developing critical thinking among nursing students

• Open access
• Published: 03 February 2023

The mediating effect of critical thinking between interest in learning and caring among nursing students: a cross-sectional study

• Lai Kun Tong 1 ,
• Mio Leng Au 1 ,
• Yue Yi Li 1 ,
• Wai I. Ng 1 &
• Si Chen Wang 1  

BMC Nursing volume  22 , Article number:  30 ( 2023 ) Cite this article

2825 Accesses

3 Citations

1 Altmetric

Metrics details

Previous studies have explored the influence of interest in learning on caring and critical thinking, as well as the relationship between caring and critical thinking. However, the mediating effect of critical thinking in interest learning and caring among nursing students has not been clarified.

Nursing students who enrolled for the 2021/2022 academic year in diploma, undergraduate, or graduate programs in five provinces of China (Guangdong, Sichuan, Jiangsu, Hunan and Macao). An online survey with a convenience sampling method was employed to collect data. The questionnaires were administered to 692 participants between January 20 and 26, 2022. Amos 26.0 was employed to establish the structural equation modelling and analyze the mediating effect of critical thinking on interest in learning and caring.

The first regression equation showed that interest in learning significantly influenced caring (β = 0.339, p  <  0.001). The third regression equation showed that critical thinking significantly influenced caring (β = 0.494, p  <  0.001). The effect of interest in learning on caring was less in the third equation than in the first equation (β = 0.154 vs β = 0.339), which indicates partial mediation. Furthermore, interest in learning had an indirect positive effect (β = 0.186, p  <  0.001) on caring mediated by critical thinking, with 95% confidence interval of 0.142 to 0.233.

Conclusions

Critical thinking was a significant mediator of the relationship between interest in learning and caring. It is suggested that nursing colleges and instructors should take into account students’ interest in learning and critical thinking as potential intervention elements to enhance caring.

Peer Review reports

Nursing students must possess highly specialized competencies to accurately assess the state of patients and cope with potential problems. The requirements for nursing students vary from region to region, but there are some commonalities, as caring and critical thinking were identified as essential competencies [ 1 ]. Caring is the core of nursing practice, caring behavior varies in different societies and cultures [ 2 ]. Caring in nursing involves respect, support, and meeting patients’ needs [ 3 ]. The implementation of caring in clinical practice can not only benefit patients’ physical and mental health [ 4 ], but also improve nurse-patient relationships and enhance patients’ satisfaction [ 5 ]. Nurses who are trained in caring display greater problem-solving skills [ 6 ], are more satisfied in their jobs [ 4 ], and have a stronger sense of professional identity [ 6 ].

Critical thinking is closely related to nursing competence [ 7 ] and patient outcomes [ 8 ]. The undergraduate nursing curriculum and the core competencies of registered nurses emphasize critical thinking [ 9 , 10 ]. To practice caring, nurse involve providing personalized nursing in response to the patients’ needs, which requires critical thinking skills [ 11 ]. Research on caring and critical thinking is not only concerned with concepts, influencing factors, but also explores the relationship between them [ 12 , 13 ]. Researchers have found that caring and critical thinking are positively related both in western and oriental nursing students [ 11 , 12 ]. Caring and critical thinking skills are not inherent, but can be developed. Nursing educators use a variety of teaching methods to foster caring and critical thinking in nursing students [ 14 , 15 ]. Learning outcome is affected by interest in learning [ 16 ]. Learning is a process influenced by interest [ 17 ], and interest in learning will have a major impact on the way students learn [ 18 ]. The greater the interest of students, the better the learning outcomes will be [ 16 ]. The following conceptual framework was established based on the previous studies: 1) interest in learning is positively correlated with critical thinking, 2) interest in learning is positively correlated with caring, 3) critical thinking is positively correlated with caring, and 4) critical thinking is a mediator between interest in learning and caring.

Previous studies have explored the influence of interest in learning on caring and critical thinking, as well as the relationship between caring and critical thinking. However, the mediating effect of critical thinking in interest learning and caring among nursing students has not been clarified. The objectives of this study were to: 1) describe caring among nursing students in China and 2) examine the relationships among interest in learning, caring, and critical thinking.

The study followed the STROBE reporting guideline [ 19 ].

Study design

A descriptive cross-sectional study was conducted between January 20 and 26, 2022 to examine the relationships among interest in learning, caring, and critical thinking among nursing students in China.

Settings and participants

The participants were nursing students from five provinces in China. The inclusion criteria were nursing students who enrolled in diploma, undergraduate or graduate programs in Guangdong, Sichuan, Jiangsu, Hunan and Macao in the 2021/2022 academic year and volunteered to participate. The exclusion criteria were nursing students who could not read or write Chinese. Due to the limited information available, it was assumed that the effect of interest in learning on critical thinking and the effect of critical thinking on caring would be small, which results in maximum variability. According to the empirical power tables, a sample size of 558 or greater is required for 0.8 power when using the percentile bootstrap to test the mediating effect [ 20 ].

A convenience sampling method was employed. The data were collected during the COVID-19 pandemic, the research team used the most widely used social media platform in China, Wechat, to recruit and promote the study. Participants scanned the QR code of the poster for access to the online survey platform. The participants read and agreed to the informed consent before starting to fill in the questionnaire.

Caring dimensions inventory

The Caring Dimensions Inventory consisted of 25 items, each measured on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree) [ 21 ]. Scores ranged from 25 to 125 points, with higher scores indicating a higher level of caring. The Cronbach’s α coefficient and content validity index of the Chinese version were 0.97 and 0.98 respectively [ 22 ].

Study interest questionnaire

Study Interest Questionnaire contained 18 items rated on a 4-point Likert scale [ 23 ]. Scores ranged from 1 to 4 points, with higher scores indicating a higher level of interest in learning. It demonstrated good reliability (Cronbach’s α coefficient = 0.90) [ 23 ].

Yoon’s critical thinking disposition

Yoon’s Critical Thinking Disposition consisted of 27 items scored on a 5-point Likert scale [ 24 ]. Scores ranged from 1 to 5 points, with higher scores indicating a higher level of critical thinking. It exhibited acceptable reliability (Cronbach’s α coefficient = 0.84) [ 24 ].

Ethical considerations

The Research Management and Development Department at the authors’ college provided ethical approval for the study (ethical approval number: REC-2021.801). All methods were performed in accordance with the relevant guidelines and regulations. The survey was conducted anonymously. Participants could withdraw from participation at any time without any loss of benefits.

Data analysis

SPSS 26.0 was used to conduct descriptive statistics on the characteristics of participants and Pearson correlation analysis on the correlation between interest learning, caring and critical thinking. A p -value ≤0.05 was considered statistically significant.

Amos 26.0 was employed to establish the structural equation modelling and analyze the mediating effect of critical thinking on interest in learning and caring. The two-sided 95% bootstrap percentile confidence intervals were computed using 2000 replications to validate the model. A 95% confidence interval without zero indicates statistical significance.

Participants’ characteristics

A total of 692 valid questionnaires were collected, with the majority of participants being female ( n  = 618, 89.3%) and an average age of 22.0. Most of the participants were enrolled in undergraduate nursing programs ( n  = 369, 53.3%) at schools mainly located in Jiangsu Province ( n  = 200, 28.9%) (Table  1 ).

Levels of caring, interest in learning, and critical thinking

The mean score was 103.62 out of 125 for caring, 2.78 out of 4 for interest in learning, and 3.65 out of 5 for critical thinking (Table  2 ).

Relationships among interest in learning, caring, and critical thinking

The correlations among caring, interest in learning, and critical thinking are shown in Table  3 . Interest in learning was positively correlated with critical thinking ( r  = 0.376, p  <  0.01). Interest in learning was positively correlated with caring ( r  = 0.339, p  <  0.01). Critical thinking was positively correlated with caring ( r  = 0.551, p  <  0.01).

Regression analysis

The results of linear regression analyses on the mediating effect of critical thinking between interest in learning and caring, are shown in Table  4 . The first regression equation showed that interest in learning significantly influenced caring (β = 0.339, p  <  0.001). The second regression equation showed that interest in learning significantly influenced critical thinking (β = 0.376, p  <  0.001). The third regression equation showed that critical thinking significantly influenced caring (β = 0.494, p  <  0.001). The effect of interest in learning on caring was less in the third equation than in the first equation (β = 0.154 vs β = 0.339), which indicates partial mediation.

Mediating effect of critical thinking between interest in learning and caring

Table  5 and Fig.  1 illustrate the mediating effects of critical thinking. Critical thinking was positively related to caring (β = 0.49, p  <  0.001). Interest in learning was positively correlated with critical thinking (β = 0.38, p  < 0.001). Moreover, interest in learning had an indirect positive effect (β = 0.49 × 0.38 = 0.186, p  < 0.001) on caring mediated by critical thinking, with 95% confidence interval of 0.142 to 0.233. As this confidence interval did not contain zero, it was concluded that critical thinking was a significant mediator of the relationship between interest in learning and caring. The direct positive effect of interest in learning on caring was 0.15 ( p  < 0.001), so the mediating effect of critical thinking was partial. The total effect of interest in learning on caring was 0.339.

Mediation model of effect of critical thinking between interest in learning and caring. Note. ⁎⁎⁎ p  < 0.001 (2-tails)

This study aimed to examine caring among nursing students in China and the relationships among interest in learning, caring, and critical thinking. Findings of this study generally supported the conceptual framework proposed in it. The results of the mediation analysis confirmed that critical thinking played a partially mediating role between interest in learning and caring among nursing students. The findings of regression showed that interest in learning had a significant impact on caring, which was similar to the results of previous studies [ 25 , 26 , 27 ]. It is suggested that increasing nursing students’ interest in learning can be beneficial to their caring. Caring is not instinctive, but gradually grows and develops through learning and practice under the influence of both environment and education [ 28 , 29 ]. The evidence is clear that students learn more when they are interested in the course [ 30 , 31 ]. However, several studies have shown that nursing students’ caring does not change throughout their educational journey, and some studies even reported a decline [ 32 , 33 ]. The two main components of caring are instrumental and expressive. Instrumental component is devoted to meeting physical and technical aspects of patients’ care, while expressive component involves meeting their psychological, social, and emotional needs [ 34 , 35 ]. The existing educational system effectively promotes instrumental caring, while expressive caring calls for more efficient strategies [ 36 , 37 ]. Critical thinking helps nursing students to perform expressive caring [ 38 ]. Nursing students who can demonstrate critical thinking have the ability to seek and examine information, and integrate information together to synthesize appropriate solutions [ 39 ]. Caring must begin by understanding the needs of patients, so that each patient can receive appropriate support according to their unique personalities [ 40 ]. Nursing students should use critical thinking in their practice of caring. Therefore, the effect of nursing students’ interest in learning on increasing caring maybe enhanced by strengthened their critical thinking.

The findings of this study revealed that interest in learning had an indirect positive effect on caring mediated by critical thinking. During this process, how does critical thinking come into play? Caring is the combination of purposeful nursing acts and attitudes designed to alleviate patients’ discomfort and meet their needs [ 41 ]. As part of the implementation of caring, it is imperative to collect and integrate all aspects of patient information in order to fully assess their condition and provide intervention accordingly [ 42 ]. Making decisions based on analysis and evaluation of problems requires critical thinking [ 43 ]. Critical thinking in clinical setting involves problem solving, caring, unbiased inquiry, intuition, and reflection in action [ 44 ]. Critical thinking enables both implicit and explicit information about the patient to be considered, as well as the integration of all useful information, so that caring can be accomplished. A positive correlation has been found between critical thinking and caring in previous studies [ 12 ]. Despite the fact that critical thinking cannot guarantee the practice of caring, it makes it possible to do so. Therefore, it is important to develop critical thinking among nursing students in order to cultivate their caring.

It was demonstrated that interest in learning was an important antecedent variable for nursing students to improve caring through critical thinking. The average score of critical thinking for nursing students in China was higher than the median in this study, indicating their critical thinking was at a medium level, but slightly lower than that of South Korean nursing students using the same instrument [ 45 ]. It is therefore suggested that courses focusing on caring should also introduce critical thinking as one of their learning outcomes in an effort to develop nursing students’ caring skills. The mediating role of critical thinking offers a new perspective for improving nursing students’ caring.

It adds to the literature on nurturing nursing students’ caring, but there are some limitations to the study. First, the findings were based on cross-sectional data, making it difficult to verify the causal relationship between variables. Future studies should employ longitudinal or experimental designs to clarify the relationship between these variables in more detail. Second, this study relied on self-reported questionnaires, resulting in an inevitable bias in information. To remedy this shortcoming, future research should focus on obtaining data using external tools such as classroom observations. Third, this study was conducted during the COVID-19 pandemic, which has significant implications for nursing students and nursing education. The results from this study should be interpreted with care once the pandemic has ended.

This study explored the little-studied topic of critical thinking and caring in nursing students, enriching the literature concerning nursing education. This study found that there was a significant relationship between interest in learning, critical thinking and caring. Importantly, this study revealed that students’ critical thinking played a mediating role in the relationship between interest in learning and caring, indicating that critical thinking may explain the relationship between interest in learning and caring.

Availability of data and materials

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

Nehrir B, Vanaki Z, Mokhtari Nouri J, Khademolhosseini SM, Ebadi A. Competency in nursing students: a systematic review. Int J Travel Med Glob Health. 2016;4(1):3–11.

Article   Google Scholar  

Tong LK, Zhu MX, Wang SC, Cheong PL, Van IK. Factors influencing caring behaviour among registered nurses during the COVID-19 pandemic in China: a qualitative study using the COM-B framework. J Nurs Manag. 2022;30(8):4071–9.

Sebrant L, Jong M. What’s the meaning of the concept of caring?: a meta-synthesis. Scand J Caring Sci. 2021;35(2):353–65.

Leyva EWA, Peralta AB, Tejero LMS, Santos MA. Global Perpectives of caring: an integrative review. Int J Hum Caring. 2010;4:7–29.

Google Scholar  

Hoff T, Collinson GE. How Do We Talk About the Physician–Patient Relationship? What the Nonempirical Literature Tells Us. Med Care Res Rev. 2016;74(3):251–85.

Zhong X, Liu X, Sheng Y. The effect of the humanistic care teaching model on nurse patient conflict and nurse turnover intention in a pediatric outpatient department: results of a randomized trial. Transl Pediatr. 2021;10(8):2016–23.

Chang MJ, Chang Y-J, Kuo S-H, Yang Y-H, Chou F-H. Relationships between critical thinking ability and nursing competence in clinical nurses. J Clin Nurs. 2011;20(21-22):3224–32.

Fesler-Birch DM. Critical thinking and patient outcomes: a review. Nurs Outlook. 2005;53(2):59–65.

World Health Organization. Global Standards for the initial education of professional nurses and midwives (WHO/HRH/HPN/08.6) 2009 [Available from: http://apps.who.int/iris/bitstream/handle/10665/44100/WHO_HRH_HPN_08.6_eng.pdf;jsessionid=D57DFC5BDD030B65568D635744261CE9?sequence=1 .

Nursing and Midwifery Board of Australia. National competency standards for the registered nurse 2006 [Available from: https://assessment.avondale.edu.au/examples/examples_docs/Nursing-and-Midwifery-Board-National-competency-standards-rn.pdf .

Arli SK, Bakan AB, Ozturk S, Erisik E, Yildirim Z. Critical thinking and caring in nursing students. Int J Caring Sci. 2017;10(1):471–8.

Pai H-C, Eng C-J, Ko H-L. Effect of caring behavior on disposition toward critical thinking of nursing students. J Prof Nurs. 2013;29(6):423–9.

Nadelson SG, Nadelson LS. Connecting critical thinking, caring, and curiosity in nurse education: exploring the beliefs and practices of nurse educators. J Nurs Educ Pract. 2019;9(8):1–10.

Nadelson SG, Zigmond T, Nadelson L, Scadden M, Collins C. Fostering caring in undergraduate nursing students: an integrative review. J Nurs Educ Pract. 2016;6(11):7–14.

Lee J, Lee Y, Gong S, Bae J, Choi M. A meta-analysis of the effects of non-traditional teaching methods on the critical thinking abilities of nursing students. BMC Med Educ. 2016;16(1):240.

Triarisanti R, Purnawarman P. The influence of interest and motivation on college students’ language and art appreciation learning outcomes. Int J Educ. 2019;11(2):130–5.

Burke J. Outcomes, learning and the curriculum: implications for NVQs, GNVQs and other qualifications. London: The Falmer; 1995.

Hidi S, Renninger KA. The four-phase model of interest development. Educ Psychol. 2006;41(2):111–27.

von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ. 2007;335(7624):806.

Fritz MS, MacKinnon DP. Required sample size to detect the mediated effect. Psychol Sci. 2007;18(3):233–9.

Watson R, Lea A. The caring dimensions inventory (CDI): content validity, reliability and scaling. J Adv Nurs. 1997;25(1):87–94.

Article   CAS   Google Scholar  

Tong L-K, Zhu M-X, Wang S-C, Cheong P-L, Van I-K. A Chinese version of the caring dimensions inventory: reliability and validity assessment. Int J Environ Res Public Health. 2021;18(13):6834.

Krapp A, Schiefele U, Wild KP, Winteler A. Der Fragebogen zum Studieninteresse (FSI). [The Study Interest Questionnaire (SIQ)]. Diagnostica. 1993;39(4):335–51.

Yoon J. Development of an instrument for the measurement of critical thinking disposition: in nursing [doctoral dissertation]. Seoul: The Catholic University of Korea; 2004.

Li X, Mo L, Zhang P, Wang Q, Huang X. A survey of humanistic care ability of nursing postgraduate students. Chin J Nurs Educ. 2019;16(2):137–40.

Chen G, Zheng C, Li H. The investigation and analysis of humanistic care ability and its influencing factors in 407 vocational nursing students. Chin Nurs Manag. 2015;15(4):409–12.

Liu X-n, Jiang Y, Zhou J, Zhu M-x, Wang X-y. Research on cognition of nursing undergraduates on caring behaviors and its related factors. Nurs J Chin People’s Liberation Army. 2010;27(10):723–6.

Sadler J. A pilot study to measure the caring efficacy of baccalaureate nursing students. Nurs Educ Perspect. 2003;24(6):295–9.

Simmons PR, Cavanaugh SH. Relationships among student and graduate caring ability and professional school climate. J Prof Nurs. 2000;16(2):76–83.

Marks RB. Determinants of student evaluations of global measures of instructor and course value. J Mark Educ. 2000;22(2):108–19.

Young MR, Klemz BR, Murphy JW. Enhancing learning outcomes: the effects of instructional technology, learning styles, instructional methods, and student behavior. J Mark Educ. 2003;25(2):130–42.

Watson R, Deary IJ, Lea A. A longitudinal study into the perceptions of caring and nursing among student nurses. J Adv Nurs. 1999;29(5):1228–37.

Murphy F, Jones S, Edwards M, James J, Mayer A. The impact of nurse education on the caring behaviours of nursing students. Nurse Educ Today. 2009;29(2):254–64.

Woodward VM. Professional caring: a contradiction in terms? J Adv Nurs. 1997;26(5):999–1004.

Watson MJ. New dimensions of human caring theory. Nurs Sci Q. 1988;1(4):175–81.

Fenizia E, Navarini L, Scollo S, Gambera A, Ciccozzi M. A longitudinal study on caring behaviors of Italian nursing students. Nurse Educ Today. 2020;88:104377.

Labrague LJ, McEnroe-Petitte DM, Papathanasiou IV, Edet OB, Arulappan J, Tsaras K. Nursing Students' perceptions of their own caring behaviors: a multicountry study. Int J Nurs Knowl. 2017;28(4):225–32.

Benner P, Hughes RG, Sutphen M. In: Hughes RG, editor. Clinical reasoning, decisionmaking, and action: thinking critically and clinically. Rockville: Agency for Healthcare Research and Quality (US); 2008.

Chan ZCY. A systematic review of critical thinking in nursing education. Nurse Educ Today. 2013;33(3):236–40.

McCance TV, McKenna HP, Boore JRP. Caring: theoretical perspectives of relevance to nursing. J Adv Nurs. 1999;30(6):1388–95.

Chen SY, Chang HC, Pai HC. Caring behaviours directly and indirectly affect nursing students' critical thinking. Scand J Caring Sci. 2018;32(1):197–203.

Watson J, Brewer BB. Caring science research: criteria, evidence, and measurement. J Nurs Adm. 2015;45(5):235–6.

Lai ER. Critical thinking: A literature review 2011 [Available from: http://images.pearsonassessments.com/images/tmrs/CriticalThinkingReviewFINAL.pdf.

Redding DA. The development of critical thinking among students in baccalaureate nursing education. Holist Nurs Pract. 2001;15(4):57–64.

Shin H, Park CG, Kim H. Validation of Yoon's critical thinking disposition instrument. Asian Nursing Research. 2015;9(4):342–8.

Download references

Acknowledgements

Not applicable.

This work was supported by a research grant from Higher Education Fund of Macao SAR Government (HSS-KWNC-2021-01). This funding source had no role in the design of this study and will not have any role during its execution, analyses, interpretation of the data, or decision to submit results.

Author information

Authors and affiliations.

Kiang Wu Nursing College of Macau, Macau, China

Lai Kun Tong, Mio Leng Au, Yue Yi Li, Wai I. Ng & Si Chen Wang

You can also search for this author in PubMed   Google Scholar

Contributions

LKT was responsible of the conceptualization, methodology, data curation, formal analysis, investigation, visualization, project administration, writing – original draft. MLA was responsible of the conceptualization, methodology, data curation, funding acquisition, investigation, supervision, writing – original draft. YY was responsible of the conceptualization, methodology, formal analysis, data curation, investigation, visualization, writing – original draft. WIN was responsible of writing - review & editing. SCW was responsible of Writing - review & editing. The authors read and approved the final manuscript.

Corresponding author

Correspondence to Yue Yi Li .

Ethics declarations

Ethics approval and consent to participate.

All experimental protocols were approved by the Research Management and Development Department of Kiang Wu Nursing College of Macau (ethical approval number: REC-2021.801) and conducted according to the Declaration of Helsinki. The Research Management and Development Department is in charge of ethical approvals of scientific research projects, as well as issuing the ethical approval documents. It was a completely voluntary, anonymous, and unrewarded study. The participants read and agreed to the informed consent before starting to fill in the questionnaire. In order to assured voluntariness, participants could withdraw at any time without losing benefits. Anonymity was guaranteed by not collecting any personal identification information (such as names). Confidentiality was ensured by storing data on a computer protected by a password known only by the researchers.

Consent for publication

Competing interests.

The authors declare that they have no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Tong, L.K., Au, M.L., Li, Y.Y. et al. The mediating effect of critical thinking between interest in learning and caring among nursing students: a cross-sectional study. BMC Nurs 22 , 30 (2023). https://doi.org/10.1186/s12912-023-01181-4

Download citation

Received : 03 September 2022

Accepted : 13 January 2023

Published : 03 February 2023

DOI : https://doi.org/10.1186/s12912-023-01181-4

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Critical thinking
• Interest in learning
• Nursing student

BMC Nursing

ISSN: 1472-6955

• General enquiries: [email protected]

The development of critical thinking among students in baccalaureate nursing education

Affiliation.

• 1 Mennonite College of Nursing at Illinois State University, USA.
• PMID: 12120496
• DOI: 10.1097/00004650-200107000-00009

Students entering nursing education present with a range of critical-thinking skills and dispositions that are affected by genetic influences, modeling by others, and formal learning experiences. The experience of higher education further contributes, positively or negatively, to the development of those skills and dispositions over time. A conceptual framework is presented as a model to explain the relationship between variables contributing to critical thinking as it is manifested in clinical judgment. A developmental model is presented to align the development of cognitive capabilities and the application of those capabilities in the subprocesses of the nursing process. Implications for nurse educators related to the understanding of critical-thinking development of students are discussed.

Publication types

• Clinical Competence / standards*
• Education, Nursing, Baccalaureate / standards*
• Educational Measurement / methods
• Models, Educational
• Nursing Education Research / methods*
• Students, Nursing / psychology*
• United States

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Nurs Midwifery Stud
• v.4(1); 2015 Mar

Critical Thinking Skills in Nursing Students: a Comparison Between Freshmen and Senior Students

Ismail azizi-fini.

1 School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, IR Iran

Ali Hajibagheri

2 Department of Medical Surgical Nursing, Faculty of Nursing and Midwifery, Kashan University of Medical Sciences, Kashan, IR Iran

Mohsen Adib-Hajbaghery

3 Trauma Nursing Research Center, Kashan University of Medical Sciences, Kashan, IR Iran

Background:

Critical thinking is one of the most important concepts in the field of education. Despite studies published on nursing students’ critical thinking skills (CTS), some suggest that there is not enough evidence supporting the relationship between content of nursing education programs and nursing students’ CTS.

Objectives:

Given the existing discrepancies, this study aimed to compare the critical thinking skills of freshmen and senior nursing students.

Patients and Methods:

This comparative study was conducted on 150 undergraduate freshmen and senior nursing students in Kashan University of Medical Sciences, during 2012. The students in the first and the last semesters of their study in nursing were entered in the study using the census method. Data were collected using a questionnaire including questions on demographic data and the California Critical Thinking Skills Test, form B. Data analysis was performed using the SPSS v.13 software. Descriptive statistics were calculated. Moreover, independent sample t-test and Spearman and Pearson’s correlation coefficients were used in the data analysis.

Both the freshmen and senior nursing students had low CTS. The mean critical thinking scores were 11.79 ± 4.80 and 11.21 ± 3.17 for the freshmen and the senior students, respectively (P = 0.511). Moreover, no significant correlation was found between the students’ score in CTS and their age, gender, high school grade point average (GPA), rank in university entrance examination (RUEE) and interest in the nursing profession.

Conclusions:

The students were low skilled in critical thinking and their CTS did not significantly change during their nursing degree. Thus it may be concluded that the nursing education program did not affect the CTS of its students. Longitudinal studies are suggested for assessing nursing students’ critical thinking over time. Moreover, revising the curriculum and preparing nursing educators for implementing innovative and active teaching strategies are suggested.

1. Background

Critical thinking is one of the most important concepts involved in the field of education. Enabling students to think critically is not only a primary purpose of higher education, but also facilitates the dynamics of academies and universities and helps them survive, develop and promotes scientific societies ( 1 ).

Introducing the concept of critical thinking into nursing education is a turning point in the process of professionalization. Despite different definitions for critical thinking, no consensus has yet been reached ( 2 , 3 ). However, critical thinking is generally defined as "a process of purposeful, interactive reasoning, criticism and judgment about what we believe and do" ( 4 ). Some have also defined critical thinking in nursing as "the process of reflective and reasonable thinking about nursing problems without a single solution and is focused on deciding what to believe and do" ( 5 ).

In the recent decades, as a result of the rapid advances in knowledge and technology, dramatic changes have occurred in healthcare organizations. Consequently, people’s demand has been increased for higher quality healthcare services, with lower costs and shorter length of hospital stay. Moreover, the aging population, complex disease processes and increased patients’ awareness, have evolved modern nursing. Thus, nurses are in need to continually improve their knowledge and competencies, to be able to provide safe and quality care in a context of constantly changing clinical situations ( 6 ).

In this changing environment, nurses need to develop their thinking and reasoning skills in order to meet the patients and families’ caring needs in collaboration with other healthcare professionals ( 7 ). Nurses as healthcare providers should be creative, self-directed and critical thinkers to be able to make appropriate decisions and solve clinical problems ( 8 ).

Karadag et al. investigated nurse educators and clinical nurses’ attitudes towards critical thinking and reported that both nurses and nurse educators believed in the crucial role of critical thinking skills (CTS) in the context of increasing complexity in modern healthcare ( 9 ). Simpson et al. also stressed that nurses should be skilled in reasoning and critical thinking to be able to appraise new knowledge. Highlighting the vital importance of CTS, the American Nurse Association also emphasizes that the nurses’ CTS should be measured as a criterion for validating outcomes of nurse education programs ( 6 ).

Several nursing authors have written about teaching methods used to strengthen CTS ( 4 ). According to Alfaro-LeFevre ( 10 ), there are at least two main reasons for nurses to learn CTS. Firstly, thinking is the key for problem solving; while, nurses without such skills are themselves part of the problem. Secondly, in critical situations, nurses should be able to take major decisions, independently and quickly. Critical thinking skills enable them to identify necessary data and distinguish problems requiring immediate intervention from those that are not life threatening. Thus, they will be able to consider the possible consequences of each action and make the right decision ( 3 ).

Bakalis et al. suggest that it is essential to establish a dialogue between teachers and students to promote CTS among learners ( 11 ). Studies have also shown a link between the students’ level of CTS and their level of academic education, age and clinical experience ( 4 , 12 ).

Despite many studies published on nurses and nursing students’ CTS, Duchscher suggests that there is no strong evidence supporting the relationship between content of nursing education programs and the nurses or nursing students’ CTS ( 12 ). Some other authors believe that there is a lack of appropriate tools for assessing nurse's CTS ( 13 , 14 ). However, Magnussen et al. ( 15 ) have reported that traditional teaching methods may hinder the ability of critical thinking while research-based learning, as a teaching method, can increase CTS.

Studies in Iran have shown mixed results in terms of nursing students’ critical thinking. Two studies by Rezaei et al. ( 16 ) and Eslami et al. ( 3 ) reported that nursing students had poor CTS. They found no significant difference between the levels of CTS in freshmen and senior nursing students. However, in two other studies, Khalili et al. ( 17 ) and McCarthy et al. ( 18 ) reported that the levels of CTS were significantly higher among senior compared to junior nursing students. Therefore, the question is whether CTS differs among nursing students at the start and the end of their nursing studies. The answer of this question would not only be important globally but also at the national level because this answer might help us evaluate the nursing curriculum and nursing educators as the main role models in the process of nursing education.

2. Objectives

Given the importance of CTS in nursing, and discrepancies in previous studies, this study aimed to compare the CTS of freshmen and senior nursing students of Kashan University of Medical Sciences (KAUMS), during year 2012.

3. Patients and Methods

A comparative study was conducted on 150 undergraduate freshmen and senior nursing students at KAUMS. All nursing students in the first and the last semester of their nursing program were entered in this study using the census method. Exclusion criteria were: being a guest student or being transferred from other universities, having an additional academic degree, and having passed some courses on critical thinking.

Data were collected using a two-part questionnaire. The first part of the questionnaire consisted of questions on demographic data (i.e. gender, age, the students’ high school grade point average (GPA), the students’ rank in university entrance examination (RUEE), and interest in the nursing profession). The second part of the questionnaire was the California Critical Thinking Skills Test, form B (CCTS form B). The CCTS form B is frequently used to assess the students' CTS ( 3 ). This scale consists of 34 questions, each with options, which are designed to evaluate critical thinking at the post-secondary level.

The CCTS form B was specifically designed to assess CTS in five areas of interpretation, analysis, evaluation, inductive reasoning and deductive reasoning. Each question is scored either one or zero for each correct or wrong answer, respectively. Thus, the lowest overall score is zero and the highest is 34 ( 19 ). The time each student spent to respond to the questionnaire was about 45 minutes.

The CCTS form B was previously translated to the Persian language by Akhoundzadeh et al. ( 20 ), and showed appropriate psychometric properties. They also confirmed the instrument’s content validity and reliability using the Kuder-Richardson coefficient, which was 0.62. The test was able to distinguish between CTS of nursing and philosophy students ( 21 ).

After obtaining permission from the authorities of the university, the instrument was passed to selected students in their breaks between classes. All students were asked to respond to the questionnaires in a private environment and returned their answers back to the researchers (the first or the second authors of this manuscript) or the secretary of the nursing department on the same day.

3.1. Ethical Considerations

Permission for this study was through the ethics committee of KAUMS. Other ethical issues in this study involved the assurance of confidentiality and anonymity of the participants. All participants were informed about the purpose and design of this research, and that their participation was voluntary. Participants signed a written informed consent for their participation.

3.2. Data Analysis

Data analysis was performed using the SPSS v.13 software. Descriptive statistics were calculated. Independent sample t-test was used to examine significant differences between mean quantitative variables of the two groups. Moreover, the Spearman and Pearson’s correlation coefficients were used to examine the correlation between the students’ scores in CTS and their age, gender, high school GPA, RUEE and interest in the nursing profession. The level of significance was considered less than 0.05.

Among all participants, 24.6% (n = 37) were freshmen and 75.4% (n = 113) were senior students. In total, 65.5% of the freshmen students and 65.3% of the seniors were females (P > 0.05). The mean age of the students was 20.5 ± 1.73 years and 22.41 ± 1.51 years, for freshmen and senior students, respectively (P > 0.05). The mean high school grade point averages of the students were 17.58 ± 1.65 and 18.38 ± 1.03 for the freshmen and seniors, respectively, (P > 0.05). The students’ mean ranks in the university entrance examination were 5186.6 and 6283.1 for the freshmen and seniors, respectively, (P > 0.05). Overall, 10.8% of freshmen students reported that they are very interested in the nursing profession, while 10.8% and 78.4% were moderately interested in or uninterested in the profession, respectively. In terms of senior students, 27.4% were very interested in the nursing profession, while 61.1% and 11.5% were moderately interested or uninterested in the profession, respectively.

The mean critical thinking scores were 11.79 ± 4.80 and 11.21 ± 3.17 for freshmen and senior students, respectively (P = 0.511). As shown in Table 1 , no significant differences were found between freshmen and senior students in terms of their mean scores for the interpretation, analysis, evaluation, inductive reasoning and deductive reasoning subscales. Both freshmen and senior students obtained the highest and the lowest mean scores in deductive reasoning and analysis subscales, respectively.

a All values are presented as Mean ± SD.

Using Pearson’s correlation coefficient, no significant correlation was found between the students’ CTS scores and their age, high school GPA, and RUEE ( Table 2 ). Moreover, using Spearman’s correlation coefficient, no significant correlation was found between the students’ CTS score and their gender and interest in the nursing profession ( Table 2 ).

5. Discussion

This study aimed to compare the CTS of freshmen and senior nursing students to determine if the current nursing education program is effective on its students CTS. Results showed that the mean critical thinking scores of freshmen and senior nursing students were at a low level. Moreover, no significant difference was observed between the mean critical thinking scores of freshmen and senior nursing students. In addition, no significant association was found between the students’ scores in CTS and variables such as gender, high school GPA, RUEE and level of interest in the nursing profession. These findings are consistent with the results of previous studies ( 22 ). Previous studies on the assessment of Iranian nursing students and nurses’ CTS have reported that the majority of nursing students and nurses in Iran have poor CTS ( 3 , 23 - 25 ). Consistent with this study, other studies have also found no significant difference between freshmen and senior nursing students' CTS ( 3 , 26 ). However, Khalili et al. ( 17 ), Babamohamadi and Khalili ( 23 ) have reported significant differences between the critical thinking scores of freshmen and senior nursing students, which is not in line with the results of the present study. These inconsistencies might not only be attributed to probable differences in learning styles of students ( 27 ) but also to the relatively different teaching styles of different nursing schools.

The results of this study showed no statistically significant positive correlations between demographic data and CTS. While Zhang and Lambert ( 27 ) and Noohi et al. ( 28 ) reported that a number of positive and negative correlations exist between demographic data and critical thinking skills. The lack of correlation between demographic data and CTS in the present study might be attributed to the characteristics of universities and their students; Mahmoodabad et al. ( 29 ), in a study from Iran, reported that students attending larger universities are somewhat different considering their GPA and RUEE, and this may affect their CTS. Another probably reason is that many of the senior students in Kashan are employed as part time nurses in healthcare centers. Therefore, as Bittencourt and Crossetti ( 30 ) have reported, students that work part time have less time to spend on intellectual activities. It seems that when students are employed in clinical settings, they spend more time in performing nursing techniques and following the routines instead of using the scientific knowledge they learned at the university. Working according to the routines usually does not need much thinking skills, and nurses simply follow the doctors’ orders. Working in this manner, would gradually affect the nurses cognitive, critical thinking and humanistic skills such as communication skills.

Furthermore, studies have reported that not only the content of education but also the teaching-learning methods at all levels of the education system in Iran (i.e. elementary, secondary and university) basically concentrate on transferring theoretical knowledge and do not focus on development of critical thinking and problem-solving skills in learners (4). Amini et al. ( 31 ) reported that this is a global problem in nursing education, and several studies indicate a lack of critical thinking and problem solving skills in undergraduate nursing programs. It has also been reported that although basic skills of critical thinking are taught to nursing students, they cannot apply them in solving problems they commonly encounter, and this may be considered as a sign of failure in nursing education systems ( 32 ). Moreover, overuse of lectures and multiple choice questions, and overlooking the nursing process in education may be among other possible reasons for the lack of CTS in Iranian nursing students ( 23 , 33 ).

It seems that nursing students have less opportunity to apply CTS in clinical settings. While techniques, such as questioning, Socratic method, learning in small groups, discussions and debates, writing diaries, problem based teaching and learning, use of case studies and other types of participative learning, have been shown to be effective in developing CTS ( 20 , 34 ). Previous studies have shown that the nursing curriculum in Iran contains a considerable amount of theoretical, redundant, unnecessary and inapplicable knowledge and nurse educators are under pressure to teach a large content in a limited time ( 4 , 35 ). Thus, making a balance between the course content and time available may be the first step in preparing the context for educators to assign more time for the development of the students’ CTS. Moreover, as Moattari et al. ( 35 ) reported, nurse educators should be prepared to implement active, student-centered, collaborative and problem-focused teaching strategies to foster the students’ CTS.

The results showed that nursing students had low CTS and these skills did not significantly change during their studies in nursing. Therefore, it may be concluded that the studied nursing education program did not affect its students’ CTS. However, the low critical thinking scores of the participants in the present study and other studies conducted in Iran may be attributed to the instruments used by these studies. Most of these studies used instruments such as CCTS Form B, and as mentioned previously, some nursing researchers believe that this instrument is not appropriate for assessing nurses or nursing students’ CTS. Thus, appropriate indigenous instruments should be developed for assessment of critical thinking in nurses. In addition, we tested our participants only one time. It is better to evaluate the evolution of critical thinking over time. Longitudinal studies are suggested for assessing the nursing students’ critical thinking over time. Moreover, revising the curriculum and preparing nurse educators for implementation of innovative and active teaching strategies are suggested. Then, the effects of such interventions can be assessed.

Acknowledgments

The researchers would like to express their gratitude to all the participants who were involved in this study.

Authors’ Contributions: All authors contributed equally in this study.

Funding/Support: This project was funded by the research deputy of Kashan University of Medical Sciences (grant No. 9017).

Paper Information

• Paper Submission

Journal Information

• About This Journal
• Editorial Board
• Current Issue
• Author Guidelines

International Journal of Nursing Science

p-ISSN: 2167-7441    e-ISSN: 2167-745X

2023;  13(1): 12-24

doi:10.5923/j.nursing.20231301.02

Received: May 28, 2023; Accepted: Jun. 21, 2023; Published: Jun. 26, 2023

Analysis of the Critical Thinking of Nursing Students in Cordillera Administrative Region (CAR)

Joman J. Baliton 1 , Mark Job G. Bascos 2

1 School of Graduate Studies, Saint Mary’s University, Bayombong, Philippines

2 School of Advanced Studies, Saint Louis University, Baguio City, Philippines

Copyright © 2023 The Author(s). Published by Scientific & Academic Publishing.

Nursing students need to develop critical thinking skills early on while undergoing educational preparation and clinical training to equip them provide safe and quality patient care. Using a mixed-method approach, this study was undertaken to determine the level of critical thinking among students, determine which variable among the dimensions do students have the greatest involvement, construct a mathematical model that explains critical thinking among nursing students through a linear combination of the variables in the dimensions of critical thinking and their profile variables, and list enhancers and barriers on critical thinking. Electronic questionnaires were administered to nursing students in the Cordillera Administrative Region (CAR). Utilizing the researcher-made Critical Thinking Instrument for Nursing (CTIN), which was tested and found to be a valid and reliable instrument to measure the level of critical thinking among nursing, it was revealed that students are generally involved in developing their critical thinking. Among the four dimensions of critical thinking, students are most involved in developing their disposition skills followed by critical thinking criteria. Students are least involved in developing cognitive skills and strategies which are equally possessed by students. The level of critical thinking can be explained by a linear combination of its four dimensions, highest educational attainment of mother, and occupation of father. Most learners identified application of skills and keeping up with trends and issues as enhancers in developing critical thinking. On the other hand, numerous school requirements were found as a barrier in developing critical thinking. It is suggested that programs for nursing students should be considered for the development of nursing students’ critical thinking by assisting them in reinforcing enhancers, improving critical thinking indicators where students are least involved, and addressing barriers to critical thinking development.

Keywords: Critical thinking, Cognitive skills, Disposition skills, Strategies, Criteria, Exploratory factor analysis

Cite this paper: Joman J. Baliton, Mark Job G. Bascos, Analysis of the Critical Thinking of Nursing Students in Cordillera Administrative Region (CAR), International Journal of Nursing Science , Vol. 13 No. 1, 2023, pp. 12-24. doi: 10.5923/j.nursing.20231301.02.

Article Outline

1. introduction, 2. research objectives, 3. methodology, 3.1. research design, 3.2. respondents, 3.3. instrumentation, 3.4. data analysis, 3.5. ethical considerations, 4. results and discussion, 4.1. level of critical thinking of nursing students, 4.2. significant difference in dimensions of critical thinking, 4.3. relationship between profile variables of nursing students and their ratings in the critical thinking dimensions, 4.4. linear combination nursing students’ profile variables and dimensions of critical thinking, 4.5. enhancers and barriers, 5. limitations of the study, 6. conclusions, 7. recommendations, acknowledgements.