critical thinking skills among nursing students

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

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

What Is Critical Thinking In Nursing?

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

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

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

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

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

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

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

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

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

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Strengths and limitations of this study

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

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

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

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

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

Introduction

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

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

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

Methods and analysis

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

Stage 1: identifying the research question

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

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Framework (PICOS) for determination of eligibility of review questions

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

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

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

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

Stage 2: identifying relevant studies

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

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

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

Supplemental material

Stage 3: study selection.

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

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Overview study selection process.

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

Stage 4: charting data

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

Tentative data charting form

Author and date.

Study title.

Journal full reference.

Aim, objective and/or research questions.

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

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

Sampling method.

Number of study participants.

Study design.

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

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

Described ethical approval and/or considerations. 29

Described teaching strategies and/or interventions targeting review focus.

Described outcomes and assessments.

Most relevant findings.

Study quality appraisal. 27 28

Tentative ethical requirements influenced by Weingarten, Paul and Leibovici.

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

Was informed consent obtained? (Yes/No)

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

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

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

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

Stage 5: collating, summarising and reporting the results

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

Stage 6: consultation stage

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

Patient and public involvement

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

Ethics and dissemination

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

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

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• ↵ Act concerning the ethical review of research involving humans (SFS 2003:460) .
• Vergnes J-N ,
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Contributors FW, EC, AW and GB were responsible for the initial design of this study. FW conceptualised the review approach and led the writing of the manuscript. FW, EC, AW and GB contributed to the protocol’s development and approved the final version of this protocol. GB, EC and AW led the supervision of the manuscript preparation.

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

Competing interests None declared.

Patient consent for publication Not required.

Provenance and peer review Not commissioned; externally peer reviewed.

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Developing Critical-Thinking Skills in Student Nurses

April 8, 2020

View all blog posts under Articles | View all blog posts under Master of Science in Nursing

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

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

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

Characteristics of Critical Thinkers

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

Interpretation

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

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

Critical thinkers consider relevant information from evidence to draw conclusions.

Explanation

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

Self-regulation

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

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

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

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

Teaching Critical Thinking to Nurses

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

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

Promoting interactions

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

Asking open-ended questions

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

Providing time for students to reflect on questions

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

Teaching for skills to transfer

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

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

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

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

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

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

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

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

For more information, contact Duquesne University today.

Critical Thinking: A Vital Trait for Nurses: Minority Nurse

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

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

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

Turning New Nurses Into Critical Thinkers: Wolters Kluwer

Critical thinking in nursing clinical practice, education and research: From attitudes to virtue

Affiliations.

• 1 Department of Fundamental Care and Medical Surgital Nursing, Faculty of Medicine and Health Sciences, School of Nursing, Consolidated Research Group Quantitative Psychology (2017-SGR-269), University of Barcelona, Barcelona, Spain.
• 2 Department of Fundamental Care and Medical Surgital Nursing, Faculty of Medicine and Health Sciences, School of Nursing, Consolidated Research Group on Gender, Identity and Diversity (2017-SGR-1091), University of Barcelona, Barcelona, Spain.
• 3 Department of Fundamental Care and Medical Surgital Nursing, Faculty of Medicine and Health Sciences, School of Nursing, University of Barcelona, Barcelona, Spain.
• 4 Multidisciplinary Nursing Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron Hospital, Barcelona, Spain.
• PMID: 33029860
• DOI: 10.1111/nup.12332

Critical thinking is a complex, dynamic process formed by attitudes and strategic skills, with the aim of achieving a specific goal or objective. The attitudes, including the critical thinking attitudes, constitute an important part of the idea of good care, of the good professional. It could be said that they become a virtue of the nursing profession. In this context, the ethics of virtue is a theoretical framework that becomes essential for analyse the critical thinking concept in nursing care and nursing science. Because the ethics of virtue consider how cultivating virtues are necessary to understand and justify the decisions and guide the actions. Based on selective analysis of the descriptive and empirical literature that addresses conceptual review of critical thinking, we conducted an analysis of this topic in the settings of clinical practice, training and research from the virtue ethical framework. Following JBI critical appraisal checklist for text and opinion papers, we argue the need for critical thinking as an essential element for true excellence in care and that it should be encouraged among professionals. The importance of developing critical thinking skills in education is well substantiated; however, greater efforts are required to implement educational strategies directed at developing critical thinking in students and professionals undergoing training, along with measures that demonstrate their success. Lastly, we show that critical thinking constitutes a fundamental component in the research process, and can improve research competencies in nursing. We conclude that future research and actions must go further in the search for new evidence and open new horizons, to ensure a positive effect on clinical practice, patient health, student education and the growth of nursing science.

Keywords: critical thinking; critical thinking attitudes; nurse education; nursing care; nursing research.

© 2020 John Wiley & Sons Ltd.

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Differences in critical thinking skills between nursing students on a fast-track versus traditional 4-year programme

Khaldoun Aldiabat

Assistant Professor, College of Nursing, Sultan Qaboos University, Oman

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Enam Alsrayheen

Independent Researcher, Canada and Oman

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Catherine Aquino-Russell

Professor, Faculty of Nursing, Moncton Site, University of New Brunswick, Canada

Mohammad Al-Qadire

Associate Professor, College of Nursing, Sultan Qaboos University, Oman

Omar Al Rawajfah

Sulaiman Dawood Al Sabei

Background:

The authors were unable to find studies comparing the critical thinking skills of nursing students on advanced standing programmes (ASP) and on traditional 4-year BN programmes in Canada. The ASP is a condensed Bachelor of Nursing (BN) programme, designed for students who already have a university degree or similar qualification.

To measure and compare the critical thinking skills of ASP students and traditional 4-year BN students.

A cross-sectional study using a self-administered questionnaire used to collect data from 100 nursing students at a university in Canada. Data were analysed using descriptive and inferential statistics. All research ethics were taken into consideration.

All participants scored highly in their critical thinking skills. However, ASP students scored significantly higher than their counterparts on the 4-year programme (M=21.6 vs M=18.9, F=4.75, P=0.035).

Conclusion:

Higher critical thinking skills among ASP nursing students is a promising sign to expand and support this type of programme as a fast and effective method to cover the shortage in nurses.

Critical thinking is one of the most desired outcomes of nursing programmes worldwide. In Canada, all nursing regulatory bodies emphasise critical thinking as part of entry-level competencies for nursing programmes in Canada to practise safely and ethically once qualified in all settings ( Canadian Nurses Association (CNA), 2015 ). This skill is salient for nurses to identify the use of evidence-informed knowledge, skills and judgement as a standard of practice for registered nurses ( Nurses Association of New Brunswick, 2012 . According to Scheffer and Rubenfeld (2000:352) , critical thinkers in nursing are characterised by ‘confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection’. The terms ‘critical thinking’, ‘clinical judgment’ and ‘clinical reasoning’ are often used interchangeably to indicate ‘the process of searching, obtaining, evaluating, analyzing, synthesizing, and conceptualizing information as a guide for developing one's thinking with self-awareness, and the ability to use this information by adding creativity and taking risks’ ( Yildirim et al, 2011:175 ). The significance of critical thinking in nursing is evident, and nursing education programmes are evaluated by nursing authorities based on the development of these skills ( Khosravani et al, 2004 ).

Preparing nursing students to become qualified nurses includes developing their critical thinking abilities: students must learn how to identify a problem, collect, interpret and prioritise data, and plan to solve the problem ( Menezes et al, 2015 ). The significance of critical thinking in nursing has been discussed throughout the literature. Papathanasiou et al (2014) discussed why it is crucial to the nursing profession:

• First, critical thinking is a significant component of the problem-solving process that enables nurses to make the best creative decisions to provide safe, competent and effective nursing interventions. In addition to knowledge and psychomotor skills, nurses use their cognitive and mental abilities to assess, analyse, synthesise, diagnose, plan, intervene and evaluate individuals, families and communities
• Second, this kind of thinking is vital for nurses to make meaningful connections between past and present history and assessments to determine the most appropriate nursing intervention, especially when they are working in settings where there are limited resources
• Third, critical thinking guides nurses' decisions when caring for ever-changing patient needs and when encountering complex situations
• Fourth, critical thinking enables nurses to think out of the box and to handle multifaceted contexts via learnt knowledge, experience and intuition when working with non-traditional cases.

Kabeel and Eisa (2016) emphasised that critical thinking in nursing reflects the scientific underpinnings of nursing science, where nurses take a logical approach to providing systematic care. Nurses use their logical thinking and goal-oriented attitudes to deliver evidence-based care, taking into account many factors: professional standards of care, ethics, procedures, rules, health policies and regulations, and applying their knowledge, skills and experience ( Tajvidi et al, 2014 ). Critical thinking allows nurses to select the best nursing interventions and nursing care for their clients using their contextual clinical experience and educational backgrounds ( Ignatavicius, 2001 ). Critical thinking is the foundation of nurses' thinking and is applied daily in practice. As such, it is an essential component of the curricula of nursing programmes. Finally, although critical thinking is a lifelong skill, the foundation for building this skill begins in undergraduate nurse education.

Many nurse education programmes struggle to integrate and teach critical thinking to their students. Shell (2001) reported that many factors hindered nursing faculty from teaching critical thinking skills. These included the unwillingness of some students to employ new learning techniques, the reluctance of some educators to foster critical thinking, the method of teaching used (ie traditional versus innovative teaching methods), lack of time to prepare and perform critical thinking activities, time constraints on faculty members and pressure to conduct research, short duration of classes and the physical educational environment.

Yildirim et al (2011) reported that nursing educators do not have sufficient time to develop the most appropriate teaching strategies to develop their students' critical thinking skills. In nursing education, it is not always effective to apply critical thinking strategies taken from the broader educational context because nursing requires the application of critical thinking in client-specific situations. Moreover, nursing educators struggle to balance course content with critical reflection. Yildirim et al (2011) suggested that students' attitudes toward learning often impaired educators from teaching critical thinking skills, namely, students focused on grades rather than learning and preferred more traditional didactic approaches to the learning process, rather than the novel approaches that have been found to enhance critical thinking.

Critical thinking among advanced standing programme students

The ‘advanced standing programme’ (ASP), the ‘accelerated track programme’ and the ‘2-year second-degree nursing programme’ are different terms used interchangeably in North America to describe a condensed Bachelor of Nursing (BN) programme, which has been designed in response to nursing shortages ( Cormier and Whyte, 2016 ). This type of programme aims to produce graduate nurses with the same skills and knowledge as their counterparts undertaking a 4-year programme but in half the time ( Cormier and Whyte, 2016 ). The ASP offers a condensed curriculum that enables students to meet requirements similar to those expected of students undertaking a traditional 4-year programme, thereby achieving the same standards and goals within a shortened time frame.

According to Cormier and Whyte (2016) , the average age of ASP students tends to be higher than that of their counterparts in the traditional programme. They have higher self-motivation to learn and are more competitive; they also achieve higher grades and National Council Licensure Examination for Registered Nurses (NCLEX-RN) scores, and they prefer creative, challenging adult learning strategies that differ from students of traditional 4-year programmes, who tend to prefer structured didactic methods. (The NCLEX-RN is an assessment of nursing competence, without which is it not possible to practise in North America.) In a study undertaken more than 20 years ago, Youssef and Goodrich (1996) compared students undertaking an accelerated programme and those on a traditional 4-year programme. They did not find significant differences between the two groups in terms of characteristics such as age, race and stress levels between the second semester and the end of the programme, nor did the two groups' critical thinking skills differ significantly. However, students on the accelerated programme had a higher grade point average. The authors suggested that perhaps this was because these students' pre-existing critical thinking skills enabled them to perform better. A study by Korvick et al (2008) involving BSc (Nursing) (n=32) and Accelerated BSc (Nursing) (n=29) students reported similar results: students on accelerated programmes showed better performance in class test scores, nationally standardised examination scores, laboratory skills performance and final course grades compared with those on traditional courses. The study also found that age was not predictive of success in either group.

In 2017, Kaddoura et al conducted a study to explore whether the critical thinking scores of students on an accelerated programme were a valid predictor of first-attempt success with passing NCLEX-RN exams to practise in the USA. The authors used data from the records of a school of nursing in Northeastern USA to compare students' critical thinking skills at the beginning and the end of their nursing programme using a standardised critical thinking test developed by Health Education Systems Incorporated (HESI). The authors took these results and compared them with the students' NCLEX-RN first-time pass rates. They found a statistically significant relationship between critical thinking skills and first-time NCLEX-RN pass rates. Newton and Moore (2013) , who measured critical thinking among nursing students using the Critical Thinking Assessment Entrance (CTAE) instrument, reported explicitly that critical thinking scores of accelerated programme students were higher than those of their traditional course counterparts.

Although many Canadian universities have adopted accelerated nursing programmes, no published Canadian studies could be found that measure critical thinking skills among ASP and traditional course students, and how the cohorts compare. Although the NCLEX-RN is now the standard entry to practise nursing that is used to assess the competency of nursing graduates in Canada, there is a dearth of knowledge about the critical thinking skills of nursing graduates. Furthermore, the authors were unable to find any Canadian studies comparing the critical thinking skills of students on a traditional 4-year BN course and students on an ASP. Therefore, this study aimed to evaluate the critical thinking skills of students at the University of New Brunswick, Canada: ASP students at Moncton campus and 4-year nursing students at the Fredericton and Saint John campuses.

A cross-sectional descriptive, comparative quantitative research design was used to collect data, using the valid and reliable California Critical Thinking Skills Test (CCTST) ( Insight Assessment, 2016 . Participants were nursing students at the University of New Brunswick and the study aimed to measure and compare the critical thinking skills of ASP students and their traditional 4-year course counterparts.

Inclusion criteria and sample size

A convenience sample of 100 nursing students (Moncton campus, n=30; Saint John campus, n=30; Fredericton campus, n=40) undertaking the Families in Populations course during the autumn/winter of 2018–2019 were invited to participate. The total number of students who were eligible to participate from the three campuses was 152: ASP, n=42; and BN, n=110.

Conceptual framework

The critical thinking conceptual model, which was developed by a panel of experts via the Delphi project ( Colucciello, 1997 ), was used to guide the study. It consists of four dimensions of critical thinking and their variables, along with indicators of outcomes to measure each dimension. The four dimensions are: critical thinking dispositions, skills, elements, and criteria. In this study, only critical thinking skills and its variables subscales—analysis, evaluation, inference, deductive reasoning and inductive reasoning—were measured using the CCTST instrument.

Instrument reliability and validity

The Delphi project was the first to clearly define the meaning of critical thinking, a definition that guided the development of the CCTST, which is a valid, reliable and objectively scored standardised tool ( Colucciello, 1997 ) used to assess critical care skills or subscales core reasoning skills. The CCTST consists of 34 multiple-choice items of short, discipline-neutral content, problem statements and scenarios that aim to measure variables within five specifically defined subscales: analysis, evaluation, inference, deductive reasoning and inductive reasoning. Each correct answer scores 1 point; the total score range is 0–34, with a higher score indicating stronger critical thinking skills. The tool takes 45-60 minutes to complete. For this study, the CCTST college-level paper and pencil form version of the tool was used. Demographic data on gender, age, programme location and type of nursing programme were collected.

The reliability of CCTST has been measured in previous studies using the Kuder Richardson-20 (KR-20) formula to estimate the tool's internal consistency, which ranged from 0.78 to 0.82. For an instrument with multidimensional scales such as the CCTST, a KR-20 score above 0.70 indicates a high level of internal consistency ( Insight Assessment, 2016 ). The tool's validity was measured through content, construct and criterion validity tests. The results indicated that it is a highly valid instrument to measure critical thinking skills ( Insight Assessment, 2016 ). A licence to use the CCTST instrument was granted by the author.

Data collection and analysis

After ethical approvals were received from the Faculty of Nursing Ethical Review Committee and the Research Ethics Board at the University of New Brunswick, a brief classroom presentation (15 minutes) was made to nursing students in their final year during one of their courses (with permission from course instructors) to recruit participants. The presentation included explanation of the study rationale, mode of participation (questionnaire) and that participation was voluntary; students had the right to withdraw at any point before submitting the questionnaire without penalty, not to answer any question on the tool and to ask the lead researcher questions related to the study.

There were no financial or academic incentives for participation in the study. Participants were assured of their confidentiality and anonymity, and were assured that their academic performance would not be affected whether they chose to participate or not. Participants were advised that completing and returning the questionnaire would be taken as implied consent. At the end of the classroom presentation, questionnaires were distributed and collected in sealed envelopes. The completed questionnaires were analysed using descriptive and inferential statistics. The significance level was set at (P<0.05) for all statistical tests.

Of 100 questionnaires distributed to the nursing students across the three campuses, 44 (44*) were returned. Thirty six participants were female (81.8*) and 8 (18.2*) were male, and average age was 22.8 years; 24 students (54.5*) were undertaking the 4-year nursing programme and 20 (45.5*) the ASP. The overall mean (M) critical thinking score for participants across both programmes was 20.1 (SD=4.2). The CCTST tool categorises the strength of participants' critical thinking as follows:

• Not manifested: 0-7
• Moderate: 13-18
• Strong: 19-23
• Superior: 24 or higher.

Table 1 presents the strength of students' critical thinking skills within each subscale. Table 2 shows that all participants had a moderate score for strength of critical thinking skills on the induction, deduction, inference and analysis skills subscales. As shown in Table 3 , the ASP students had a higher overall mean score (M=21.6, SD=2.1) compared with those on the 4-year course. Students in both groups scored moderate strength for all critical thinking subscales, with the exception that the ASP students had a stronger score on their evaluation skills than their counterparts in the 4-year programme (7.6. versus 6.1 respectively).

The one-way ANOVA test (F) was used to refute the null hypothesis that two groups are the same (F=4.75, P=0.035). This result showed that the difference between the groups was statistically significant. Another way to check the importance of any differences is to examine the mean percentile scores for the groups (49th versus the 65th): the 4-year programme group had a mean of 18.9. This mean was similar to the overall mean of all health science undergraduate students across North America who were studied to measure their critical thinking using CCTST ( Insight Assessment, 2020 ); the ASP group's overall mean score (M=21.6) was considered to be ‘high performing’ on the CCTST instrument.

The results showed that participants on both nursing programmes had high scores for the strength of their critical thinking skills. However, the ASP students had significantly higher scores on their critical thinking skills than their 4-year programme counterparts (M=21.6 versus M=18.9, F=4.75, P=0.035). This result supports the research hypothesis and rejects the null hypothesis, namely that the students undertaking the ASP have stronger critical thinking skills than their counterparts in the 4-year course. Because of the study's small sample size, comparing these results with the findings of previous studies with larger sample sizes was a challenge to enable accurate comparison. However, in contrast to previous studies, these results found stronger critical thinking skills among participants than has previously been shown among their counterparts in other countries.

For example, using the same tool as this study, research undertaken in Iran by Azizi-Fini et al (2015) recorded mean critical thinking scores among first-year students and senior nursing students as 11.79 and 11.21 respectively. Among many studies conducted in Iran, 10 reported that critical thinking among nursing students as being below average ( Sharifi et al, 2017 ).

The results of the study reported in this article also indicate that the average scores of critical thinking skills among participants were higher than previously recorded among other Canadian nursing students. For example, in Meherali et al's (2015) study, students achieved a weak overall mean score (M=243.70) on their critical thinking skills using the California Critical Thinking Disposition Inventory (CCTDI), which classifies those scoring below 280 as negatively disposed towards practising critical thinking, those with a score of 210–280 ambivalently disposed and those with a score of 280–420 positively disposed. The authors concluded that BN students might lack some of the attributes indicative of ideal critical thinkers. Similarly, Profetto-McGrath (2003) assessed critical thinking among Canadian BN course students in a Western Canadian university and found that only 38* of 228 nursing students had adequate levels of critical thinking skills (see Table 1 for the average CCTST scores).

A study conducted in India by Nirmala and Shakuntala (2011) found that nursing students had poor critical thinking skills. Nursing students in Hong Kong also failed to show adequate levels of critical thinking on the CCTDI ( Tiwari et al, 2003 ). Kaya et al (2017) conducted a longitudinal study among students at Istanbul University, Turkey, to determine the strength of nursing students' critical thinking skills and emotional intelligence over the course of an academic year, and found low levels of critical thinking skills and intermediate levels of emotional intelligence both at the beginning and at end of the academic year.

By comparison with previous studies, therefore, participants in the study described in this article showed a higher level of and stronger critical thinking skills than their counterparts both in Canada and elsewhere.

There could be a number of reasons that the findings in this study were not congruent with previous studies. One possible interpretation is that previous studies were conducted in different countries which have different cultures, different nursing and general educational systems, different expectations and outcomes from nursing programmes, and also that different instruments were used to measure critical thinking skills among the study cohorts in other countries.

Enhancing critical thinking among nursing students at the University of New Brunswick is an essential requirement and an expected outcome within both nursing programmes. Enhancing students' critical thinking skills is one of five stated outcomes for every course within the undergraduate nursing curricula at Brunswick. Emphasising these outcomes has enhanced the critical thinking skills of students on both nursing programmes, leading them to have better critical thinking scores than nursing students in previous studies.

A study conducted in the Philippines by de Leon-Abao (2014) —to determine the influence of teachers' instructional competence on the intermediate students' reading comprehension skills profile and their critical thinking ability—concluded that it does play a significant role in enhancing students' critical thinking skills. At the University of Brunswick, the Center for Enhanced Teaching and Learning continually encourages university educators, including nursing educators, to attend teaching and learning workshops and conferences, and to take part in teaching kaleidoscope sessions. The latter are one day conferences that take place at the end of each semester where faculty members from different specialties meet to display and share the innovative teaching methods they used during the semester to teach different topics. In addition, the center invites faculty members to enhance their skills in certain teaching methods through a residency visiting scholar programme. This type of training has contributed positively to enhancing students' critical thinking skills. The staff in the department are also always ready for free consultations and mentorship for nursing faculty at the University of New Brunswick.

Therefore, within many nursing courses, non-traditional and evidence-based teaching methods are used to teach undergraduate nursing students. Examples of non-traditional strategies include: using art and drama, reflective journal writing, case studies, problem-solving teaching methods, integration of clinical and theory components, peer learning, group discussions, team project work, flipping the class format, and implementation of different assignment formats for theory and clinical components (eg concept maps, multiple-choice and essay exams, oral exams, computer-based exams, simulation, care-plans, etc). Moreover, admission to the nursing programmes at the University of New Brunswick is competitive. Students who are selected for the 4-year course or the ASP will have achieved the highest marks in their secondary or university education respectively. Therefore, higher scores in critical thinking are expected of all undergraduate nursing students at the University of New Brunswick.

The results of this study also support the hypothesis that students on the ASP have stronger thinking skills than their counterparts on the 4-year programme. The result is congruent with findings from studies cited earlier in this article ( Youssef and Goodrich, 1996 ; Korvick et al, 2008 ; Newton and Moore, 2013 ; Cormier and Whyte, 2016 ; Kaddoura et al, 2017 ). However, although ASP students recorded higher overall mean scores on their critical thinking skills, students on both programmes recorded moderate scores on the critical thinking subscales for analysis, inference, evaluation, induction and deduction ( Table 2 and Table 3 ). This may be because the data were collected from participants 6 months before they had completed their nursing degrees, and before they were to undertake their 12 weeks of preceptorship in clinical practice, as well as before they began to prepare intensively for their national entry exam (NCLEX-RN).

All of these contexts and experiences will contribute to enhancing the critical thinking skills of nursing students, even before they can be described as newly qualified nurses. In summary, the overall findings showing that nursing students have high scores for critical thinking skills indicate that these student cohorts are in an educational environment that adheres to high standards and promotes critical thinking skills, which is a required lifelong skill that enables nurses to provide optimum and safe care.

Limitations and recommendations

External validity and generalisability of the findings cannot be guaranteed because of the limitations of this study. The study cohort consisted of a small convenience sample of nursing students and the findings cannot therefore be generalised to all students undertaking nursing programmes in New Brunswick province, across Canada or more widely in universities across the world. Another limitation is that the study sample was selected from the English-speaking university campuses in New Brunswick, with no participants from French-speaking universities.

The data were collected using CCTST, a tool that was designed to measure general critical thinking skills not related specifically to nursing or any other specific discipline, which might not have accurately reflected participants' responses on critical thinking skills related to their future profession, which could be a limitation. Another limitation was that critical thinking was measured only 6 months before the students completed their programmes, rather than at the point of entry to the course, at the start of their learning.

Grade point averages and the results of HESI were not taken into consideration as indicators of critical thinking abilities among participants in this study, which provides an incomplete picture of the students' real critical thinking skills and how they were enhanced throughout their time of learning on the nursing programmes. For future studies, it is recommended that a larger random sample size involving students from both English- and French-speaking universities be engaged in a Canada-specific context, using a range of valid and reliable instruments designed explicitly to measure the critical thinking skills of nursing students or students in the health sciences, and that other critical thinking indicators such as grade point averages and HESI results are taken into consideration.

Longitudinal and qualitative studies are needed to understand the influence of nursing education on enhancing students' critical thinking skills. Based on the results of this study, it is recommended to enhance the current curriculum with a greater focus placed on promoting the dimensions of critical thinking using evidence-based teaching methods. Incorporating critical thinking courses earlier in the curriculum for different undergraduate nursing programmes is recommended too.

Assessing nursing students' critical thinking skills on a regular basis is also recommended to assess their level of preparedness for practice and to make prompt interventions if necessary. Despite these limitations, the results of the study are significant and provide a rationale for decision-makers in New Brunswick province to invest in expanding and adding more student places to the ASP in nursing to cover the shortage in nurses locally, nationally and internationally.

Nursing students in this study had high/strong overall mean scores for their critical thinking skills. However, students in the ASP group had significantly higher/stronger scores than their counterparts on the regular 4-year programme. Students undertaking both courses scored a moderate mean against the critical thinking subscales of analysis, inference, evaluation, induction, and deduction. Showing strong and higher critical thinking skill levels of ASP students is a promising sign to expand and support the ASP option as a fast and effective method to address the shortage of nurses nationally and internationally. However, further studies with larger sample sizes, with findings that support those reported in this study, are needed before making any final decision to expand the ASP option.

• Students undertaking both the 4-year course and the advanced standing programme (ASP) had moderate scores on the strength of their critical thinking skills across the dimensions that were assessed
• ASP students had a higher overall mean score for critical thinking compared with those on the 4-year course
• The stronger and higher level critical thinking skill levels of the ASP students is a promising indication for expanding and supporting the ASP option as a fast, effective method to address the nursing shortage

CPD reflective questions

• Consider other innovative teaching methods, other than those mentioned in the literature, that can be used to enhance critical thinking skills among nursing students
• How do you think online teaching and the use of technology affects the critical thinking skills of nursing students?
• If nursing students in a certain institution showed low scores in their critical thinking skills tests, what do you consider could be the possible reasons for this? What are the possible solutions to address the issue?