Critical Thinking in Nursing: Scoping Review of the Literature

This article analyzes the current state of scientific knowledge concerning critical thinking in nursing. It discusses the growing interest in studying critical thinking in nursing and the development of training strategies to enhance critical thinking skills among students and professionals. The article also highlights the need for further research on critical thinking among working professionals and the promotion of critical thinking in nursing care.

R E S E A R C H P A P E R
Critical thinking in nursing: Scoping
of the literature
Esperanza Zuriguel Pérez RN
PhD Student, Hospital Vall d’Hebron, University School of Nursing, University of Barcelona, Barce
Maria Teresa Lluch Canut RN PhD
Professor, University School of Nursing, University of Barcelona, Barcelona, Spain
Anna Falcó Pegueroles RN MHSc PhD
Professor, University School of Nursing, University of Barcelona, Barcelona, Spain
Montserrat Puig Llobet RN PhD
Professor, University School of Nursing, University of Barcelona, Barcelona, Spain
Carmen Moreno Arroyo RN
Professor, University School of Nursing, University of Barcelona, Barcelona, Spain
Juan Roldán Merino RN PhD
Professor, Sant Joan de Deu School of Nursing, University of Barcelona, Barcelona, Spain
Associate Professor, Rovira i Virigili University, Tarragona, Spain
Associate Professor, School of Nursing, Autonomous University of Barcelona, Barcelona, Sp
Accepted for publication March 2014
Zuriguel Pérez E, Lluch Canut MT, Falcó Pegueroles A, Puig Llobet M, Moreno Arroyo C, Roldán
International Journal of Nursing Practice 2014; ••: ••–••
Critical thinking in nursing: Scoping review of the literature
This article seeks to analyse the current state of scientific knowledge concerning critical thinking i
used consisted of a scoping review of the main scientific databases using an applied search strate
published from January 1999 to June 2013 were identified, of which 90 met the inclusion criteria. T
is that critical thinking in nursing is experiencing a growing interest in the study of both its concep
as in the development of training strategies to further its development among both students and p
the analysis reveals that critical thinking has been investigated principally in the university setting
models, with a variety of instruments used for its measurement. We recommend (i) the investigat
among working professionals, (ii) the designing of evaluative instruments linked to conceptual mo
cation of strategies to promote critical thinking in the context of providing nursing care.
Key words:critical thinking, nurses, nursing, nursing education, systematic review.
Correspondence:Esperanza ZuriguelPérez,HospitalValld’Hebron,Passeig de la Valld’Hebron,119-129 08035 Barcelona,Spain.Email:
[e-mail]
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International Journal of Nursing Practice 2014; ••: ••–••
doi:10.1111/ijn.12347 © 2014 Wiley Publishing Asia Pty Ltd

INTRODUCTION
Critical thinking (CT) is a cognitive process that includes
rational analysis of information to facilitate clinical reason-
ing, judgment and decision-making.1 The complexity and
ever-changing nature of the health-care workplace, along
with the need for care centred on the patient in tandem
with practice based on evidence, combine to highlight CT
as a competence of great importance in education and in
professional practice.
Severalinternationalorganizationshave putforward
initiatives to pay greater attention to CT. For example,
the National League for Nurses2 included CT as a specific
criterion in the accreditation of academic programs. For
its part,theJointCommission forAccreditation for
Healthcare Organizations3 included CT among its norms
as a key skill in nursing.
CT is particularly important in the nursing profession,
given itspotentialimpactupon the care thatpatients
receive.The capacityof thenursingprofessionalto
achieve improvements in the quality of care depends, in
large measure, upon developing CT skills so as to improve
diagnostic decisions.4
CT is a process that can be explored and then assimi-
lated during both the educational period and the profes-
sionalcareer that follows. Nevertheless, some problems
associated with itremain to be resolved,such asthe
ambiguous nature of the concept, measurement of it and
strategies for better developing it.
The present article reports on a review of studies
lished in the past 14 years, with the aim of analysin
current state of knowledge regarding CT in nursing.
METHODS
We carried out a scoping review of the scientific lite
ture on CT in nursing and related concepts,following
the guidelines set forth in the PRISMA standard5 (Pre-
ferredReportingItemsfor SystematicReviewsand
Meta-Analyses).Studieswere identified principally by
means ofsystematic conventionalsearches ofelectronic
databases. Various combinations of the following m
subject headings (MeSH) were used: ‘criticalthinking’,
‘problem solving’, ‘decision-making’, ‘judgment’, ‘c
petence’ and ‘nursing’. The search strategy was car
out in MEDLINE,CINAHL, LILACSand Cochrane
Library Plus.Table 1 presentsthe search strategy that
was used.
In addition,a secondary search wascarried outby
reviewing the bibliographic references cited in the s
thatwere included.The language forthe review was
English, and the publications considered ran from Ja
1999 to June 2013. The review was limited to origin
articles.The search strategy was notrestricted by any
particular research design. Figure 1 illustrates the s
procedure that was followed.
Some 1518 referenceswere obtained,of which 93
were eliminated as duplicates. A process of discrim
Table 1 Strategy for bibliographic search
MEDLINE CINAHL Cochrane Library Plus LILACS
#1: ‘critical thinking’
#2: ‘nursing’
#3: #2 AND # 3
#4: ‘nursing [majr]’
#5: (‘thinking [majr]’ OR ‘clinical
competence/standards [MeSH]’)
OR ‘nursing care/standard [MeSH]’
#6: (#4) AND #5
#7: (‘thinking [MeSH]’ OR ‘clinical
competence/standards [MeSH]’)
or ‘nursing care/standard’
#8: ‘nurses [MeSH]’
#9: #7 AND #8
#1: ‘critical thinking’
#2: ‘nursing care’
#3: ‘clinical competence’
#4: #1 AND #2
#5: #1 AND #3
#6: #1 AND #2 AND #3
#1: ‘critical thinking’
AND ‘nurs*’
#1: ‘critical thinking’
#2: ‘nursing’
#3: ‘critical thinking’
AND ‘nursing’
#4: ‘clinical judgment’
AND ‘nurs*’
2 E Zuriguel Pérez et al.
© 2014 Wiley Publishing Asia Pty Ltd

was then carried out by means of analysis of the titles and
abstracts of the remaining 1425 citations. The 155 docu-
ments that passed this filter were then subjected to further
screening based on a reading of the complete text, which
led to the elimination of an additional50 papers. In the
end 90 articles were included in the review.
Analysis was carried out in two stages. First, descrip-
tive aspectsof the studieswere analysed,and then a
topical analysis of the studies was carried out.
The variablesstudied included the productivity and
methodological characteristics of the sample.
The productivity characteristics included the following:
•Number of articles by year
•Country oforigin ofthe study,with 13 categories:
USA, Sweden, UK, Turkey, the Netherlands, Canada,
Australia,China,Korea,Iran,South Africa,Mexico
and Jordan
The methodologicalcharacteristicsincludedthe
following:
•Study design type,with six categories:descriptive,
quasi-experimental,experimental,qualitative,mixed
methodology, analysis
•Sample type, with four categories: nursing students,
working nurses, nursing teachers, nursing managers
•Sample size, defined by the range between lowest
highest values
•Aim of the study, with four categories according to
main topic ofthe study:evaluation ofstrategies for
advancing CT, evaluation of the components of CT
nursing students and working nurses, perception o
in students, analysis of the factors that influence C
For this last category the following subcategories w
identified:workplace,clinicalcompetence,nursing
process, self-sufficiency, clinicaljudgment, diagnostic
precision
RESULTS
Description of the studies
Analysis of the annual distribution of publications on
revealed increasing interest in this subject in recent
with a notable surge of production in the year 2010,
be seen in the details of the MEDLINE search by pub
tion date (Fig. 2).
In terms ofthe country oforigin ofthe studies, the
majority were carried out in the USA (n = 66; 73.3%
Europe was the second most productive source of ar
(n = 20; 22.2%), divided among Sweden (n = 7; 7.7%
the UK (n = 6; 6.6%), Turkey (n = 5; 5.5%) and the
Number of citations identified in the
databases
(n =1510)
MEDLINE
(n =1297)
Cochrane
(n = 10)
CINAHL
(n = 200)
LILACS
(n = 3)
Number of citations identified in
the secondary search
(n = 8)
Number of duplicate citations
eliminated (n = 93)
Number of citations screened
(n = 1425)
Citations eliminated following
analysis of title and abstract
(n = 1285)
Articles with complete text
analyzed
(n = 140)
Articles excluded following
analysis of complete text
(n = 50)
Articles included in the review
(n = 90)
Reasons for exclusion
The subject is not the aim of the review (n = 43)
Not found in due time (n = 2)
Not relevant (n = 5)
Screening IdentificationEligibilityInclusion
Figure 1.Flowchartof the resultsof the
search according to the PRISMA standard.
Critical thinking in nursing 3
© 2014 Wiley Publishing Asia Pty Ltd

Netherlands (n = 2; 2.2%). Other studies were carried
out in Canada (n = 7; 7.7%), Australia (n = 4; 4.4%),
China (n = 5; 5.5%), Korea (n = 1; 1.1%), Iran (n = 1;
1.1%),South Africa(n = 1;1.1%),Mexico (n = 1;
1.1%) and Jordan (n = 1; 1.1%).
In terms of the type of study design, the percentages
were as follows:the greatestnumber were descriptive
(n = 32; 35.5%), geared toward evaluating educational
strategies for advancing CT, measuring CT skills in stu-
dentsand analysingfactorsrelated to CT.In lesser
numberswere quasi-experimentalstudies(n = 10;
11.5%), experimental studies (n = 6; 6.6%) and studies
with mixed methodology (n = 5;5.5%).These design
typeswere used to evaluate the impactof educational
initiatives on the CT skills of students. Next were quali-
tative studies (n = 17; 18.8%), which focused principally
on exploring the perception of CT in students.
Finally,analyticalarticles (n = 20;22.2%) explored
various aspects of CT.
As to the populations under study, CT was examined
mainly in nursing studentsamplesatvariousstagesof
training(n = 42;48.8%)and lessso in samplesof
workingnurses(n = 16;17.7%),nursingteachers
(n = 3; 3.3%) and nursing managers (n = 1; 1.1%).
Sample size ranged from 6 to 2144, depending on the
research design (Table 2).
Regarding the main topics of the studies, the following
focuses of interest were identified: (i) evaluation of strat-
egiesfor promoting CT in the field ofeducation,(ii)
evaluation of the CT of students or nurses by means of
variousmeasuring instruments,(iii) exploration ofthe
perception of CT in students and (iv) analysis of several
factors related to CT and their influence upon the results,
such astheworkplace,clinicalcompetence,nursing
Figure 2.Distribution of the recovered bibliographic references by
year of publication (January 1999–June 2013). Source: MEDLINE.
Table 2 Type of population studied and range of sample size by research design
Descriptive (n = 27)† Quasi-experimental
(n = 10)†
Experimental (n = 6)† Qualitative (n = 17)† Mixed methodology
(n = 5)†
n (%) SR n (%) SR n (%) SR n (%) SR n (%) SR
Nursing students‡ 19 (70.3) 120–350 9 (90.0) 13–163 3 (50.0) 31–100 — 11 (68.7) 7–36 3 (60.0) 8–53
Working nurses§ 7¶ (2.5) 14–2144 1 (10.0) 58 3 (50.0) 95–249 4 (25.0) 8–19 1 (20.0) 31
Nursing teachers — — — — — — 2 (12.5) 6–12 1 (20.0) 6–11
Nursing managers1†† (3.7) 12 — — — — — — — —
† Number of studies in which sample type is specified.‡ Students at different levels of studies.§ Nurses with varying levels of expertise.¶ In one study the sample included students and
working nurses.†† In one study the sample included working nurses and nursing managers. SR, sample range.
4 E Zuriguel Pérez et al.
© 2014 Wiley Publishing Asia Pty Ltd

procedure, perception of self-sufficiency in students and
clinicaljudgment.Table 3 presents the classification of
the articles by the main topic under study and the research
design type.
Topical analysis
Topical analysis of the contents of the articles examined
led to groupingthem intothreemainareas:(i)
conceptualization of CT, (ii) measurement of CT and (iii)
strategies for promoting CT.
Conceptualization of CT
CT in nursing is seen as specific and distinct from CT in
other disciplines owing to the dynamics ofthe clinical
process, the affective dimension of nursing practice and
the incorporation of nursing knowledge.6 The definitions
of CT found in the literature are diverse,7,8although one
of the mostoften cited is thatof Facione et al.9 These
authors define CT as the intellectualprocess thatcon-
sciously, deliberately and in a self-regulated manner tries
to arrive at a reasonable judgment. There is general rec-
ognition of the fact that CT is a complex process whose
componentsincludecognitiveabilitiesand attitudinal
dispositions.10–13
CT has been defined as controlled, useful thinking that
requires strategies in order to obtain the desired results.1
According to other authors it is the process of searching,
obtaining, evaluating, analysing, synthesizing and concep-
tualizinginformation13
; its attributesare reflection,
context, dialogue and time.14
For a number of authors there is at present a continuing
lack of clarity about the concept.6,15,16
The complexity is
owing to the factthatCT requiresvarioustypesof
knowledge—abstract, generalizable and applicable in dif-
ferent situations. It depends upon experience and contex-
tual factors (the work flow; social and political factors).
The definition of CT in nursing has been supplemented
by alternative terms:clinicalreasoning,clinicaljudgment,
problem-solving,clinicaldecision-makingand nursing
process.17,18
The process of clinical reasoning appears in the
literature linked to the making of professional judgments,
resolution ofproblemsand making ofdiagnostic deci-
sions. It has been described as the cognitive process of
application of CT, knowledge and experience in clinical
practice.19–21
Anotherconceptrelated to CT,clinicaljudgment,
is defined asthe resultattained by meansof clinical
reasoning.22 Although CT is not centred upon the search
Table 3 Classification of the selected articles by research design and object of the study, n (%)
Descriptive
(n = 32)
Quasi-experimental
(n = 10)
Experimenta
(n = 6)
Qualitative
(n = 17)
Mixed methodology
(n = 5)
Analytical articles
(n = 20)
Evaluation of strategy for the promotion of CT14 (43.7) 8 (80.0) 3 (50.0) 9 (52.9) 5 (100) 16 (80.0)
Evaluation of CT in students 8 (25.0) 2 (20.0) — — — —
Evaluation of CT in nurses 1 (3.0) — — — — —
Perception of CT in students — — — 8 (47.0) — —
Workplace and CT 4 (12.5) — — — — —
Clinical competence and CT 4 (12.5) — — — — —
Nursing process and CT 1 (3.0) — — — — 1 (5.0)
Self-sufficiency in students and CT — — 1 (16.6) — — —
Diagnostic precision and CT — — 2 (33.3) — — 2 (10.0)
Clinical judgment and CT — — — — — 1 (5.0)
CT, critical thinking.
Critical thinking in nursing 5
© 2014 Wiley Publishing Asia Pty Ltd

for a response, the resolution of problems seeks to obtain a
result.13,17,23,24
CT facilitatesthe making ofdecisions,
understood as the systematic process ofevaluating and
deciding that contributes to obtaining a desired result.19
Another concept linked with CT is the nursing process.
This is a cognitive process that involves the use of CT skills
to obtain desired results. The nursing process constitutes
the basis of CT skills in nursing.25,26
Measuring CT
Six standardized instruments for evaluating CT in nursing
studentsand working nurseshave been identified:the
CaliforniaCriticalThinkingDispositionInventory
(CCTDI),the CaliforniaCriticalThinking SkillsTest
(CCTST), the Health Science Reasoning Test (HSRT), the
Watson–Glaser CriticalThinking Appraisal(WGCTA),
thePerformance-Based DevelopmentSystem (PBDS)
and the CriticalThinking Diagnostic(CTD).Table 4
presents the measuring instruments.
In the studiesusinga quantitativemethodology
(n = 53; 5.8%), the CCTDI27 was the most frequently
used instrument (n = 8; 15.0%) for examining the dispo-
sition of nursing students,28–31
working nurses,32,33
nursing
managers7 and nursing teachers.34
The CCTST35(n = 4; 7.5%) was used to measure the
CT skillsof nursing students,36,37postgraduate nursing
students38 and recently graduated nurses.39
The HSRT,40designed to evaluate the CT skills of stu-
dents and professionals in the health sciences, was used in
one study (n = 1; 1.8%) for construct validation.21
Other research studies (n = 4; 7.5%) have employed
the WGCTA41 as an instrument in the evaluation of the
CT skillsof studentsamples42 and ofworking nurse
samples.23,43,44
With the aim ofjointly analysing disposition and CT
skill,someauthorshaveusedtheCCTDI andthe
CCTST15,34,45–47
(n = 5;9.4%),offering as a resultthe
positive correlation between the two instruments. Others
have used the CCTDI and the WGTCA48,49
(n = 2; 3.7%)
without,however,finding statistically significantrela-
tions. The studies that used the CCTDI and the HSRT50–52
(n = 3; 9.6%) did not provide information on the corre-
lation between the two instruments.
Finally, there are two instruments that were used to
evaluate nursing competence in terms ofCT skills, the
PBDS53 (n = 1; 1.8%) and the CTD54 (n = 1; 1.8%).
It will be noted that several instruments are frequently
combined in the same study in order to analyse factors
influencingCT, such as expertise,55 educational
level,23,50,56
failure to rescue,56 self-confidence,50,57
learn-
ing style,19 self-esteem,52 work complexity,57 levelof
anxiety,58 job satisfaction59 and diagnostic precision.32,60
Faced with the choice ofinstruments,some authors
have opted for using alternative methods ofevaluation,
suchas therubric,61,62 theconceptmap,63 thecase
study64,65
and the questionnaire.57,66,67
From theyear2000 onward,variousresearchers
focusedtheirattentionon an evaluationof CT by
meansof qualitativemethods,usingsemistructured
interviews,68–70group discussions,62 online discussions71
and questionnaires.72,73
Strategies for promoting CT
There is interest in developing postgraduate and m
training programs that include specific strategies fo
development of CT skills in nursing students. The m
frequently analysed strategies are simulations usin
tomicalmodels, questioning, group dynamics, reflecti
diaries, the creating of concept maps and teaching
focused on reasoning.
Studies thathave used simulation as a didactic tech-
nique have posted good results in the development
skillsand dispositionsin nursing students74–78 and in
working nurses,56 with the exception of two studies that
failed to find significantresultsfollowing exposure to
simulation.79 Other studies have linked simulation with
the development of clinical judgment,61especially follow-
ing post-simulation debriefings.80
The use of questioning as a didactic technique en
ages reflection and stimulates CT in students6,81,82
and in
inexperienced nurses.65,83
Group dynamics encourages the development ofCT
skillsin students6 without,however,showingany
improvement among working nurses.36
The reflective diary is reported to be an effective
egy for increasing CT skillsin students6,57,65in thatit
encourages reflection, the assimilation ofnewly learned
material and the creation of new knowledge.
The concept map is an analytical tool that helps i
synthesizing, organizing and prioritizing of data in a
sequence. Some studies opted for using the concep
to encourage the development of CT skills, which b
positive results among both students37,67,80
and beginning
nurses.66
The use ofeducationalmodels focused on reasoning
provedeffectivein developingCT skills.Examples
6 E Zuriguel Pérez et al.
© 2014 Wiley Publishing Asia Pty Ltd

Table 4 Description of the instruments used to measure critical thinking.
Instrument Dimensions and items Scoring scale Means of
administering
Time (min)
to administer
Psychometric characteristics
California Critical Thinking Disposition
Inventory, Facione & Facione (1992)27
7 dimensions (75 items)
• Search for truth
• Mental breadth
• Willingness to analyse
• Willingness to systematize
• Self-confidence in reasoning
• Curiosity
• Cognitive maturity
Six-point Likert Self-reporting 15–20 Internal consistency: α = 0.90,27α = 0.7127
;
α = 0.7430(Danish); α = 0.8729(Arabic)
Content validity confirmed by panel of experts27
California Critical Thinking Skills Test
(Forms A and B),
Facione (1990)
5 dimensions (34 items)
• Analysis
• Evaluation
• Inference
• Deductive reasoning
• Inductive reasoning
Multiple choice; context:
everyday situations.
Self-reporting 45 Internal consistency: Forms A and B KR-20 = 0.70,35
0.8435
Content validity confirmed by panel of experts32
Health Science Reasoning Test, Facione (2006)40 dimensions (33 items)
• Analysis
• Evaluation
• Inference
• Deductive reasoning
• Inductive reasoning
Multiple choice; context:
health science situations.
Self-reporting 50 Internal consistency: KR-20 = 0.8140
Content validity confirmed by panel of experts40
Watson–Glaser Critical Thinking Appraisal
(Forms A and B), Watson and Glaser (1991)41
5 dimensions (long version 80 items, short
version 40 items)
• Inference
• Recognition of assumptions
• Deduction
• Interpretation
• Evaluation of arguments
Multiple choice Self-reporting 45 Internal consistency: Forms A and B α = 0.45, 0.6941
;
α = 0.8544
, 0.7144 (Taiwan version)
Correlation coefficient: Forms A and B 0.21, 0.5041
Perfomance-Based Development
System, Del Bueno (1990)53
3 dimensions
• CT skills
• Interpersonal skills
• Technical skills
Responses in
narrative form
Vignettes 240 Equivalence reliability: 94%53
Critical Thinking Diagnostic, Berkow et al. (2011)54 5 dimensions (25 items)
• Problem recognition
• Clinical decision-making
• Prioritization
• Clinical application
• Reflection
Six-point Likert Self-reporting 15 Internal consistency: α = 0.9754
Correlation coefficient: 0.9354
Content validity confirmed by panel of experts54
KR-20, Kuder–Richardson; α, Cronbach’s alpha.
Critical thinking in nursing 7
© 2014 Wiley Publishing Asia Pty Ltd

include the Developing Nurses’ Thinking Model,60Struc-
tured Observation and Assessmentof Practice,55 Paul’s
Modelof CriticalThinking,84 and the ClinicalJudgment
Model.85
Learning based on problems86,87was introduced into
nurse training as a method for promoting the develop-
ment of CT, the acquisition of knowledge and the devel-
opmentof the ability to resolve problemsand make
decisions.However,the resultsof a recentsystematic
review yielded no evidence of improvement in CT among
nursing students.88
Furthermore, orientation programs have yielded satis-
factory results in the developmentof CT skills among
nurses starting out in their careers.59
Finally,some studies have provided evidence ofthe
contribution of information technology and communica-
tion technology in fostering CT.71,89
DISCUSSION
The presentscoping review ofthe conceptof CT in
nursing and related concepts has clearly shown this to be
an area of interest in nursing, even though it has turned up
a number of difficulties in researching the topic.
Regarding the conceptualization of CT, we found, as
have other previous reviews,90,91
that there is no univer-
sally accepted conceptualframework for describing and
evaluating CT in nursing.The studies suggestthatthe
conceptualization ofCT needsto be consolidated and
adapted beyond the merely theoreticalto the current
health-care system and the clinical environment. There is
a need for clarification of the terminology related to CT
used in the literature.
As for the measurement of CT, we found, as did prior
reviews,92,93 thatthecurrentlyavailablestandardized
instrumentsare notsensitive formeasurementin the
nursing discipline.
CT hasbeen identified asan essentialelementin
nursing practice, yet there is little evidence that there is
regular evaluation of CT competence.
CT applied to clinical practice encourages professional
activity based on evidence and advances those aspects of
the profession related to competence. The acquisition of
CT skills, in bringing about safer, more competent care,
could serve to improve diagnostic precision and decision-
making, yielding more favorable outcomes for patients.
Nevertheless,ourreview ofthe literature hasshown
there to be only a limited number ofstudies exploring
CT in clinicalpractice.It mightbe the casethat
optimized CT skills improve the quality of patient ca
but the exact relation between CT and outcomes re
unclear.
Finally,asto the strategiesfor advancing CT,we
found, as have other researchers, inconsistent conc
regarding the evaluation ofteaching and learning strat-
egies for nursing students.48 This might be owing to the
complexity of the construct and to the lack of a con
modelof CT that would permit its evaluation in allits
dimensions. The nursing profession has not adopted
evaluation standard for CT,which makesit extremely
difficultto generalize results.In orderto be able to
improve CT skills in the clinical setting specific stre
and weaknesses need to be identified.
The challenge for the future of research into CT li
focusing on the developmentof models and evaluation
instruments that are specific to the discipline of nur
and in analysing those factors that encourage and t
that inhibit the acquisition of CT, so as to develop s
egies to foster CT in clinical practice.
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