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Critical Thinking in Nursing: Tips to Develop the Skill

4 min read • February, 09 2024

Critical thinking in nursing helps caregivers make decisions that lead to optimal patient care. In school, educators and clinical instructors introduced you to critical-thinking examples in nursing. These educators encouraged using learning tools for assessment, diagnosis, planning, implementation, and evaluation.

Nurturing these invaluable skills continues once you begin practicing. Critical thinking is essential to providing quality patient care and should continue to grow throughout your nursing career until it becomes second nature. 

What Is Critical Thinking in Nursing?

Critical thinking in nursing involves identifying a problem, determining the best solution, and implementing an effective method to resolve the issue using clinical decision-making skills.

Reflection comes next. Carefully consider whether your actions led to the right solution or if there may have been a better course of action.

Remember, there's no one-size-fits-all treatment method — you must determine what's best for each patient.

How Is Critical Thinking Important for Nurses? 

As a patient's primary contact, a nurse is typically the first to notice changes in their status. One example of critical thinking in nursing is interpreting these changes with an open mind. Make impartial decisions based on evidence rather than opinions. By applying critical-thinking skills to anticipate and understand your patients' needs, you can positively impact their quality of care and outcomes.

Elements of Critical Thinking in Nursing

To assess situations and make informed decisions, nurses must integrate these specific elements into their practice:

• Clinical judgment. Prioritize a patient's care needs and make adjustments as changes occur. Gather the necessary information and determine what nursing intervention is needed. Keep in mind that there may be multiple options. Use your critical-thinking skills to interpret and understand the importance of test results and the patient’s clinical presentation, including their vital signs. Then prioritize interventions and anticipate potential complications. 
• Patient safety. Recognize deviations from the norm and take action to prevent harm to the patient. Suppose you don't think a change in a patient's medication is appropriate for their treatment. Before giving the medication, question the physician's rationale for the modification to avoid a potential error. 
• Communication and collaboration. Ask relevant questions and actively listen to others while avoiding judgment. Promoting a collaborative environment may lead to improved patient outcomes and interdisciplinary communication. 
• Problem-solving skills. Practicing your problem-solving skills can improve your critical-thinking skills. Analyze the problem, consider alternate solutions, and implement the most appropriate one. Besides assessing patient conditions, you can apply these skills to other challenges, such as staffing issues . 

How to Develop and Apply Critical-Thinking Skills in Nursing

Critical-thinking skills develop as you gain experience and advance in your career. The ability to predict and respond to nursing challenges increases as you expand your knowledge and encounter real-life patient care scenarios outside of what you learned from a textbook. 

Here are five ways to nurture your critical-thinking skills:

• Be a lifelong learner. Continuous learning through educational courses and professional development lets you stay current with evidence-based practice . That knowledge helps you make informed decisions in stressful moments.  
• Practice reflection. Allow time each day to reflect on successes and areas for improvement. This self-awareness can help identify your strengths, weaknesses, and personal biases to guide your decision-making.
• Open your mind. Don't assume you're right. Ask for opinions and consider the viewpoints of other nurses, mentors , and interdisciplinary team members.
• Use critical-thinking tools. Structure your thinking by incorporating nursing process steps or a SWOT analysis (strengths, weaknesses, opportunities, and threats) to organize information, evaluate options, and identify underlying issues.
• Be curious. Challenge assumptions by asking questions to ensure current care methods are valid, relevant, and supported by evidence-based practice .

Critical thinking in nursing is invaluable for safe, effective, patient-centered care. You can successfully navigate challenges in the ever-changing health care environment by continually developing and applying these skills.

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THE THEORY OF Critical Thinking of Nursing

MARTIN, CHERYL

About the Author Cheryl Martin, PhD, RNC, is an associate professor of nursing at Bethel College, Mishawaka, Indiana. The author is grateful to Dr. Marilyn Oermann for her guidance and direction.

Critical thinking is a thought process used by nurses for clinical decision-making. This descriptive correlational study focused on the relationships among critical thinking, decision-making, and clinical nursing expertise during a clinical simulation. A midrange theory, developed from Benner (1) and Paul (2), states that as novice nurses become experts and develop clinical expertise through experience and the acquisition of knowledge, critical thinking is developed and used for clinical decision-making. > A convenience sample of 149 nursing students, graduate nurses, and expert nurses was selected for the study. Critical thinking was measured with the Elements of Thought Instrument (ETI) and a decision score was calculated. Critical thinking and decision-making increased with the level of clinical expertise. Related demographics included college credits taken, years in nursing practice, and grade point average. The findings were consistent with the midrange Theory of Critical Thinking of Nurses.

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The Value of Critical Thinking in Nursing

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

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

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

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

How Do Nurses Use Critical Thinking?

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

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

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

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

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

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

Top 5 Ways Nurses Can Improve Critical Thinking Skills

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

Case-Based Approach

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

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

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

Practice Self-Reflection

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

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

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

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

Develop a Questioning Mind

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

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

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

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

Practice Self-Awareness in the Moment

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

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

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

Use a Process

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

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

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

Common Critical Thinking Pitfalls in Nursing

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

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

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

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

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

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

An Essential Skill for All Nurses

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

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

Frequently Asked Questions About Critical Thinking in Nursing

How are critical thinking skills utilized in nursing practice.

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

How does nursing school develop critical thinking skills?

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

Do only nurse managers use critical thinking?

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

Meet Our Contributors

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

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

Jenna Liphart Rhoads, Ph.D., RN

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

Nicholas McGowan, BSN, RN, CCRN

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

Critical Thinking in Nursing

• First Online: 02 January 2023

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• Şefika Dilek Güven 3  

Part of the book series: Integrated Science ((IS,volume 12))

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Critical thinking is an integral part of nursing, especially in terms of professionalization and independent clinical decision-making. It is necessary to think critically to provide adequate, creative, and effective nursing care when making the right decisions for practices and care in the clinical setting and solving various ethical issues encountered. Nurses should develop their critical thinking skills so that they can analyze the problems of the current century, keep up with new developments and changes, cope with nursing problems they encounter, identify more complex patient care needs, provide more systematic care, give the most appropriate patient care in line with the education they have received, and make clinical decisions. The present chapter briefly examines critical thinking, how it relates to nursing, and which skills nurses need to develop as critical thinkers.

Graphical Abstract/Art Performance

Critical thinking in nursing.

This painting shows a nurse and how she is thinking critically. On the right side are the stages of critical thinking and on the left side, there are challenges that a nurse might face. The entire background is also painted in several colors to represent a kind of intellectual puzzle. It is made using colored pencils and markers.

(Adapted with permission from the Association of Science and Art (ASA), Universal Scientific Education and Research Network (USERN); Painting by Mahshad Naserpour).

Unless the individuals of a nation thinkers, the masses can be drawn in any direction. Mustafa Kemal Atatürk

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Güven, Ş.D. (2023). Critical Thinking in Nursing. In: Rezaei, N. (eds) Brain, Decision Making and Mental Health. Integrated Science, vol 12. Springer, Cham. https://doi.org/10.1007/978-3-031-15959-6_10

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

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

What is Critical Thinking in Nursing?

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

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

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

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Philosophies, Models, and Theories: Critical Thinking Structures

Chapter 3 Philosophies, Models, and Theories Critical Thinking Structures Martha Raile Alligood It is not simply knowing a lot of things; it is a way of knowing things. (Levine, 1988) “Theory development in nursing science is critical for evolution of the discipline” ( Clarke & Lowry, 2012, p. 333 ), and growth of the profession is dependent on nurses knowing and using nursing theoretical works in their practice of nursing. Studies continue to generate evidence of the connections among knowledgeable use of nursing theoretical works, education, and quality nursing practice ( Bigbee & Issel, 2012 ; Erickson, 2007 ; Fawcett & Garity, 2009 ; Hatlevik, 2012 ; Im & Chang, 2012 ; McCrae, 2011 ; Sieloff & Bularzik, 2011 ). This evidence is vital for the practicing nurse. This chapter sets the stage for the chapters that follow and introduces new understandings as Carper’s (1978) patterns of knowing are proposed as types of nursing theory and evidence for nursing practice ( Fawcett, 2012a ). These works represent the empirical pattern or the science of nursing understood as a type of theory and the form of evidence necessary for quality nursing practice ( Carper, 1978 ; Fawcett, 2012a ). Descriptions of the levels of abstraction of these nursing works from seven nursing models, three philosophies of nursing, and six theories of nursing illustrate their linkages with the practice level in middle-range theory. The theoretical frameworks guide professional practice; organizing the thought processes for decision making and reasoning for quality nursing practice. The content of nurses’ decisions may be unique nursing knowledge, but the modes of making practice decisions are generic processes of logic and critical thinking ( Scriven & Paul, 2004 ). Nursing theoretical works (philosophies, models, theories) are knowledge structures that link logically with inherent critical thinking processes. A key part of this chapter presents points to be considered when selecting a nursing theoretical work to guide your practice. You may discover that certain of the works resonate with you more than others. A good fit between the nurse and the theoretical work selected is important and is usually related to mutual values inherent in a theoretical work and the nurse. Chapter 4 presents an insightful discussion of the moral obligations and values inherent in theoretical works. Once a theory is selected it is recommended that you expand your understanding of that theory by reading published materials written by the theorist. I want to introduce you to the use of the clinical case of Debbie in this text. Debbie has been featured in each application chapter since the first edition of this text in 1997. The case of Debbie was written by Dr. Ken Phillips, author of the Roy chapter. The idea for this feature sprang from a classroom teaching/learning exercise I had used with graduate students. Each student was asked to select a nursing framework and develop a plan of care for the same case (Mrs. Corbett). Their presentations illustrated the similarities and differences in the focus and plan of care when thought and action were guided by a particular nursing framework. This exercise led to important insights and understandings of the frameworks by the students. Therefore, that feature was included in the plans for the first edition of this text. The authors of the chapters in the Application section ( Chapters 5 through 20 ) have developed a plan of care for Debbie, and each author also introduces a case of his or her choice and plan of care for that person. As you read the application chapters, watch for the unique focus of each philosophy, model, and theory noticeable in the care of Debbie. This text focuses on the use of theoretical works in practice. The reader is referred to Nursing Theorists and Their Work ( Alligood & Tomey, 2010 ) for analytical critiques of the philosophies, models, and theories. The Relationship of Philosophies, Models, and Theories The philosophies, models, and theories of a discipline are theoretical structures that address the central concepts of that discipline. The science of nursing is recognized as a fundamental pattern of knowing for nurses ( Carper, 1978 ). Fawcett (2005) proposes a nursing metaparadigm based on Kuhn’s (1970) philosophy of science and paradigm development. The metaparadigm specifies disciplinary boundaries of human beings, environment, health, and nursing as a context to understand the interrelationships among those elements of contemporary nursing science ( Fawcett, 2005 ). Theoretical knowledge may be differentiated by the way it is named or labeled. A model tends to be named for the person who authors it, for example, the Neuman Systems Model. Grand theories tend to be named for the outcome they propose, for example, the Theory of Optimal Client System Stability, and theories tend to be named for the characteristics their content demarcates as an explanatory shell of the outcomes they propose. An example is Gigliotti’s (2003) theory of women’s multiple role stress, which she validated as middle range with the age groups of women and forms of stress ( Gigliotti, 2011 , 2012 ). Table 3-1 presents types of nursing knowledge at each level of abstraction and an example of nursing knowledge for each type. •  The metaparadigm is the most abstract set of central concepts for the discipline of nursing (i.e., human being, environment, health, nursing), and these concepts are defined within each of the conceptual models and according to the philosophy of that model. •  Philosophies present the general meaning of nursing and nursing phenomena through reasoning and logical presentation of ideas ( Alligood, 2005 ). Although Nightingale (1946) did not present her philosophy on the relationship of patients and their surroundings as a theory, her philosophy contains implicit theory that guides nursing practice. •  Conceptual models (also called paradigms or frameworks) such as the Neuman Systems Model ( Neuman & Fawcett, 2011 ) are the next less abstract set of concepts in the structure. •  Grand theory (e.g., Neuman’s Theory of Optimal Client System Stability) is next as the level of abstraction descends. Theory can be considered grand when it is nearly as abstract as the model itself and when the usefulness of the model depends on the soundness of that theory. Grand theory is especially useful in research and practice because it is more general, and theories specifying the details of practice can be derived from it. •  Theory is the next less abstract level; it is more specific than grand theory but not as specific as middle-range theory (e.g., Optimal Client System Stability in specific settings). •  Finally, as mentioned earlier, middle-range theory is the least abstract set of concepts and the most specific to nursing practice (e.g., promoting Optimal Client System Stability through a stress reduction intervention in the work environment). The understanding of theory terminology is developed over time with knowledge of works at the different levels of abstraction ( Fawcett, 2005 ; Reynolds, 1971 ). TABLE 3-1 A Structure of Nursing Knowledge Types and an Example of Each Type Knowledge Type Examples of Types of Nursing Knowledge Metaparadigm Human beings, environment, health, nursing Philosophy Nightingale’s philosophy Conceptual models Neuman Systems Model Grand theory Optimal Client System Stability Theory Flexible line of defense moderates Optimal Client System Stability Middle-range theory Flexible line of defense moderates stress levels for Optimal Client System Stability in women who are enacting multiple roles ( Gigliotti, 2011 ) Knowledge types based on Fawcett, J. (2005). Contemporary nursing knowledge: Conceptual models and theories (2nd ed.). Philadelphia: F. A. Davis. Philosophies are theoretical works that address one or more of the metaparadigm concepts (person, environment, health, and nursing) in a broad philosophical way. Philosophies address questions such as: •  What is nursing? •  What is the nature of human caring? •  What is the nature of nursing practice? •  What is the social purpose of nursing? ( Alligood, 2005 ). Therefore, philosophies are broad statements of values and beliefs that propose general ideas about what nursing is, what nursing’s concerns are, and how the profession addresses its moral obligation to society. Each philosophy is a unique view of nursing. Nursing models are frameworks or paradigms of the science of nursing that address the person, environment, health, and nursing metaparadigm. What this means in terms of nursing practice is that the way you think about people and about nursing has a direct effect on your approach with people, what questions you ask, how you process the information that is learned, and what nursing activities are included in your care. Therefore, a model provides a perspective of the person for whom you are caring, specifies the focus for the delivery of care, and structures the reasoning, critical thinking, and decision making in your practice. Nursing theories derive from models and are guiding structures for reasoning and decision making about the person, the person’s health situation, and the care indicated. Theories are composed of sets of concepts, but they are less broad and propose specific outcomes. Theories may have been derived from a philosophy, a nursing model, a more abstract nursing theory, or a model or framework from another discipline. Theories are based on propositions or relationship statements that are consistent with theoretical works from which they are derived, but a theory coming from a nursing model such as Theory of Accelerating Change (based on Rogers’ Science of Unitary Human Beings) or Theory of the Person as an Adaptive System (based on Roy’s Adaptation Model) is more focused and guides your approach and perspective. When you approach people from the perspective of a certain nursing theory and ask questions, process information, and carry out specific activities, an outcome is anticipated based on the theory. This is true whether the theory is guiding the design and delivery of nursing care or the design and conduct of a research project. Just as theory strengthens nursing practice, theory-based research produces evidence for practice ( Fawcett, 2012a , b ). Theories have been specified as important forms of evidence. Evidence-based nursing practice is encouraged but is dependent on ways to recognize quality evidence. And the quality of evidence-based practice is dependent on recognition of quality research ( Fawcett & Garity, 2009 ). Middle-range theory is the least abstract in the structure of knowledge and as the term range suggests middle-range theories are at various levels of abstraction. These theories are at the practice level, and include details of nursing practice. Grand Theories such as Rogers’ Theory of Accelerating Change, Roy’s Theory of the Person as an Adaptive System, and Neuman’s Theory of Optimal Client System Stability are examples of grand theories because they are broad and their level of abstraction is close to the model from which they are derived. When a theory is at the grand theory level, many middle-range applications of that theory can be developed for practice by specifying factors such as: •  The situation or health condition •  The client population or age group •  The location or area of nursing practice (e.g., home, hospital, community) •  The action of the nurse or nursing intervention The process of specifying the details in the theory makes it less abstract and less broad; therefore, it applies to specific types of patients, in specific situations, and proposes specific outcomes about the care for the patient. Research reports of studies that test middle-range theories and specify the details yield findings that are evidence for evidence-based practice. In this theory utilization era the communities of scholars surrounding nursing theoretical works (philosophies, models, and theories) continue to grow and expand globally ( Bond, Eshah, Bani-Khaled, et al., 2011 ; Im & Chang, 2012 ). Growth in the development and use of middle-range theory in research and practice has exploded in the global nursing literature. Expansion is obvious by publications in scholarly nursing books and journals. A few recent examples are Bultemeier (2012) in Malawi and the long history of Neuman’s Systems Model in Holland ( Merks, Verberk, Kuiper, et al., 2012 ). Nursing theory societies have global members who contribute ideas for middle-range theory development, testing, and use in theory-based practice ( Biggs, 2008 ; Bond, et al., 2011 ; Daiski, 2000 ; Dobratz, 2008 ; Dunn, 2005 ; Fawcett & Garity, 2009 ; Frey, Sieloff, & Norris, 2002 ; Gigliotti, 2012 ; Im & Chang, 2012 ; Sieloff & Frey, 2007 ). Discussion of these types of nursing theoretical works follows, and the application chapters in Part II ( Chapters 5 through 20 ) of this text illustrate nursing practice with each type. Philosophies Philosophies provide us with broad general views of nursing that clarify nursing values to answer broad disciplinary questions. Three nursing philosophies are included in this chapter that present different philosophical views of nursing. Examples of these differing views are noted in the works of Nightingale (1946) , Watson (1979) , and Benner (1984) . Nightingale’s Philosophy of Nursing Nightingale (1946) provides an answer to the question “What is nursing?” in her often-cited work Notes on Nursing: What It Is and What It Is Not . In that work Nightingale distinguishes nurses from the household servant of her day, contrasts the differences between nursing and medicine, and specifies the concern of nursing to be involved with health as well as illness. She includes directives for her unique perspective that is focused on the relationship between patients and their surroundings (often referred to as environment). She addresses the categories of pure air, pure water, efficient drainage, cleanliness, and light and provides directives on diet, noise, rest, and the nurse’s responsibility for protection and management of the care of the patient. Nightingale’s work is very relevant to current nursing practice, as reflected by the nursing literature. For example, Erlen (2007) cites Nightingale in regard to patient safety and error reduction in care of orthopedic patients. Bolton and Goodenough (2003) recognized Nightingale’s work for the nursing contribution to quality improvement, and Jarrin (2012) describes situated caring in nursing and the environment. In Chapter 5 , Kim Bolton describes her nursing practice using Nightingale as a guide, illustrates with case applications, and adds an updated bibliography. Watson’s Philosophy of Nursing Watson (1979 , 2011) continues to provide a unique approach to nursing as first proposed in Nursing: The Philosophy and Science of Caring. Her work states that nursing is a human science that addresses the nature of human caring. She suggests a return to the earlier values of nursing, which emphasized the caring aspects ( Watson, 1988 ). In this philosophical work she also introduces theoretical propositions for the human-to-human relationships of nursing and specifies 10 carative factors to guide application of her work in nursing practice. Transpersonal caring is the proposed approach to achieve connectedness in which the nurse and the patient change together. Emphasis is on harmony for unity in body, mind, and soul, and illness represents disharmony as the nurse and the patient participate together in their relationship. Watson’s work has been used to direct care in various areas of practice and nursing administration to address nurse effectiveness in caring ( Persky, Nelson, Watson, et al., 2008 ). Watson (2011) has updated her caring science, its measurement ( Nelson & Watson, 2011 ), and its curriculum approach ( Hills & Watson, 2011 ). In Chapter 6 , the authors discuss Watson’s work in nursing practice and illustrate with case applications. Benner’s Philosophy of Nursing Benner (1984) provides yet another philosophical view of nursing with emphasis on the nature of nursing practice, specifically how knowledge of practice is acquired and how it develops over time. In this way her work might be viewed as personal knowing using Carper’s (1978) patterns. Her interpretive research led to a description of the progression of nurses from novice to expert and an awareness of the importance of caring in nursing. Benner’s work has been used to guide the examination of nursing practice innovations and changes. Benner and colleagues (2010) assessed nursing education for quality improvement recommendations. Her work guides patient care ( Levy, 2004 ) and the development of nursing knowledge ( Altmann, 2007 ). In Chapter 7 , Benner scholar Karen Brykczynski, reviews Benner’s work, illustrates its utilization and application with case presentations, and discusses use of the interpretive approach in her nursing practice. Nursing Models Nursing conceptual models (or frameworks) provide comprehensive perspectives for nursing practice. Models are broad conceptual structures that provide holistic views and specific foci of nursing. They are organizing frameworks for a particular perspective of nursing practice, such as adaptation, person-environmental process, interaction, or self-care. This section reviews seven works that have been specified as nursing models by analysis and evaluation ( Fawcett, 2005 ; Fawcett & Garity, 2009 ). Johnson’s Behavioral System Model In nursing practice with the Behavioral System Model, the nurse views the person as a system of behaviors ( Johnson, 1980 ). The actions and responses of the person comprise a system of interacting subsystems. Therefore, assessment of the subsystems leads to an understanding of the behavior of the patient. Seven subsystems and three theories of the Johnson Behavioral System Model are presented in Box 3-1 . BOX 3-1 Subsystems of Johnson’s Behavioral System Model and Theories Subsystems Attachment or affiliative Dependency Ingestive Eliminative Sexual Aggressive Achievement Theories Theory of the Person as a Behavioral System Theory of a Restorative Subsystem ( Grubbs, 1974 ) Theory of Sustenal Imperatives ( Holaday, et al., 1997 ) The Theory of the Person as a Behavioral System is a grand theory implied in the model. Two middle-range theories have been derived from the model: the Theory of Sustenal Imperatives, developed by Holaday, Turner-Henson, and Swan (1997) and based on the work of Holaday (1974) and Grubbs (1974) and the Theory of a Restorative Subsystem ( Grubbs, 1974 ), that proposes an additional subsystem to the seven-subsystem model developed by Johnson (see Box 3-1 ). Johnson’s model was recently applied to adolescent dating relationships for developmental understanding ( Draucker, Martsolf, & Stephenson, 2012 ). In Chapter 8 , Johnson scholar Bonnie Holaday illustrates the utilization and application of the model and theory in nursing practice (see Box 3-1 ). King’s Conceptual System Nurses practicing with King’s Conceptual System think in terms of three interacting systems: a personal system, an interpersonal system, and a social system ( King, 1971 , 1981 , 1997 ). Nursing practice with this system is interactive because the nurse views the patient as a personal system with interpersonal and social systems. King identifies a group of concepts for each of the systems, that, when considered together, specify the processes of that system. The concepts of the three systems and theories derived from that model are presented in Box 3-2 . BOX 3-2 King’s Conceptual System and Theories Personal System Concepts Perception Self Growth and development Body image Time and space Interperson System Concepts Interaction Communication Transaction Stress Role Social System Concepts Power Authority Status Decision making Role Organization Theories Theory of Goal Attainment ( King, 1981 ) Theory of Departmental Power (Sieloff, 1991, 1995) Theory of Personal System Empathy ( Alligood & May, 2000 ) Theory of Empathy, Self-Awareness, and Learning Style ( May, 2000 ) Theory of Decision-Making in Women Eligible for a Cancer Clinical Trial ( Ehrenberger, et al., 2002 ) Theory of Nursing Empathy by University of Tennessee–Knoxville Empathy Research Team ( Alligood, 2007 ) King (1981) developed the Theory of Goal Attainment from her own Conceptual System. Her theory that perceptual congruence and transactions in the nurse-patient interaction lead to goal attainment has been applied in many different areas of nursing practice ( Alligood, 2010 ; Sieloff & Frey, 2007 ). Frey and Sieloff (2002) observed middle-range theory development as a major extension of King’s work. So they updated their first book ( Frey & Sieloff, 1995 ) in a second book, Middle Range Theory Development Using King’s Conceptual System ( Sieloff & Frey, 2007 ). King’s many contributions to nursing have been noted ( Clarke, Killeen, Messmer, et al., 2009 ). Sieloff and Bularzik (2011) updated the Sieloff-King Instrument for Organizational Assessment of Group Power. The King International Nursing Group (KING) maintains a website and holds annual conferences. In Chapter 9 , Mary Gunter, a King scholar, presents King’s work and practice applications (see Box 3-2 ). Levine’s Conservation Model Nursing practice with the conservation model and principles focuses on conserving the patient’s energy for health and healing ( Levine, 1967 , 1991 ). Four principles that constitute conservation for the whole person and three theories are noted ( Box 3-3 ). BOX 3-3 Levine’s Four Conservation Principles and Theories Conservation Principles Energy Structural integrity Personal integrity Social integrity Theories Theory of Conservation Theory of Therapeutic Intention Theory of Redundancy Theory of Health Promotion for Preterm Infants ( Mefford, 2004 ; Mefford & Alligood, 2011a , b ) The Theory of Conservation is a grand theory that is implicit from the model and principles. Levine proposed two middle-range theories: the Theory of Redundancy that described the fail-safe systems of the human body and the Theory of Therapeutic Intention. Of these two theories, the Theory of Therapeutic Intention has been used by Schaefer (1991) in nursing practice and found highly relevant based on the connection to intervention. Mefford proposed (2004) and tested the middle-range Theory of Health Promotion for Preterm Infants based on Levine’s Conservation Model ( Mefford & Alligood, 2011a , b ). In Chapter 10 , Karen Moore Schaefer illustrates use of Levine’s model and application of the conservation principles in nursing practice (see Box 3-3 ). Neuman’s Systems Model When practicing nursing with The Neuman Systems Model ( Neuman, 1982 , 1989 , 1995 , 2002 , 2011 ), the nurse views the client as a system of five variables interacting with the environment while focusing on stressors as they relate to client health. The five variables are physiological, psychological, sociocultural, developmental, and spiritual. These variables interact systematically with the lines of resistance, the normal line of defense, and the flexible line of defense as the client system responds wholistically with intrapersonal, interpersonal, and extrapersonal stressors as the two theories—the Theory of Optimal Client System Stability and the Theory of Prevention as Intervention—propose ( Neuman & Fawcett, 2011 ). The Theory of Optimal Client System Stability is adaptable with changes in clients or other details of the client situation. The Theory of Prevention as Intervention is inherent in the systematic model because interventions are focused on increasing awareness of stress and stress reduction for a prevention outcome. Both theories are useful in practice, linking nursing action with outcomes. These broad theories have many applications with age, health status, and stressors specified. Casalenuovo (2002) tested a middle-range theory of well-being in persons with diabetes. Other Neuman scholars continue to use the model in various areas of practice ( Bigbee & Issel, 2012 ; Cazzell, 2008 ; Gigliotti, 2003 ; Lowry, Beckman, Gehrling, et al., 2007 ). In Chapter 11 , Kathleen Flaherty demonstrates utilization and application of the Neuman Systems Model in nursing practice (see Box 3-4 ). BOX 3-4 The Neuman Systems Model and Theories Patient Variables Physiological Psychological Sociocultural Developmental Spiritual System Defense Lines of resistance Normal line of defense Flexible line of defense Theories Theory of Optimal Client System Stability ( Neuman, 2011 ) Theory of Prevention as Intervention ( Neuman, 2011 ) Theory of Adolescent Vulnerability ( Cazzell, 2008 ) Theory of Moderation of Stress Levels in Women in Multiple Roles ( Gigliotti, 2012 ) Theory of Maternal Student Role Stress ( Gigliotti, 2011 ) Theory of Infant Exposure to Tobacco Smoke ( Stepans & Knight, 2002 ) Theory of Well-Being for Fatigue in Diabetics ( Casalenuovo, 2002 )

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The Importance of Critical Thinking in Nursing

An American Association of Nurse Practitioners (AANP) survey found that a majority of nurse practitioners saw three or more patients per hour. Nurse practitioners see patients of all ages with a broad spectrum of potential ailments. Critical thinking skills in nursing improve patient outcomes by enabling evidence-based decision-making. 

Nurse practitioners gather considerable amounts of patient data through evaluations, tests and conversations. Each patient's information can be interpreted and analyzed to determine the best courses of action for their health. A growing emphasis on critical thinking in nursing stems from the increasing importance of nurse practitioners in primary care.

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Growing need for critical thinking in nursing.

There is a significant shortage of primary care services throughout the United States. GoodRx identified 80% of counties as "health care deserts" or locations without easy access to necessary services. This data includes the following categories relevant to family nurse practitioners:

• 9% of counties lack enough primary care providers to serve the local population
• Residents in 20% of counties are at least 30 minutes away from hospitals
• Residents in 45% of counties are at least 20 minutes away from community health centers

"Health care deserts" are worsening because of a shortage of primary care physicians. The Association of American Medical Colleges ( AAMC ) estimates up to 48,000 more primary care providers are needed to meet patient care needs by 2034. This shortfall translates to a lack of preventive care and increased reliance on emergency care facilities.

The U.S. Bureau of Labor Statistics ( BLS ) projects a 52% growth in nurse practitioner roles by 2030. This growth is fueled not only by "health care deserts" but an aging population and public health threats like COVID-19. Critical thinking by nurse practitioners can overcome these challenges even with limited resources and stressful situations.

The Critical Thinking Process

The first step in incorporating critical thinking into patient care is understanding the critical thinking process. The National League for Nursing Accreditation Commission ( NLNAC ) defines critical thinking as:

"the deliberate nonlinear process of collecting, interpreting, analyzing, drawing conclusions about, presenting, and evaluating information that is both factually and belief based."

Critical thinking in nursing does not move in a straight line because each patient is unique. There isn't a one-size-fits-all diagnosis for patients because there isn't a single type of patient. Nurse practitioners can apply the following steps in the Clinical Reasoning Cycle as they evaluate patient care decisions.

Consider the Situation

First impressions of new patients can distract from effective evaluations. Personal experiences and assumptions may lead to hasty conclusions about patient needs. The first step to critical thinking in nursing involves a dispassionate consideration of the facts.

Nurse practitioners often have the basic facts about their patients' conditions before stepping into exam rooms. A simple repetition of the patient's age and reported illness counters assumptions that can negatively impact patient care.

Collect Information

Critical thinking requires the synthesis of existing and new information for effective analysis. Nurse practitioners can pull useful details from patient charts and histories when they are available. An evaluation of visual appearance, speech, blood pressure and other metrics builds on this previous work.

Skilled practitioners automatically apply their knowledge of physiology, pharmacology and other areas during the collection process. They also keep best practices, cultural competence and ethics in mind while working with patients. This recall makes it easier to process information during diagnosis.

Process Information

There is a multi-step process for turning raw information into useful insights for patient care. Nurse practitioners effectively process patient data by:

• Analyzing information within the context of normal and abnormal ranges
• Separating relevant and irrelevant data while finding information gaps
• Focus on relationships between symptoms and cues
• Deduce potential causes of health problems
• Compare similar situations between current and past patients
• Predict potential outcomes and complications from treatment

Nurse practitioners are ready to diagnose patient conditions following this process. Depending on symptoms, they'll have considered and eliminated multiple diagnoses based on careful consideration of the facts. This step also takes into consideration risks for other health issues without treatment.

Set Goals and Act

A patient's course of treatment should follow the SMART model for goal-setting. The best treatment plans are Specific, Measurable, Achievable, Realistic and Timely to support the measurement of their efficacy. This model creates a repeatable process that is effective across patient demographics and conditions.

Critical thinking in nursing produces clear goals that are essential to patient adherence to treatment. Treatment plans may include prescribed medications, therapies and visits with specialists. Nurse practitioners collaborate with their patients and colleagues on supportive frameworks for effective treatment.

Evaluate and Reflect

Follow-up appointments provide opportunities for evaluation of treatment plans. Nurse practitioners compare past and present metrics when determining improvements in patient conditions. A useful method for evaluating success is whether the following rights of clinical reasoning were applied:

• Right patient
• Right action
• Right reason

Frequent reflection on this process is essential for improvement as a nurse practitioner. Self-directed explorations of what should have been done and what could have happened in each case sharpen critical thinking skills. An understanding of what was learned in each case creates points of comparison for future patients.

Improving Your Critical Thinking

Critical thinking in nursing improves through thoughtful deliberation and frequent use. Nurse practitioners should speak with their colleagues and mentors about their applications of critical thinking. Frequent collaboration on patient care also places the focus on evidence-based care rather than personal assumptions.

Updated knowledge of nursing resources and tools makes it easier to implement critical thinking in nursing. Medical journals and continuing education courses reinforce what nurse practitioners have learned throughout their careers. Carson-Newman University provides a strong foundation for improved critical thinking through its Online MSN-FNP.

Preparing for Clinical Decisions at Carson-Newman

Carson-Newman's innovative program prepares BSN & MSN-educated nurses for future roles as family nurse practitioners (FNPs). The in-person requirements for this 100% online degree are clinical placements and a three-day campus residency. Students can complete the Online MSN-FNP in as little as 32 months.

Every course in the program is taught by an experienced nurse educator who also practices in their community. Carson-Newman reinforces the importance of critical thinking in nursing with courses on topics including:

• Advanced Health Assessment
• Advanced Pathophysiology
• Advanced Primary Care Nursing for Adults

FNP students receive full support from Carson-Newman to identify clinical placements in their communities. They also receive one-on-one guidance from Student Success Advisors throughout their time at the University. This commitment to nursing education helped Carson-Newman reach the top third of graduate nursing programs in U.S. News & World Report's rankings.

Contact an enrollment advisor today to learn how Carson-Newman can prepare you for a role as an FNP.

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Thinking Like a Nurse: The Critical Thinking Skills in the Nursing Practice

Thinking how to nurse is thinking like a nurse. Florence Nightingale (1860) wrote on her notes that women who have charge of the other’s health—to which the application of her integrated experiences must teach herself to think how to nurse, a self-learning acquired from “hints”.

Perhaps, Nightingale referred “hints” as the use of critical thinking skills in patient’s care. The ability to think critically was the foundation of nursing practice started from historic times and is becoming one of the key performance indicators for both students and nursing professionals nowadays.

Educational system continues to evolve and progresses heeding to the needs of the society, and parallel to the changing educational structure and methodology. However, Haber (2020) reported that only 75% of employers claim that the students they hire who underwent 12 or more years of formal education lack of critical thinking and problem-solving abilities despite the progress in the educational system.

What is Critical Thinking?

Critical thinking skills, a fundamental skill that plays a pivotal role in our daily survival. In general terms, the skill will not stop in memorization, the process goes beyond connecting the dots from one to concept to another, problem-solving techniques, think creatively, and apply the learned knowledge in new ways (Walden University, 2020). Kaminske (2019), defines critical thinking skills as a domain-specific skill on the ability to solve problems and make effective decisions that require expertise to be applied in a range of situations and scenarios.

In the nursing practice, Critical thinking skill works in assimilation with critical reasoning as a practice-based discipline of decision-making to the health care professionals. Critical thinking is the process of the intentional higher level of thinking to identify patient’s health care needs and appraise evidence-based practice to make choices in the delivery of care.

On the other hand, clinical reasoning as integrated to clinical thinking in application to clinical situation works as a cognitive process to utilized thinking strategies to gather and critically analyze the data concerning the health care needs of the patient, organized the information according to its prioritization, and formulate efficient nursing care plans to improve patient’s outcomes (Berman, et al., 2016).

“Critical thinking is the intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action”, a precise definition presented by Michael Scriven and Richard Paul at the Eighth Annual International Conference on Critical Thinking and Education Reform during the summer of 1987 (Lakhanigam, 2017).

Lakhanigam added the definition published by the Journal of Nursing Education in 2010 that describes critical thinking as the process involving interpretation and analysis of the problem, reasoning to find a solution, applying, and finally evaluation of the outcomes”. Regis College (2020), emphasized the use of deductive reasoning in observation, analyzing information, formulate conclusions, and performing appropriate actions in a self-directed process .

Theories on the Physiology of Thinking

From the ancient theory of “tabula rasa”, as describes in Wikipedia (2020) that humans are born without built-in mental content, and all knowledge is collected by the brain from experiences and perceptions. In this computer age, a neurologist discovered neurological pathways on how to re-program or reformat our brains like computers by analyzing how the brain appears to process, recognize, remember and transfer information at the level of neural circuits, synapses and neurotransmitters. Willis (2012) discussed the brain’s neuroplastic response to stimulation called neuroplasticity. The information is processed in the reflective and cognitive functions of prefrontal cortex wherein learning incorporated into networks of longterm conceptual memory.

Neuroplasticity is greatly affected by stress, boredom and frustration as seen in the neuroimaging scans of students showed that active metabolic states block the processing in the prefrontal cortex. In response to stress, the amygdala as the switching station became hyperactive resulting to switches of input and output away from the prefrontal cortex down to the control of the lower reactive brain, this response is called fight/flight/freeze (act out/zone out). In this situation, the lower brain’s reactive behaviours are in control. This will result in the loss of information access to the prefrontal cortex and new learning is not retained.

Elseways, Knowles (1984) four principles of andragogy of adult learning included (a.) experiences from mistakes that provide the basis for the learning activities; and (b.) the importance of problems and crisis, as adult learning is problem-centred rather than content-oriented; as well as (c.) involvement in the planning and evaluation of learning; and lastly, (d.) that adults are most interested in a subject that is relevant to their job and personal life.

Learning and thinking as applied in a higher-level context, Ausubel’s assimilation theory may recount the theories on critical thinking. In this theory, Ausubel claimed that learning occurs as a result of the interaction between the acquired learning and the cognitive structure in application to practice (Seel, 2012). Moreover, critical analysis and differentiation of interrelationships between concepts called concept mapping refines the knowledge into a more organized, precise, specific, and integrated learning.

In different circumstances, nursing as a professional working in a toxic environment of the sick, pained, hopeless, weak, and dying patients; bullying, queen bee syndrome, and seniority egoism of colleagues; and backbreaking workloads—have reported cases of work-related boredom and stress. The application of the three theories may improve mentoring-learning strategies in meaningful nursing education and training.

Theories on learning acquisition from the collection of information, physiologic processing on cognitive-reflective functions of the brain, concept mapping, and internal/external utilization of knowledge in application to critical thinking are the frameworks of a skilled critical thinker.

Characteristics of a Skilled Critical-Thinker

Health care system can go a long way, achieving a considerable success having employees that possess the ability to think critically thus decreasing errors in clinical judgments. For this purpose, every nurse is required to obtain the characteristics of an excellent skilled critical thinker.

The study of Scheffer and Rubenfeld revealed the common qualities among internationally diverse expert nurses from nine different countries supporting the idea of critical thinking in nursing that encompasses logic and reasoning (Berman, et. Al., 2016), and that includes:

11 Affective Components of a Skilled Critical-Thinker Nurse:

• Perseverance
• Open-mindedness
• Flexibility
• Inquisitiveness
• Intellectual integrity
• Perspective

7 Cognitive Skills of a Skilled Critical-Thinker Nurse:

• Information seeking
• Discriminating
• Transforming knowledge
• Applying standards
• Logical reasoning

Critical Thinking Beyond Exigency and Expediency

Undeniably, nurses with critical thinking ability diversified with effective problem-solving and efficient decision-making skills are the most in-demand and highly valued in the field of the health care industry and academe.

As a nurse striding in the most complicated, stressful and multi-tasking job, you are responsible for making life-changing decisions under the pressure of time and emotions. These reasons as to why critical thinking skills in nursing practice plays a vital role in the care of the patient. Luna (2020), cited seven importance of critical thinking skills in the practice of nursing, such as:

• Nurses’ Critical Thinking Heavily Impacts Patient Care
• It’s Vital to Recognizing Shifts in Patient Status
• It’s Integral to an Honest and Open Exchange of Ideas
• It Allows You to Ensure Patient Safety
• It Helps Nurses Find Quick Fixes and Troubleshooting
• Critical Thinking can Lead to Innovative Improvements
• It Plays a Role in Rational Decision Making

Critical thinking skill is needed in problems identification and implementation of interventions resulting in improved patients outcomes, as well as development in nursing practice by providing new insights on the learned knowledge. Feedback and reflections provide interconnections between nursing research , critical thinking and the nursing practice (Berman, et. Al., 2016).

Critical Thinking Skills: The Mastery, Update and Upgrade

Critical thinking skill is an ability beyond thinking rationally and clearly. It is a process of thinking independently and working at your own feet in formulating own opinions or new theory by utilizing critical analysis on the interrelationship of two or more ideas and delineating conclusions without external control (Wabisabi Learning, 2020).

Modified Wabisabi Learning’s 12 Solid Strategies for Teaching Critical Thinking Skills, and its Application to Nursing Education, Training and Practice:

1. Practice on Eloquence in Question and Answer (Solution Fluency)

Mastery requires ample amount of practice to become highly skilled in critical thinking. Accustom to deliberate open discussions encouraging brainstorming on issues affecting the practice and daily living by using explicit open-ended questions and comprehensive instructions for problem-solving may provide opportunities to apply knowledge into practice as well as encouraging the transfer of ideas between domains (Haber, 2020). Brainstorming is an excellent learning tool to exercise critical thinking (Walden University, 2020) particularly if applied in a situational crisis or a hospital scenario.

2. Create a Foundation

From the theory of back to basic, mastery of low-level skills is a requirement in preparatory to the application of critical thinking skills (Kaminske, 2019).

Learning experiences from theoretical and experiential knowledge are good foundations to start critical thinking. Moreover, practicing thinking skills obtained from theoretical and experiential undertakings improve intellectual ability (Berman, et. al., 2016). Practical understanding and specialization on a particular focus may excel you more in thinking critically. The competence and skills acquired from clinical experience are the most essential learning in developing clinical judgment.

3. Consult the Classics

Nursing theorists and their work are the best examples of consulting the classics. In critical thinking, nurses identify claims based on facts, conclusions, judgment/opinions and evidence-based practice. Exploring nursing theorists and their works are like exploring great minds, acquiring lessons on character motivation, refuting theories or formulating a new theory from existing theory. Case studies and in-depth objective critiques of nursing theories may not only promote critical thinking but act as a leverage to bridge the gap between theory and practice.

4. Create an Environment for Open Communication

During clinical rounds, nurses and/or students with a clinical instructor are engaged into thinking process by providing the opportunity to communicate assessment data, collaborate ideas, formulate nursing care plan, and discuss the various context of the situation from different perspectives (Di Vito-Thomas, 2005).

5. Use Information Fluency

Information fluency is mastering the proper use of information and to the ability to intuitively analyze and interpret it in unearthing knowledge and appropriate facts useful in solving a problem (Wabisabi Learning, 2020).

Knowledge of medical conditions, procedures and its connections to patient’s care are important in building critical thinking. Learning from available resources like medical journals, surfing the internet, and meaningful dialogue with colleagues can increase your medical know-how (Jillings, 2020).

6. Utilize Peer Groups

Peer groups, particularly well experienced and highly skilled colleagues are an excellent source of information, questions, and problem-solving techniques as it expands thinking and viewpoints. It also develops interpersonal skills like teamwork and resolving conflicts (Berman, et. Al., 2016).

7. Try One Sentence of Reflections at a time

Reflections will teach the learner to apply their knowledge, logic and reasoning by explaining themselves in a low-pressure setting. It provides an opportunity to explore situations with a different approach and better solutions for future use (Jillings, 2020).

The mastery of metacognition helps the learner to use reflection in defining clinical experiences and explore ways on how to improve it. Recollecting facts and events in patient’s care may integrate the learner into different concepts by connecting different ideas from one another (Di Vito-Thomas, 2005).

8. Problem-solving with Reasoning

Understanding rationale, the sets of reasons or logical basis for a course of action assist the learners to gain a broad knowledge of the topic and promotes a higher level of understanding. Problem-solving guided by rationale is a technique to the use of deductive and inductive reasoning in the thinking process (Di Vito-Thomas, 2005).

9. Roleplaying and Return Demonstration

Role-playing is a self-directed activity that encourages analytic and creative thinking. It helps the learner to internalize empathy while compromising in portraying a role or another persona creating a wider chance for memory retention.

Practice and repetition of observed procedures during return demonstration creates an avenue for re-thinking ways on how to do a task properly with ease in your own phase as you implement it by yourself.

10. Thinking and Speaking With Sketch (Concept Mapping)

Incorporating a concept with multiple perspectives and connecting complex ideas in a structured way to search for potential solutions. These processes create an abstract concept that encourages logical arguments used in critical thinking (Kaminske, 2019).

Interactive activities such as case study with a panel discussion, observing clinical dynamics during in-depth arguments, making a multidisciplinary joint care plan for patient promotes an environment for critical thinking thus facilitating the development of clinical judgment (Di Vito-Thomas, 2005).

11. Do Some Prioritizing and Decision-making

Make critical thinking as a culture and not just an activity by encouraging decision-making. Prioritizing through analyzing information, applying knowledge, and evaluating a prospected solution are the cornerstones of decision-making. This will allows the learner to apply learned theories to a different scenario by weighing the advantages and disadvantages of different solutions and option in deciding best practices.

12. Correct Misconceptions and Personal Bias

Personal beliefs greatly influence one’s ability to think critically as people always seek out ideas that conform to their own beliefs (Kaminske (2019). Several factors that act as the pitfalls in critical thinking are misconceptions, personal bias, and assumptions—which can bring a learner into a wrong direction. A discussion with colleagues who have mastery in evidence-based practice and conducting more in-depth investigations can give ideas and extends point of view (Jillings, 2020).

Conclusion and Suggestions:

Analytical skills through keen observation, understanding important data, and identifying a pattern of recognition; problem-solving capacity by connecting relationship of phenomena, data interpretation guided by significance and rationale; and use of reflection and evaluation abilities in formulating conclusion are the important factors in clinical judgment and decision-making.

Critical thinking is a learned skill resulted from a rolled-up innate curiosity in the application of strong theoretical and experiential foundations in solving clinical problems that direct to the best care decision, which produce positive patient outcomes and improve patient care services.

In this era of technological advancement where machine replaces almost of everything, critical thinking still plays an important role in the nursing practice. Nurses who can manipulate complex clinical situations with efficient skills on critical/analytical thinking, problem-solving and decision-making are often in the front line to compete for the position with greater autonomy and higher chances for opportunities.

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Critical theory and its contribution to the nursing discipline

Affiliations.

• 1 Universidad de Valparaíso, Chile, [email protected].
• 2 Universidad de Costa Rica, Costa Rica, [email protected].
• 3 Universidad de Concepción, Chile, [email protected].
• 4 Universidad de Concepción, Chile, [email protected].
• PMID: 25230045
• DOI: 10.17533/udea.iee.v32n2a18

This article reflects on the Critical theory, stemming from the most important philosophical concepts and the modifications it has endured over time. Thereafter, we expose the contribution of the Critical theory to Nursing. This emphasizes on the contextual analysis of the phenomena and it is a self-critique to prevent dogmatisms and totalitarianisms. It postulates that in order to establish a truth, we must consider the historical conditions within which said truth emerges. Jürgen Habermas, with his Theory of Communicative Action, reorients the original postulates of the Critical theory, making it more coherent from the social point of view, through the Guiding Interests of Knowledge. Nursing professionals who follow the Critical theory highlight the need to improve the description of the construction of knowledge with an emancipating and liberating purpose, which permits Nursing to provide responses to approach reality through a global and dialectic vision and from a democratic position of knowledge, construct research from the social situational reality that is part of its daily experience; everything that can be unified as a "Philosophy of Nursing Care", which should be incorporated onto the professional formation of the discipline and onto the research area.

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Reflective and critical thinking in nursing curriculum

O pensamento crítico-reflexivo nos currículos de enfermagem, el pensamiento reflexivo y crítico en los currículos de enfermería, maría antonia jiménez-gómez.

1 Universidad Nacional de Colombia, Facultad de Enfermería, Bogotá, Colombia.

Lucila Cárdenas-Becerril

2 Universidad Autónoma del Estado de México, Facultad de Enfermería, Toluca, México.

Margarita Betzabé Velásquez-Oyola

3 Universidad Nacional José Faustino Sánchez Carrión, Facultad de Medicina Humana, Huacho, Lima, Peru.

Marcela Carrillo-Pineda

4 Universidad de Antioquia, Facultad de Enfermería, Medellín, Colombia.

Leyvi Yamile Barón-Díaz

5 Universidad Nacional de Colombia, Facultad de Medicina, Bogotá, Colombia.

to evaluate the teaching of transversal competence of the Reflective and Critical Thinking that is fundamental in the decision-making and solution of nursing problems, in degree programs of public and private institutions in the Andean region.

multi-center, cross-sectional, exploratory-descriptive study, with mixed approach in 5 countries.

76 nursing programs participated in the study. The Reflective and Critical Thinking was found as a subject, subject content and didactic strategies. Of the 562 subjects reviewed, this type of thinking is found in 46% of the humanities area and 42% in the area of research and professional discipline. It is important to train teachers to achieve coherence between the pedagogical model approach, teaching strategies and evaluations.

Conclusion:

nursing programs in the Andean region contemplate the critical thinking as cognitive and personals skills of communication. They also use real situations analysis, supervised practice, simulation labs and specifically learning based in problems to develop the capacity to solve them, decision-making and develop communication skills, including analysis, synthesis and evaluation.

avaliar o ensino da competência transversal do pensamento crítico-reflexivo, fundamental na tomada de decisões e solução de problemas de enfermagem, nos programas de graduação de instituições públicas e privadas da região Andina.

Método:

estudo multicêntrico, transversal, exploratório-descritivo, com abordagem mista em cinco países.

Resultados:

76 programas de Enfermagem participaram do estudo. O pensamento crítico-reflexivo foi constatado como disciplina, conteúdo de disciplina e estratégias didáticas. Das 562 disciplinas revisadas, este tipo de pensamento se encontra em 46% da área de humanidades e 42% na área de pesquisa e profissional-disciplinar. Existe a necessidade de capacitar os docentes para obter coerência entre a proposta do modelo pedagógico, as estratégias didáticas e a avaliação.

Conclusão:

os programas de enfermagem da região Andina contemplam o pensamento crítico como habilidades cognitivas, de comunicação e pessoais. Da mesma forma, utilizam a análise de situações reais, estágio supervisionado, laboratórios de simulação e, principalmente, a aprendizagem baseada em problemas, com a finalidade de desenvolver a capacidade para solucionar problemas, tomar decisões e desenvolver habilidades comunicativas, incluindo análise, síntese e avaliação.

evaluar la enseñanza de la competencia transversal del Pensamiento Reflexivo y Crítico, fundamental en la toma de decisiones y en la solución de problemas de enfermería, en los programas de grado de instituciones públicas y privadas de la región Andina.

estudio multicéntrico, transversal, exploratorio-descriptivo, con abordaje mixto en 5 países.

76 programas de Enfermería participaron en el estudio. El Pensamiento Reflexivo y Crítico se encontró como asignatura, contenido de asignatura y estrategias didácticas. De las 562 asignaturas que han sido revisadas, este tipo de pensamiento se encuentra en el 46% del área de humanidades y el 42% en el área de investigación y profesional disciplinar. Está la necesidad de capacitar a los docentes para lograr coherencia entre el planteamiento del modelo pedagógico, las estrategias didácticas y la evaluación.

Conclusión:

los programas de enfermería de la región Andina contemplan el pensamiento crítico como habilidades cognitivas, de comunicación y personales. Asimismo, utilizan el análisis de situaciones reales, la práctica supervisada, los laboratorios de simulación y, principalmente, el aprendizaje basado en problemas, con la finalidad de desarrollar la capacidad para solucionar los problemas, tomar decisiones y desarrollar habilidades comunicativas, incluyendo el análisis, la síntesis y la evaluación.

Introduction

Globalization brought with it changes in all aspects of life: social, political, economic and cultural. Moreover, the nursing profession is evolving, so that it is increasingly moving away from the biomedical model of care, focused on the instrumental, to focus on people’s health care, with primacy of dialogue and agreements between the professional and the person under care. As part of a multiprofessional team, this requires changes in the curricular proposal and, in turn, a qualifying teacher for a new profile of graduate, whereby reflection, self-criticism and professional responsibility are developed ( 1 ) .

Therefore, it is necessary to work intensely to reduce the dichotomies that are present in nursing programs, namely: between theory-practice; training and the reality of professional practice; and the student as a passive part of the teaching-learning process and the professional who is required, active, proactive, creative, analytical, with contextual perspective, flexible, with logical thinking, able to carry out a permanent and continuous search for information, able to contribute with his profession to the solution of health problems.

The General Conference of the United Nations Educational, Scientific and Cultural Organization (UNESCO), at its 38th session, held in Paris from 3 to 18 November 2015, “Recommendation about Adult Learning and Education” states in one of its objectives the need to develop people’s capacity to think critically and to act with autonomy and a sense of responsibility ( 2 ) .

Critical thinking (CT) is a process and a learning outcome ( 3 - 4 ) and the clinical judgment is the result of this process. The development of the clinical judgment (clinical reasoning skills) is one of the most important and challenging tasks of being a nurse. Clinical reasoning precedes clinical judgment and the decision-making that is important in professional and personal life.

In order to achieve professionals with reflective and critical thinking (RACT), it is necessary to make deep changes in the educational dynamics, in the teaching and student roles, in the use of pedagogy and didactics to transmit knowledge, the curricular structure, the strategies of teaching-learning. These changes are expected to be centered on the student, who must actively participate in the learning process in order to achieve greater development of his or her capacities for reasoning, self-learning, self-evaluation, self-management and self-regulation. Likewise, it is expected that teachers to be critical and creative, attending to individual ways of learning, encouraging the development of good thinking in the student ( 3 ) .

Literature points out that critical thinking is the “essential foundation for education, since it is the basis for adaptation to the individual, social and professional demands of daily life in the 21st century and beyond” ( 4 ) . The world changes fast and new realities arise, so there is a fundamental need of people to develop capabilities that allow them to respond and adapt themselves to these changes.

Critical thinking is “the process of seeking, obtaining, evaluating, analyzing, synthesizing and conceptualizing information as a guide, to develop self-conscious thinking and the ability to use this information by adding creativity and taking risks” ( 4 ) .

Authors pointed out one of the first definitions of critical thinking: “knowledge, skills and attitudes” ( 5 ) and, since the end of 1980, various strategies for its teaching have been discussed at all school levels ( 4 ) . On the other hand, authors point out the importance of generating opportunities to develop RACT in students. Therefore, some authors emphasize the importance of developing it in all health situations in favor of the patient ( 4 , 6 - 7 ) . The nursing professional developing RACT will know where, when and how to use their knowledge, skills, values and attitudes.

The motivation for nurse training in the Andean region became evident in the 1960s. In particular, Colombia generated the first degree program in 1958, which was approved in 1961. In the same period, Venezuela, Ecuador, and Peru initiated undergraduate programs; in the case of Bolivia, it happened only until 1970 ( 8 ) .

The 1980s were marked by the rise of postgraduate programs, increased development of research and the generation of knowledge. The 1990s saw a boom in graduate, specialization, masters, and doctoral programs, the latter especially in education. However, there were also more options for the qualification of nursing professionals for the teaching role. On the other hand, the Higher Education Quality Assurance System ( Sistema de Aseguramiento de la Calidad de la Educación Superior ) was implemented, as well as the Accreditation of the programs and the own regulations or nursing law emerged in each country of the region.

The first decade of the 21st century brought the development of the highest level of nursing education, the doctorate, and, with it, the generation of nursing knowledge in the region and its progress towards consolidation as a discipline ( 8 ) .

Throughout this journey, there was a permanent motivation for balance and congruence between the graduation profiles and the reality of the job, based on the permanent motivation for the adaptation of the curriculum, the teaching-learning strategies, the evaluation processes, and the teacher qualification to respond to this constantly changing context.

The literature ( 9 - 11 ) shows the need to expand the research in the area of education, to achieve greater development of research and to work in education and nursing policies and practices. On the other hand, the latter shows the need to implement and evaluate pedagogical and didactic strategies that help the student to develop a critical judgment, justified decision making, comprehensive memory and communicative competence ( 11 ) .

For its part, the Ibero-American Network for Research in Nursing Education ( Red Iberoamericana de Investigación en Educación en Enfermería - RIIEE), in 2011, identified as a research priority, “The development of RACT in nursing students”, within the tree of the problems detected in its research line Higher Education and Nursing. For the development of this research purpose, the Network suggested a multicenter macroproject with the theme “Strategies to develop the RACT in nursing students: situation in Latin America”. In fact, the conceptual paradigm refers to “critical theory and constructivism, since RACT is an analytical, cyclical, broad and systematic process, but not rigid; its analysis and interpretation allows to have elements for decision-making, as well as to make informed choices” ( 8 - 12 ) .

The project involves five of the six regions that make up the RIIEE: the Andean region (Bolivia, Colombia, Ecuador, Peru and Venezuela), Brazil, the Southern Cone, Europe, and Mexico and the Caribbean. The investigation is planned in three stages: 1. Diagnose; 2. Planning and implementation of interventions; and 3. Evaluation. The diagnostic stage includes: 1. The state of the art on scientific production in RACT and teaching strategies for its development; 2. Characterization of educational strategies for teaching the RACT collected in nursing literature; 3. To determine the development of the RACT competence in the different nursing curriculum; 4. To identify the educational strategies used by teachers to develop the competence of reflective critical thinking in nursing students; 5. To identify levels of critical thinking in nursing students according to the classification of Paul and Elder (unreflective thinker - master thinker). Objectives 4 and 5 are currently being developed.

The analysis of the “Scientific Production in RACT in Nursing in 1990-2012 in Ibero-America” produced among others the following conclusion: the formation of a critical reader and the investigative process are strategies that help university students to be critical and autonomous and to access more critically to the knowledge of the disciplinary area. For this, teachers are required to make of each moment and situation in the teaching-learning relationship an open forum for reflection, debate, questioning and contrasting of the different perspectives around the area of professional training and society’s problems ( 8 ) .

After reviewing the literature on the web of science by using the descriptors critical thinking and nursing, education and curriculum, it was not possible to find studies that analyzed the presence of RACT in the curriculum of nursing degree programs. However, it is very striking the motivation to analyze the importance of its development and studies that demonstrate its value, as well as the use of different and combined teaching-learning strategies to achieve the formation of RACT in nursing students.

This study was done with the purpose of to evaluate the teaching of transversal competence of the Reflective and Critical Thinking that is fundamental in the decision-making and solution of nursing problems, in degree programs of public and private institutions in the Andean region.

The coordinating group of RIIEE developed the research project from which the research groups of each country and region of the Network were made up, integrated by members of the Network and researchers in education and nursing, who are also teachers in Higher Education Institutions (HEI), and mostly with PhD academic level. The HEI in Nursing (HEIN) were identified through the Ministries of Education, the Associations of Schools and Universities of Nursing of each country and the Latin American Association of Schools and Universities of Nursing ( Asociación Latinoamericana de Escuelas y Facultades de Enfermería - ALADEFE).

The project was benefited from the Declaration of Helsinki (Ethical principles for medical research on human subjects) and the current ethics legislation in each country, was approved by the Ethics Committee of the University of Antioquia, Colombia, by Act No. CEI-FE 2015-25 on July 31, 2015. The respect for privacy and confidentiality were ensured to each Program Director, with the informed consent signed by each participant. The project was also sent to them and their understanding was guaranteed. In turn, we conceded the right to choose what information they wanted to share. Confidentiality was maintained by institutional coding. Finally, was given a deadline of 15 days to obtain the response of acceptance to participate.

The target population of this research were 187 undergraduate nursing programs in the Andean region: Bolivia (47), Colombia (47), Ecuador (21), Peru (62) and Venezuela (10). We considered only the nursing curriculum of the HEI, recognized by the Associations of Schools and Colleges of Nursing of each country or its counterpart, regardless of whether they were public or private. Resulting in the nursing curriculum of 76 Institutions that correspond to the 40.64% HEIN that teach undergraduate nursing in the Andean region: Bolivia (7), Colombia (38), Ecuador (11), Peru (14), and Venezuela (6). Due to the difficulty in obtaining the information, we checked web pages, contacted HEIN members, made contacts by telephone, in some cases, we made personal visits and, finally, the complete program was requested in PDF format for the complete the instrument of the research group. In addition, the HEIN did not refused to participate, but some institutions did not respond to the invitation. The result of this process: 30 institutions accepted to participate and provided the complete information, and out of 46 partial results were obtained. An HEIN database of the names, telephone numbers and e-mail addresses of the authorities in charge of managing the programs was created in order to follow up on their responses.

After identifying, during 2011 and 2012, the theoretical and conceptual framework of RACT from different authors and different perspectives (education, pedagogy, psychology and nursing), despite the abundance of literature about the subject, we concluded that the concept is very unclear from a nursing point of view ( 13 - 14 ) .

However, it was necessary to establish a concept that was accepted by the research group of the Network, that allowed to determine a starting point or consensus to carry out this work and, without detriment to seek some level of fidelity to the multiple approaches of the scholars of this research object, that was understandable for the group and reflected what was intended to be done in its research phases and stages.

The Network took as a theoretical framework the approaches made by Paul ( 15 ) and Paul; Elder ( 16 ) , the elements of the CT and the attitudes of the Critical Thinker proposed by these authors. With the material analyzed, RIIEE constructed the following concept: “Reflective and critical thinking is a complex, systematic and deliberate process of reasoning, self-directed and action-oriented. It is primary purpose to choose, based on intellectual and affective processes (cognitive, experiential and intuitive), the best response options that favor the solution of nursing problems, in well-defined contexts and in accordance with the ethical postulates of the profession that allow it to act with rationality and professional autonomy” ( 8 ) .

The research process included the conceptual and theoretical analysis of the curriculum, the updating of the context of research development in nursing education in each country of the region, the characterization of the HEIN and, finally, the results of the state of the art on teaching strategies for the development of the RACT 1990-2012, Andean region.

Once the exhaustive bibliographic review was carried out, the instrument was designed based on the concept of Stenhouse ( 17 ) , the curriculum as a macro concept that encompasses the socializing function of the school is at the same time pedagogical ideas, structure of contents in a particular form, precision of them, reflection of educational aspirations more difficult to translate in concrete terms and skills to promote in the students ( 16 ) . In Posner ( 18 ) , who raised the great number of phenomena involved in the curriculum; Gimeno-Sacristán; Pérez-Gómez ( 19 ) , there is five categories in which the definitions of curriculum can be articulated: as an organized knowledge structure, production technology system, instructional plan, set of learning experiences and problems solution.

Based on the aforementioned, the specific instrument for this investigation was constructed with three parts. The first with 10 items, with general information from the HEI or University. Each University is subdivided into Centers that are parted into Colleges and these are divided into programs: name, geographic location, type of institution, accreditation data, mission, vision, objectives, curricular guidelines for degree programs, web page, and data about who completed the instrument. The second, 28 items, for the College, School, Department or Nursing Program (typology to identify HEIN in the region), with the following subsections: general aspects of the nursing program, character within the institution, number of sites where the program is offered, accreditation data (date, resolution, and time of accreditation), program justification, mission, vision and objectives of the program, evaluation process, graduation profile, pedagogical model, number of hours and credits, curricular structure (nursing program subjects that correspond to each area or component). Finally, the general characteristics of the teachers: kind of affiliation with the institution, time worked, and maximum educational level achieved. The third, 9 items, for specific information about each of the subjects: name, component or area to which it belongs, number of hours and credits, type of subject (theoretical, practical and theoretical-practical), contents, teaching-learning methodologies and evaluation process.

The members of the research group carried out an analysis of the validity of the content of the instrument. Afterwards, the pilot test was conducted, starting with its implementation in each of the HEI in which the researchers worked; the results were analyzed and the corresponding adjustments were made in its structure. Subsequently, the adjusted instrument was tested with five members from the region, one from each country, but different from the research group. Because of this test, we decided to design a guide to facilitate the completion of the instrument and ensure objectivity in the collection of information, because of the language differences. It is possible to obtain the final version of the instrument from the authors of the project.

Each participant received the letter of invitation, the project, the informed consent, the instrument to collect the information and the corresponding guide for its completion in hands and by e-mail.

The information obtained was reviewed and, in some cases, it was necessary to request the complementation of some aspects of the instrument. Then we proceeded to codify the HEI or Universities and the HEIN. The information was included in Excel tables designed with the predetermined categories and subcategories, which were later incorporated into the SPSS statistical analysis program, version 19. The information was processed using descriptive statistics, with frequency distributions and average analysis, and analyzed by institution, by country and as an Andean region, according to the categories and subcategories determined, allowing comparisons between countries and conclusions to be drawn as a region.

The analysis of the information was carried out using the deductive-inductive method, considering the objectives of the project and the revised conceptual theoretical framework, with the aim of determining the presence of the RACT, explicit and implicit, in each categories, the coherence of the approaches between University-College-Program, the coherence between the objectives, contents, teaching-learning strategies and the evaluation process in each subject. In this sense, we analyzed the linearity or coherence with respect to what was proposed, developed and evaluated in relation to the RACT and, finally, the contradictions and inconsistencies found in the aforementioned approaches were pointed out. We considered national and international studies about the subject for the analysis and discussion of the results obtained, in addition to the documents mentioned above.

According to the information obtained by the research group, the Andean region has 2,552 HEI; 410 with character of universities and 160 are public, 220 are private and 14 are in special regime. There are 167 universities with nursing programs, 146 affiliated and recognized by the respective Associations of Schools and Colleges of Nursing in each country. The number of accredited nursing programs in the Andean region is 43: Colombia (20), Peru (20) and Bolivia (3). Precisely, of the 20 accredited institutions in Colombia, 11 already have their certifications renewed, which are of 8, 6 and 4 years; 5 and 6 years for Ecuador and 3 years for Peru. Bolivia is just beginning the process and Venezuela has no information about it.

The total population of HEIN by country was Bolivia 47, Colombia 42, Ecuador 21, Peru 62 and Venezuela 10. A total of 76 HEIN answered: Bolivia 7; Colombia 38; Ecuador 11; Peru 14 and Venezuela, 6. These institutions constituted the sample of the study.

Twenty-one of these institutions are certified: in Colombia 20 and in Bolivia 1; 12 did not include this information and 41 were not yet certificated. Of the total number of institutions that provided the information, 47 are public, 26 private and three do not know the information. Administratively, 36 are programs; 22 Colleges; 21 Schools and one Department.

The number of hours and credits of the programs showed considerable heterogeneity: the average number of hours was 5,552.3, corresponding on average to 232.11 credits. Regarding the number of hours per credit, the lowest is in Peru, which has 13 hours per credit, and the highest is in Colombia, with 48 hours corresponding to one credit. There are institutions that do not work with credits, especially in Bolivia; others did not included this information, among them Ecuador and Venezuela.

The main characteristics of the 912 teachers developing nursing programs in the Andean region are: 501 (54.9%) with a Specialist degree; 634 (69.51%) with a Master’s degree and 58 (6.35%) with a PhD; 249 (27.3%) with a postgraduate degree in Education.

From a general perspective, it should be noted that of the five countries in the region only Venezuela and Peru explicitly present the RACT in their Organic Law (OL) or Higher Education Law in terms of integral and permanent formation of reflective critical citizens (LOE, 2009, or Organic Law of Education, in Venezuela) ( 20 ) and (Law 30220, 2014, or University Law, in Peru) ( 21 ) .

The results of RACT’s presence are presented below: Universities or HEI; in Colleges, Programs, Schools and Departments, that is, in HEIN; and in the subjects.

When analyzing the information of the Universities or HEI, we found the RACT as direct mention, indirect mention and evidence of traditional positions was found. Directly, it was found as a training purpose in Bolivia, Colombia and Peru: receptor and analytical constructor, with critical conscience; as methodology to achieve it, in Colombia and Peru: “ promoting reasoning, the CT and creative”; as a result of learning in Ecuador and Venezuela: capable of solving problems, CT promoter.

The indirect mention was found as result in the five countries of the Region, as a strategy in Bolivia, Ecuador, Peru and Venezuela: integral formation, relation practical theory; and as objective in Colombia: future graduates with ethical conscience, autonomy, democratic spirit and highly qualified.

There are still traditional postures: teaching, evaluation as a final product, training in instrumental action, the educational process as providing knowledge.

By going a little deeper into the HEI, we found that 88% (38) consider the RACT: 63% (27) in the mission; 7% (3) in the vision; 51% (22) in the objectives and 30% (13) in the curricular guidelines. Among these, three defining categories were identified. The first, as a training purpose: prepare professionals and leaders with CT and social conscience . The second, as a methodological strategy to achieve its development: to develop and implement pedagogical methods that encourage reasoning, CT and creativity, and that encourage habits of discipline and productive work . And the third, as a result of the formation process that includes the subject: Training of critical, self-managed, creative and proactive men and women; and, moreover, refers to the projection and utility: with the promotion of CT and the generation of knowledge, thanks to the strengthening of critical analysis, anticipation and vision of the future and development of viable alternatives to the problems.

At HEIN, RACT is expressed in the graduation profile, objectives, curricular guidelines and mission. Table 1 shows the data summarized in relation to the number and percentage in which the RACT is presented in the subcategories and with regard to the total. The information recovered allows us to identify that the RACT ranks first with 38.3% in the graduation profile, followed by 35% both in the curricular guidelines and in the objectives; thirdly, is in the mission, 26.7%, and finally, with 11.7% it is in the vision. Bolivia has the highest percentage of presence in its curricular guidelines, followed by Colombia in its graduation profile, objectives, and mission, while Venezuela is in one before the last place with a 28% of presence in its mission and is not present in the profile or in the curricular guidelines. Peru has the last place and presents it only in the objectives of the programs.

In a cross-sectional view of what is proposed by curricular programs, three categories were identified to be highlighted. The first, the development of cognitive and personal skills, expressed as the training of professionals with scientific, technical, critical, analytical and reflective knowledge, as well as communication, oral and written expression skills; and referred to a critical, creative, participative, supportive, innovative and sensitive attitude towards social change.

The second, the way in which its development could be achieved, among which the research stands out: promote and develop research, generating knowledge in the different areas of nursing that contribute to universal science and the solution of health problems; and the use of technologies: learns permanently developing the capacity of abstraction, analysis, synthesis and using information technologies . The third, its finality, related to the ability of individuals, families and community groups to interfere and make decisions in the solution of health problems, to provide comprehensive care with the capacity to solve health problems in changing and emerging environments.

Concerning the pedagogical models expressed in the HEIN, a variety was found in the denomination. First of all, the constructivist approaches are highlighted in eight (8) Institutions, with some connotations as the model social-critical-constructivist and second, the cognitive - humanistic in four (4). Other models or approaches were also identified, among them: dialectic, technological, psychological, the problematic schools, the Active, Reflective, Dialectic, Innovative and Critical . Finally one institution works with the model based on the pillars of education , in which learning to know, learning to do, learning to be and learning to live together, which includes, educating for life, educating for life, educating for work, educating in society and for society ( 22 ) .

The RACT in the subjects of the programs of Nursing in the Andean region

Only 29 of the 76 HEIN participants in the study were able to obtain information on subjects (38.15%), and 22 (75.86%) of these in nursing programs, RACT was present in different elements of the subjects. 562 subjects were reviewed, 159 (29%) of which have no information about teaching strategies or evaluation. Moreover, some programs record the same teaching and assessment strategies for all subjects in the program, 45 (8%).

Table 2 presents the results by subcategory and the total presence of RACT in the different groups of subjects, basic area or foundation subjects (which introduce and contextualize the student in the field of knowledge), Research, Humanities (the study of the behavior, conditions and performance of the human being), disciplinary professional area (gives the basic grammar of the profession and discipline) and those of the flexible area (the student chooses them according to personal interests, allow to the learner to approach, contextualize and study in depth aspects of the profession and discipline, allowing to learn tools and other kinds of knowledge, leading to develop interdisciplinarity, flexibility and diversity).

The information provided makes it possible to indicate RACT as a subject: Workshop of Critical Thinking and Introduction to CT ; second, as a subject content: CT in Nursing, and, third, RACT is evidenced in teaching-learning strategies.

The highest percentage of subjects in which RACT is evident correspond to the area of humanities, with 46% (55), in which analysis of real situations, group work, concept maps, role playing and seminars are predominant.

In second place, it is in the professional-disciplinary area with 42% (307) subjects with the predominance of the following strategies: supervised clinical practice, clinical case, problem-based learning, simulation laboratories, and the nursing process. The research is in the same place, 42% (41) subjects. The most commonly used strategies are: critical discussions of research reports and articles, project development, workshops, and problem-based learning.

In the last place, subjects from the basic or foundation area 144 (24%). Including discussion workshops, concept maps and case studies.

A great variety of strategies have been identified, among them are: presentation and discussion of clinical case, group work, clinical practice, flipchart, observation guides, debates, discussion about specific topics, resolution of case studies, support of the nursing care plan, investigative reports , workshop development.

What is evaluated: the development of competencies, the acquisition of skills, the development of superior cognitive processes, the professional spirit and the development of processes and independence.

Finally, in some of the subjects, the intentionality of the evaluation of the RACT is explicitly presented: written works about the topics of each seminar in which the proper handling of the bibliography is evidenced, the capacity for criticism, analysis and synthesis, evidence of problem solving, case analysis and Nursing Based in Evidences , didactic relationship analysis and fundamental elements of the RACT, conceptual knowledge, written and oral reflections, group work, practical reflections and group discussions.

It is evident that traditional evaluation techniques still exist: evaluating procedural aspects, dexterity, motivation and initiative in the procedures, memory evaluation, participation in class, oral and written interventions and, finally, the replication of the topics studied in classes.

Therefore, the analyzed programs show interest in including as an important element in their future graduates the development of the RACT. This aspect is vanishing in the development of the subjects. It is evident in the pedagogical strategies, but it is lost until disappearing in most of the evaluative processes.

The analysis results of the plans and programs of the HEI and HEIN allow to conclude that the proposes of the Law of Higher Education to develop the RACT in the students does not guarantee that it is included in the subjects and evaluations.

What is stated in HEI and HEIN allows us to infer that epistemological and theoretical contradictions are present in the Institutions and among them. It makes necessary an epistemological, theoretical and methodological consideration in order to achieve alignment and coherence between the purposes in the curricular guidelines and what is programmed in the curricular plans for the concrete work with the students. This matter goes against comprehensive training, since it is demonstrated that critical and reflective skills contribute to train professionals with greater ability to care for patients ( 23 ) .

It should be noted that it is the University or HEI that determines the philosophical bases that will guide the academic units that compose it, so that they, in turn, incorporate these principles into their academic programs. The results show that there is no linearity between the proposals of the university with respect to its mission, vision, objectives, graduation profile, curricular guidelines, and what is proposed in the nursing degree programs. There is more linearity in Institutions with a longer trajectory and development, private and public ones.

The analysis of the areas in which the subjects are grouped made it possible to identify that the subjects of the humanities area have the highest percentage of presence of the RACT. This result can be explained by the strategies used, but even more by the subjects under study, since it has been demonstrated that the teaching-learning strategies based on the humanities have a significant impact on the development of skills such as clinical reasoning ( 24 ) . The subjects in the professional area use strategies such as case study, supervised clinical practice and other relatively new ones as problem-based learning and simulation laboratories. Strategies that, by involving simulation or potential practical actions, contribute to enhance critical skills and make decisions that lead to the future professional committing fewer errors during the care of patients ( 25 - 26 ) .

By contrast, it is not the same with the subjects of the foundation or basic area in which it is necessary to return to some knowledge aspects that already exists, such as anatomy, physiology, anthropology, psychology, statistics, among many others. For some students these topics are very difficult and involve, on several occasions, an excellent dose of memory. However, the teaching strategies that develop the RACT are not so frequent. It is important doing more research on this point to sustain if it is true.

On the other hand, for the majority of HEIN, training is conceived as qualification and progress achieved by people and as a principle of theories, concepts, methods, models, strategies and courses of pedagogical action that aim to understand and qualify the teaching. In some cases, the transfer of knowledge is approached, but it still underlies the concept of learning as acquisition of knowledge built and finished; the teacher is the one who has the knowledge and the student is who learns what teacher knows.

The curricula of the Andean region include explicit elements that contribute to the development of the RACT, such as reading, writing and reasoning, allowing to the future professional to know how to learn, reason, think creatively, generate and evaluate ideas, make decisions and solve problems ( 24 ) . It includes as proposals the development of social skills, with emphasis on oral and written communication, cognitive skills including problem solving, establish different alternatives, understand the consequences of actions, make decisions and critical thinking ( 16 ) . Also, intend to achieve in the student some characteristics of the critical thinker like to be creative, innovative, proactive, analytical, participatory, entrepreneurial, self-critical, supportive, humanistic, ethical and scientific ( 27 ) .

Regarding the pedagogical models proposed by the HEIN, inconsistencies between the approach of constructivist approach and meaningful learning are evident. The axis is the student and the repetitive approach in the subjects with master class methodology, reading guides and analysis made by teacher, but not by the student. It shows a traditional model centered on the teacher, with an emphasis on memory, comprehension and the application of concepts. Some subjects focus learning on the acquisition of concepts, despite using the integrating project as a teaching-learning strategy, workshops and practice as evaluation. The pretense for the development of the RACT is not in line with the evaluation, with the examination, in the application of contents, since it is centralized in aspects of memory and knowledge, in an asymmetric theory-practice relationship.

Although significant learning is intended and the importance of integrating it into the formation of learning approaches with the intention of promoting critical thinking, added with successful learning experiences ( 28 ) , it is not really concrete how it could be achieved. Strategies such as simple repetition and teaching for the acquisition of concepts show the persistence of the traditional educational models.

This study found there is no a clear structure to operationalize the theories of the proposed pedagogical models, even though there are expressions that point to RACT. Thus, the elements important for its development are presented in the teaching and learning strategies in a more remarkable way.

The curricular guidelines express the intention to transcend technical rationality and behavioral objectives ( 29 ) , from the positivist, rationalist or empirical analyst paradigm, to the humanist and critical curriculum ( 30 ) to the socio-critical paradigm and critical thinking based on hermeneutic processes ( 31 ) . The social and contextual (political, economic and cultural) aspects that influence and determine the health behaviors of the people are still incipient in the curricula ( 32 ) .

According to what has been demonstrated, it is possible to state that there is no predominance of a pedagogical model, but a mixture of several models in the same program with varied influences. The presence of the following models was identified: Traditional Pedagogical, Behavioral, Cognitive, and Social Pedagogical, the latter being very tenuous ( 33 ) .

There are four fundamental elements to forming critical thinkers: first, the question; second, the creation of continuous opportunities to participate in dialogue, debate, research, and critique; third, self-evaluation and hetero-evaluation; and fourth, teachers as models of critical thinkers ( 32 ) . Considering these elements, we can assure that the creation of opportunities is present with more intensity in some curricula, and self-evaluation and hetero-evaluation have begun to be implemented especially in public institutions.

Mentioning the subjects, it is not evident that the thought is motivated by complex kind of questions that encourage exploration, generate evaluation, create concepts and knowledge ( 33 ) .

The literature points out that the Socratic questions stimulate the student to use existing knowledge, since they promote a greater understanding and integration of new knowledge, they foment the habit of thinking critically ( 8 , 34 ) . Other authors suggest, for the reports, questions about the purpose, information, concepts, assumptions, implications, points of view and the questions, as elements that favor analysis, the evaluation of ideas and reasoning ( 24 , 35 ) .

Like other researches, this study found that the most used strategies in the progress of the professional area that promote the development of RACT are the case study ( 24 , 36 ) , problem-based learning ( 24 ) , supervised clinical practice ( 37 ) , the nursing process ( 4 , 38 ) and simulation laboratories ( 34 , 37 - 38 ) . In this article, we only refer to two of these strategies, which were selected because of the great advance of information and communications technologies. The growing need to access this kind of infrastructure as a fundamental part in the training of future professionals and as an example of a single teaching and learning strategy is not sufficient to achieve the RACT, rather, the use of different techniques enhance its development, as we will see below.

We agree with the conclusion of authors who suggest that Problem-Based Learning and simulation labs are active strategies that develop RACT in nursing students ( 37 ) .

The case study, moreover, promotes active learning, helps to solve clinical problems, promotes the development of critical thinking skills ( 34 - 35 ) , in addition, it allows to integrate knowledge, to think as a professional, to analyze individual situations in specific contexts from different angles, to use theoretical concepts in the delimitation of a concrete problem ( 36 ) . It also stimulates collaborative and team work, the work with different points of view. The question-problem is the motivator in the search for alternative solutions, is useful in simple and complex situations, allows to apply theory in practice, promotes the exchange of ideas, teaches students to learn to control their own thinking and promote the exchange of ideas and intellect ( 37 ) . In addition, it helps to incorporate time management and take responsibility. It also facilitates the integration of the four elements of the Nursing metaparadigm: the person receiving the care, health as purpose, the nature of the nursing and the context or environment.

The case study allows the simultaneous implementation of other strategies that further enhance the development of RACT, such as concept maps, the analysis and selection of scientific evidence, the nursing process, nursing history, role-playing, argued discussion and debate.

In contradiction to all the positive aspects of the case study in the development of RACT, the dichotomy between theory and practice in a large number of the curricula reviewed is an obstacle to achieving all the benefits pointed out. Since some teachers are in charge of the development of the theoretical subject in the classroom, others are in charge of their practical part in other spaces that require this care.

Regarding the practice based on simulation models, a study ( 38 ) shows how the promotion of RACT is relevant. In this connection, it highlights the importance of including simulation as a key element in curricula, because it ensures skills in this kind of thinking ( 38 ) and gives students the opportunity to show their ability in decision-making, critical thinking and other skills ( 39 ) . Other authors emphasize its importance when students reflect it on their thinking process and show how it guided their actions ( 34 ) .

There is efficiency of simulation laboratories when accompanied by active strategies, such as the conceptual map before each laboratory session, a visual aid that allows the concepts, objectives, justification, expected results and possible complications to be described in a logical manner if the procedure is not carried out in the appropriate manner ( 34 ) . The same author suggests the use of high-level questions to stimulate reason more than memory. He also suggests assigning an observer, who will ensure analysis and reflection on patient safety, communication, teamwork and leadership, among others ( 34 ) . The reflection of the group around the whole process carried out will be the end of the laboratory ( 15 , 34 ) .

Another study concluded that simulation as a pedagogical method allows students to recognize, interpret and integrate new information with previous knowledge in order to make decisions about the best direction to follow. The authors state that simulation, as an educational method, provides an opportunity to systematically structure learning to help students acquire deep content knowledge and to facilitate the development of thought processes; that simulation experiences stimulate students’ RACT skills and help them become more competent in caring for patients in complex conditions ( 37 ) .

We agree with what has been found in other studies emphasizing that simulation laboratories by themselves do not guarantee the development of RACT skills, but if combined with other strategies and implemented with adequate pedagogy, the results will be much more effective in terms of CT skills ( 34 , 37 - 38 ) .

It is also possible to find correspondence with that was discovered in the State of the Art of scientific production in RACT in the Andean region. The students perceive that “Clinical simulation is a valuable strategy for the acquisition, complementation and integration of the theoretical part with the practical part, because it seeks to make decisions according to the CT” ( 38 ) .

The evaluation of the subjects is cumulative and formative. In some cases, a diagnosis of the level of the student’s participation in the subject is made; it is evaluated in the intermediate and at the end with the objective of promotion to another level. In other cases, a teaching-learning balance is done to verify the fulfillment of the objectives and competences. Self-evaluation and heteroevaluation are increasingly used, implying a process of reflection, analysis and self-criticism.

Precisely, evaluation appears as one of the weakest points when analyzing the presence of RACT in curricula. Therefore, we agree that the “best teaching practice begins by establishing learning outcomes and continues with a focus on helping the student to achieve satisfactory results”. If the proposal is to achieve a higher order thinking, the evaluation will be oriented towards the synthesis, analysis and evaluation of knowledge ( 40 ) .

Overall, the strong approaches to RACT training formulated at HEI, HEIN, as evidenced by some of the teaching and learning strategies presented in the subjects, become much weaker in the evaluation process, with predominance of traditional evaluation models, and in some cases, the intention to evaluate RACT is outlined.

The curricula of Colleges and Schools of Nursing in the Andean region explicitly contemplate reflective and critical thinking in their mission, vision, objectives, graduation profile and didactic strategies, and implicitly as integral formation. However, there is a tension between what is proposed by the HEI and HEIN and what is implemented and evaluated in the subjects. The presence of RACT in the proposed didactic strategies is much more evident, but it is not sufficiently objective or explicit in the evaluation processes.

Despite the great diversity of pedagogical models, there is a clear intention to facilitate the development of RACT. In addition, although a constructivist model is proposed centered on the student, dialogical, active, reflexive, innovative and critical, this model is more centered on the teacher than on the student; on knowledge over a relationship between equals; more on results than on the learning process. Likewise, knowledge is considered as something finished, fixed and the ultimate truth.

In order to be able to teach the RACT to the nursing student it is necessary to include it in the nursing curriculum, teachers who are professionals in the areas of Education and Nursing and with RACT in their training. Teachers should create spaces for the development of RACT, know and implement the different and complementary didactic strategies that facilitate its learning and that analyze the students in relation to the level of RACT achieved.

The authors of this article suggest that the projects currently developed with teachers and students in Ibero-America should be finalized and retaken with the implementation and evaluation of strategies that value the development of RACT.

RACT is considered an indispensable element in personal and professional development, in order to have autonomy, confidence, the ability to make decisions, reach clinical judgment and, the most important, provide individualized, comprehensive and human nursing care. In summary, graduates should be able to work as members of the health team with sufficient clarity of the role and identity they should have, because they have to integrate and experience the four paradigms of the Nursing.

The limitations of the study are

The complexity of the project due to the number of participating countries and the different research groups;

The large number of public and private nursing schools and colleges in the Andean region;

The limitation in accessibility to the complete information of the curricula of each institution;

The minimal presence of information on the official web pages of each institution, school or nursing college;

No response and lack of interest from different schools and nursing colleges, public and private, to participate of this project;

Limited access of current and recent updates of the curricula of nursing colleges to develop this project.

The research group made efforts to reduce these limitations and devised multiple options that were proposed to the institutions, in order to facilitate the provision of information and its complementation when necessary.

Applications for practice

The innovation and contributions expected with this research are based fundamentally on documenting and analyzing of the diverse existing evidences about if RACT is contemplated in the nursing curricula or not, the strategies used by teachers to create and promote it in nursing students and the evaluation processes employed. It provides insights about how RACT’s competence in nursing is addressed in the context of the Andean region and other regions of Ibero-America, its weaknesses and strengths, as well as the improvements that can be made. The final intention of the research is to offer, as a network and collegial body, proposals for teaching, learning and evaluation that will enable the empowerment of new generations of nurses, using RACT as a center of innovation and development.