The
To estimate the effectiveness of problem-based
effectiveness of problem-based learning on development
learning in developing nursing students’ critical
of nursing students’ critical thinking: A systematic review
thinking.
and meta-analysis. International Journal of Nursing Studies,
51(3), 458-469. doi: 10.1016/j.ijnurstu.2013.06.009
S24
Gerdeman, J., Lux, K., & Jacko, J. (2013). Using con- To describe the use of concept mapping as a teach-
cept mapping to build clinical judgment skills. Nurse ing strategy in the development of critical thinking
Education In Practice, 13(1), 11-17. doi: 10.1016/j. skills.
nepr.2012.05.009
S25
Spínola, A., & Amendoeira, J. (2012). O estudante de enferma-
To identify dimensions related to the care process
gem no processo de cuidados: Uma reflexão. Retrieved from
valued by students in clinical practice.
http://hdl.handle.net/10400.15/613
S26
Godinho, C., & Amendoeira, J. (2012). A importância de To understand how students learn how to use
ambientes de aprendizagem crítica. Retrieved from http:// critical thinking skills in clinical judgment for deci-
hdl.handle.net/10400.15/614 sion-making in care learning contexts.
S27
Spínola, A., & Amendoeira, J. (2014). O processo de cuida-
To analyze the perception of the care process in
dos: Análise da conceção dos estudantes de enfermagem.
clinical practice using a specific computer strategy.
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Oliveira, S. (2014). Simulação clínica com participação de atores
To understand how clinical simulation involving
no ensino da consulta de enfermagem: Uma pesquisa-ação
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Conceptualization of critical thinking ing about thinking in order to systematize,
Given the variability of concepts found in the rationalize, and clarify the cognitive process
literature, researchers face major challenges in that focuses on decision-making (Loving &
this area. Based on the analysis of the stud- Wilson; Paul; Turner, as cited in Tajvidi et al.,
ies included in this review, we realized that 2014), as a trend characterized by an inner
there is an attempt to associate alternative motivation to solve problems and make de-
terms to critical thinking, such as: clinical cisions by thinking (Huan & Vickie, as cited
decision-making, analytical thinking, clinical in Salsali et al., 2013) and also as a reasonable
judgment, critical judgment, creative think- and reflective thinking about the decision to
ing, problem-solving, reflective thinking, and be made, including the ability to compare
diagnostic reasoning (Brudvig, Dirkes, Dut- and contrast several alternatives (Landis &
ta, & Rane, 2013; Gerdeman, Lux, & Jacko, Michael, as cited in Fero et al., 2010).
2013; Mann, 2010; Whiffin & Hasselder, Due to the multiple changes in health systems
2013). However, this strategy does not seem and the increasing demand for healthcare de-
appropriate given the high variability of relat- livery, some authors argue that nurses should
ed concepts. For this reason, it is imperative incorporate and develop critical thinking
to clarify the concept of critical thinking. skills, not only because evidence shows that
The analysis of the studies conducted during such ability is likely to influence clinical judg-
the timeframe established for this review ment, decision-making and problem-solving,
showed that only a few studies aimed to pro- but also because it is an essential component
vide or update the definition for the concept in nurses’ professional practice (American As-
of critical thinking, and that authors used sociation of Colleges of Nursing, 2008; Na-
preexisting concepts, with the exception of tional League for Nursing, 2006; Simpson &
Tajvidi, Ghiyasvandin, and Salsali (2014) Courtney, as cited in Godinho & Amendoei-
who conducted their study in Iran where the ra, 2010 and Mann, 2010).
knowledge produced on this topic was scarce. According to the studies included in this re-
Although there is no universally accepted view, many authors emphasize the importance
definition, we believe that the concepts put of critical thinking in nursing, considering it
forward by Facione (1990) and Facione, as an essential component of professional re-
Facione, and Sanchez (1994) are the most sponsibility and quality. Tajvidi et al. (2014)
consensual ones, with various references mentioned that the definition of Watson and
throughout the literature reviewed, name- Glaser (1980), despite being old, continues to
ly the studies of Brudvig et al. (2013), Fero be widely accepted in the scientific commu-
et al. (2010), Mann (2010), Marchigiano, nity. For these authors, critical thinking is a
Eduljee, and Harvey (2011), Salsali, Tajvidi composite of attitude, knowledge, and skills,
and Ghiyasvandian (2013). Thus, the first such as the ability to define a problem, choose
concept, obtained after a study of expert con- information to be used in the solution, rec-
sensus, conceptualizes critical thinking as the ognize explicit and implicit assumptions,
intentional and self-regulatory judgment that formulate and select relevant and promising
results in the interpretation, analysis, evalu- hypotheses, and draw conclusions after the
ation, and inference of reality and an expla- validation of inferences (Watson & Glaser,
nation of the evidential, conceptual, method- 1980).
ological, and criteriological considerations on However, some researchers from developing
which judgment is based. The second concept countries are still interested in clarifying the
adds that critical thinking is a complex pro- concept of critical thinking in nursing. On
cess that involves cognitive abilities (such as the one hand, Tajvidi et al. (2014) concluded
interpretation, clarification, deduction, and that the definition of critical thinking is still
inference), scientific knowledge, intellectual changing and is related to the context where
honesty, and an attitudinal willingness that it takes place, and that nursing teachers and
can be developed. students are responsible for the development
In the latest definitions found, critical think- of this logical, situational, purposive, and out-
ing emerges as metacognition, that is, think- come-oriented thinking process. On the oth-

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er hand, Scheffer and Rubenfeld (as cited in challenge relevant assumptions of reasoning
Mann, 2010), using same method as Facione for decision-making; the ability to combine
(1990) in a community of nurses, conclud- experience, knowledge, and reasoning in
ed that the definition of critical thinking was the identification and analysis of alternative
limited to a cognitive component (composed frameworks taking into account the context;
of confidence, contextual perspective, creativ- and an attitudinal component that incor-
ity, flexibility, inquisitiveness, intellectual in- porates the affective domains, which are ca-
tegrity, intuition, open-mindedness, persever- pable of influencing the logical, situational,
ance, and reflection) and a component related purposive, and outcome-oriented thinking
to the critical thinking ability (composed of process.
analysis, applying standards, discriminating,
information seeking, logical reasoning, pre- Strategies for promoting critical thinking
dicting, and transforming knowledge). After the analysis of all articles, we divided
Based on the analysis of the multiple defi- the strategies for promoting critical thinking
nitions, we believe that critical thinking en- in nursing students into eleven domains/top-
compasses three key elements: the individu- ics. Table 3 shows in detail the characteristics
al’s intellectual ability to seek, identify, and and evidence of these strategies.
Table 3
Strategies for promoting nursing students’ critical thinking

Strategies Evidence and their characteristics Author/s

Writing about a critical situation, describing the actions, thoughts and
emotions during the contact with the patient and interaction with the
health professionals’ team, offers an opportunity for students to reflect and Mun (2010)
Written or oral think critically about the experience, develop critical thinking and commu-
narratives nicative skills, and promote a reflection-based nursing practice.
Describing and reflecting on their first and most important priority of care
is a strategy that improves students’ levels of confidence for using critical Marchigiano et al. (2011)
thinking skills.
It improves nursing students’ patient evaluation skills. They can be devel-
Raurell-Torredà et al.
oped in various learning environments, should be planned, and require
(2015)
teachers’ training.
The collaboration and discussion between students and professionals in the
selection of cases enable the development of critical thinking skills, creativ- Head and Bays (2010)
ity, and appreciation of group work.
Case-based
learning It offers nursing students an opportunity to enhance their judgment and
critical thinking skills by applying theory in practice. Students acquire
knowledge about patient care in the real context, thus obtaining a holistic
Forsgren, Christensen, and
understanding of the uniqueness of each health problem. Reflections and
Hedemalm, (2014)
discussions in seminars widen students’ perspectives, improve their capacity
for cooperation, help them to achieve long-lasting knowledge, and bring
them closer to professional practice.

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 Case studies integrated into online simulations allow students to analyze
their own critical thinking and become aware of the importance of critical
Guhde (as cited in Godin-
thinking for an appropriate clinical judgment. Students believe that this
ho & Amendoeira, 2012)
strategy is essential for the development of skills to deal with complex situ-
ations, reducing errors in clinical decision-making.
Problem-based learning in simulation, using pictures, movies, or human
simulation can improve the identification and recognition of the problem
and the communication of essential information, and promote appropriate,
Fero et al. (2010)
logical, and prioritized nursing interventions. This strategy can support the
Case studies based development of nursing students’ critical thinking skills, thus improving
on clinical simu- their performance.
lations In laboratory classes, using a simulator in a recreated scenario fosters the
development of critical thinking, exposing students to critical situations in Horan (as cited in Godinho
a non-threatening environment. Teachers need to receive training for the & Amendoeira, 2012)
development of these strategies.
Simulation strategies have a major potential for the development of critical
thinking and reflective skills when used under a pedagogical constructivist
theory. Experiencing a nursing intervention in a simulated environment
Oliveira (2014)
allows students to reflect on practice and attitudes in a real context, pro-
viding a meaningful learning that does not occur simply by the presence in
the context, but by the reflection on the context, providing it a meaning.
Scenario-based learning makes the bridge between the classroom and the
real clinical environment. Although some students have reported that they
Vivien, Tham, Lau, Mei,
do not like to be involved in this type of role-playing, evidence shows that
and Kiat (2010)
it enhances critical thinking skills. This strategy can be developed in various
Scenario-based learning settings, should be planned, and requires teacher’s training.
learning
This strategy integrates learning and promotes critical thinking. It allows
Lisko and O’Dell (2010);
students to combine theoretical knowledge and skills learned in laboratory
Godinho and Amendoeira
and clinical practice. Context-related learning promotes the development
(2012)
of critical thinking skills.
The development of care plans is an effective strategy to promote critical
thinking. In addition, it is possible to argue that designing care plans us-
ing the strategy of concept mapping provides a greater contribution to the Atay and Karabacak (2012)
development of critical thinking skills in students when compared to con-
Care plans with ventional care plans.
or without con-
cept mapping In the design of care plans, students have to analyze information, determine
relevance, make connections, set priorities, select appropriate information,
apply pertinent knowledge, and evaluate the outcomes of an intervention, Marchigiano et al. (2011)
and such activity improves their levels of confidence for using critical think-
ing skills.
Although there is no significant relationship in the assessment of critical
thinking before and after the implementation of a teaching program based
on the grand rounds learning strategy, the results of the second assessment
Grand rounds showed a greater increase in critical thinking skills in the intervention group Mann (2010)
than in the control group. The qualitative analysis showed that students
value the potential of this strategy to help them to solve problems in clinical
practice since it promotes joint analysis, discussion, and reflection.
This strategy is an innovative tool for critical thinking through active en-
Interactive and gagement of students, asking questions and providing feedback on a series
multimedia learn- of nursing case studies. Although the results were not fully enlightening, the Morey (2012)
ing technology cognitive and social effects of animated pedagogical agents seem to facilitate
critical thinking in nursing students.
The traditional method of problem-based learning can be effective in the
development of problem-solving and critical thinking skills in nursing
students. However, the inclusion of innovative activities (e.g., role-play- Chan (2013)
ing) can positively influence students’ perceptions of creativity and critical
Problem-based thinking in nursing care.
learning
Problem-based learning is an effective learning approach that encourages
students to learn autonomously. The evidence in this review and meta-anal- Kong, Qin, Zhou, Mou,
ysis shows that the use of this strategy can improve nursing students’ critical and Gao (2014)
thinking when compared with traditional lectures.

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 Nursing students must demonstrate academic skills consistent with higher
education. The structured critical appraisal of publications requires students
Research and
to think critically about the results before applying their findings. These Whiffin and Hasselder
analysis of publi-
transferable skills, including critical thinking and objective reasoning, are (2013)
cations
necessary for students to think critically and creatively about complex prob-
lems in clinical practice.
Concept maps provide students with a tool to understand the relationships
between client data in the clinical setting. This strategy is an interactive way
Concept mapping to promote self-directed learning while fostering the growth of crucial clin- Gerdeman et al. ( 2013)
ical judgment skills in nursing students. It also helps students to organize
their thoughts, plan and prioritize patient care, and think critically.
Strategies for the promotion of self-training enable students to integrate the
care process into clinical teaching. The pedagogical process should focus on
Promotion of strategies that promote students’ responsibility for their training/learning.
self-accountability This strategy encourages reflection and promotes the acquisition of critical Spínola and Amendoeira
through training/ thinking skills. In addition, students value the process of learning about (2012)
learning the care process with a focus on reflection and responsibility and emphasiz-
es knowledge acquisition based on the integration and implementation of
knowledge into the daily practice in clinical teaching.

Two studies included in this literature review, cept mapping (S3 and S10) or only concept
S1 and S10, showed that the narrative is a mapping (S26). Within the nursing process,
valid strategy for promoting critical thinking care plans are an essential tool for solving
in nursing students. Written or oral narratives problems with autonomy and professional-
allow for an effective communication between ism. They are also crucial in nursing training
students and teachers by enabling the identi- not only because they allow applying theo-
fication of situations in clinical practice where retical knowledge into clinical practice, but
critical thinking is needed, shedding a light also because they allow students to think crit-
on the guidance provided by the supervisor/ ically about the necessary clinical judgements
tutor. In addition to encouraging the devel- (Marchigiano et al., 2011).
opment of communication skills, this strate- In the literature analyzed, we found referenc-
gy enables the students to develop an appreci- es to other effective strategies for promoting
ation of their inner resources for thinking and critical thinking in nursing students, includ-
learning, grow intellectually and morally, and ing: grand rounds (S5), which is characterized
develop their ability to understand the com- by the creation of discussion groups with pro-
plexity of each situation, adapting strategies fessionals, students, and teachers, providing
that are available to them for solving conflicts a forum where critical thinking and clinical
(Mun, 2010). judgement skills are developed in the clini-
Case-based learning (S4, S13, and S14), case cal environment (Mann, 2010); interactive
studies based on clinical simulations (S8, and multimedia learning technology (S11),
S26, and S28), scenario-based learning (S2, which is an innovative tool for critical think-
S17, and S26) and problem-based learning ing through online activities (Morey, 2012);
(S15) are simultaneously the most common research and analysis of scientific publications
and most studied strategies used by teachers/ (S19); and promotion of self-training (S25)
clinical supervisors to promote critical think- using the reflective process for the analysis of
ing. These strategies can help students to be responsibility, interpersonal and multipro-
critically reflective, giving them an opportu- fessional relationships, and critical/reflective
nity to analyze problems, phenomena, and thinking (Spínola & Amendoeira, 2012).
real clinical situations, and linking the class- With regard to the limitations of this review,
room to the real clinical environment (Vivien it is should be noted that it was impossible to
et al., 2010). include every existing scientific study. For this
According to the literature, another valid reason, searches were limited to three online
strategy for the development of critical think- databases (MEDLINE® with full text, CI-
ing skills in nursing students is the develop- NAHL Plus with full text, and Cochrane) to
ment of care plans in combination with con- include studies available in full-text and open

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access, published within a limited timeframe, further studies, namely quantitative and ex-
and with restrictions related to the language perimental studies, should be developed on
of publication (Portuguese and English). the creation, implementation, and develop-
ment of these strategies, as well as on the as-
sessment of their effectiveness.
Conclusion Finally, it can be concluded that the educa-
tion of professionals oriented to think criti-
This study allowed us to understand that the cally about their daily performance should
concept of critical thinking in nursing is a begin in initial training. Schools and nursing
complex and multidimensional process that teachers/supervisors are responsible for cre-
encompasses the individual’s intellectual abil- ating environments conducive to students’
ity to seek, identify, and challenge relevant as- reflection, creativity, and confidence, and for
sumptions of reasoning for decision-making; identifying, developing, and implementing
the ability to combine experience, knowledge, innovative strategies that encourage the de-
and reasoning in the identification and anal- velopment of critical thinking skills. In this
ysis of alternative frameworks taking the con- way, it will be possible to achieve a transform-
text into account; and an attitudinal compo- ing effect on the meaning of the profession
nent that incorporates the affective domains, in society.
which are capable of influencing the logical,
situational, purposive, and outcome-oriented
thinking process. References
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