critical thinking and reflective practice in healthcare

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• v.31(1); 2021 Feb

Teaching Critical Thinking and Problem-Solving Skills to Healthcare Professionals

Jessica a. chacon.

Department of Medical Education, Paul L Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX USA

Herb Janssen

Associated data, introduction.

Determining approaches that improve student learning is far more beneficial than determining what can improve a professor’s teaching. As previously stated, “Lecturing is that mysterious process by which the contents of the note-book of the professor are transferred through the instrumentation of the fountain-pen to the note-book of the student without passing through the mind of either” [ 1 ]. This process continues today, except that the professor’s note-book has been replaced with a PowerPoint lecture and the student’s note-book is now a computer.

In 1910, the Flexner report noted that didactic lectures were antiquated and should be left to a time when “professors knew and students learned” [ 2 ]. Approximately 100 years later, the Liaison Committee on Medical Education (LCME) affirmed Flexner’s comment and suggested that student learning must involve active components [ 3 ]: It seems somewhat obscured that almost 100 years separated these two statements.

Our strategy requires the following: student engagement in the learning process; a curriculum that develops a foundation for each student’s knowledge acquisition; focusing primarily on student learning instead of professor teaching; helping enable students develop critical thinking skills; and encouraging students to develop “expertise” in their chosen discipline.

Six fundamental topics that play a role in the development of a health sciences student’s critical thinking ability will be described. In “Section I,” these topics will be discussed independently, highlighting the importance of each. In “Section II: Proposed Curriculum and Pedagogy to Improve Student Learning,” the topics will be united into a practical approach that can be used to improve student learning, curriculum, pedagogy, and assessment.

Foundation Knowledge

Students use mnemonics to provide a foundation for new information. Although mnemonics help students associate information that they want to remember with something they already know, students learn tads of information that is not placed into a practical, meaningful framework developed by the student [ 4 , 5 ]. This commentary highlights the problem of recalling facts when these facts are presented in isolation. The responsibility for this resides not with the student, but with a curriculum that teaches isolated facts, instead of integrated concepts.

A taxonomy for significant learning presented by Dr. Fink emphasizes the need to develop foundational knowledge before additional information can be learned in an effective manner [ 6 ]. He provides suggestions on developing specific learning goals in given courses. Two of his most important criteria are (1) the development of a foundation of knowledge and (2) helping students “learn how to learn” [ 6 ].

Learning Approaches and Abilities

Howard Gardner introduced the concept of multiple intelligences in the 1980s [ 7 ]. Gardner expanded this idea to include intelligence in the areas of (1) Verbal-linguistic, (2) Logical-mathematical, (3) Spatial-visual, (4) Bodily-kinesthetic, (5) Musical, (6) Interpersonal, (7) Intrapersonal personal, (8) Naturalist, and (9) Existential. He concluded that students gifted in certain areas will be drawn in that direction due to the ease with which they excel. While it is important to recognize these differences, it is crucial to not ignore the need for student development in areas where they are less gifted. For example, students gifted in mathematics who fail to develop intrapersonal and interpersonal skills will more likely become recluse, limiting their success in real-world situations [ 7 , 8 ]. Similar examples can also be found in the medical world [ 7 , 8 ].

Based on Gardner’s work, it seems evident that students admitted to our health sciences schools will arrive with different skills and abilities. Despite this, educators are required to produce graduates who have mastered the competencies required by the various accrediting agencies. Accomplishing this task demands sensitivity to the students’ different abilities. While the curriculum remains focused on the competencies students must demonstrate when training is complete. Creating this transition using a traditional lecture format is difficult, if not impossible.

Active Engagement

In 1910, Flexner suggested that didactic lecture is important; however, it should be limited only to the introduction or conclusion of a given topic [ 2 ]. Flexner stated that students should be given the opportunity to experience learning in a context that allowed them to use scientific principles rather than empirical observations [ 2 ]. Active engagement of the student in their learning process has been recently promoted by the LCME [ 3 ]. This reaffirmation of Flexner’s 1910 report highlights the incredibly slow pace at which education changes.

Critical Thinking

Critical thinking is an active process that, when applied appropriately, allows each of us to evaluate our own activities and achievements. Critical thinking also allows an individual to make minor, mid-course corrections in thinking, instead of waiting until disastrous outcomes are unavoidable.

Educators in Allied Health and Nursing have included critical thinking as part of their curriculum for many years [ 9 ]. Medical educators, on the other hand, have not fully integrated critical thinking as part of their curriculum [ 10 , 11 ].

Bloom’s taxonomy has often been used to define curriculum [ 12 ]. The usefulness and importance of Bloom’s taxonomy is not to be underestimated; however, its limitations must also be addressed. As Bloom and his colleagues clearly stated, their taxonomy describes behavioral outcomes and is incapable of determining the logical steps through which this behavior was developed [ 12 ]. Bloom highlights this shortcoming in his initial book on the cognitive domain. He described two students who solved the same algebra problem. One student does this by rote memory, having been exposed to the problem previously, while the other student accomplishes the task by applying mathematical principles. The observer has no way of knowing which approach was used unless they have prior knowledge of the students’ background [ 12 ]. The importance of this distinction becomes apparent in medical problem-solving.

Contextual Learning

Enabling students to learn in context is critical; however, trying to teach everything in context results in a double-edged sword [ 13 ]. On the one hand, learning material in context helps the student develop a solid foundation in which the new information can be built. On the other hand, the educator will find it impossible to duplicate all situations the student will encounter throughout his or her career as a healthcare provider. This dilemma again challenges the educator to develop a variety of learning situations that simulate real-world situations. It seems that “in context” can at best be developed by presenting a variety of patients in a variety of different situations.

In the clinical setting, the physician cannot use a strict hypothesis-driven study on each patient, but must treat patients using the best, most logical treatment selected based on his or her knowledge and the most reliable information.

Development of Expertise

Several researchers have studied the characteristics required of expert performance, the time required to obtain these traits, and the steps that are followed as an individual’s performance progresses from novice to expert.

Studies involving expert physicians have provided data that can be directly used in our attempt to improve curriculum and pedagogy in the healthcare profession. Patel demonstrated that medical students and entry-level residents can recall a considerable amount of non-relevant data while the expert cannot [ 14 ]. Conversely, the expert physician has a much higher level of relevant recall, suggesting they have omitted the non-relevant information and retained only relevant information that is useful in their practice. Using these methods, the expert physicians produce accurate diagnosis in almost 100% of cases, while the medical students can achieve only patricianly correct or component diagnosis only [ 14 ].

In the healthcare setting, both methods are used. The expert physicians will use forward reasoning when the accuracy of the data allows this rapid problem-solving method. When the patient’s conditions cannot be accurately described using known information, the expert diagnostician will resort to the slower hypothesis-driven, backward reasoning approach. In this manner, the highest probability of achieving an accurate diagnosis in the shortest time will be realized [ 14 ].

Section II: Proposed Curriculum and Pedagogy to Improve Student Learning

The following section will outline several distinct but interrelated approaches to accomplish the six educational principles discussed above. The topics will be highlighted as they apply to the specific topic and each section will be comprised of curriculum, pedagogy, and assessment.

Developing a Knowledge Base Using Active Learning Sensitive to Students’ Abilities

Students admitted into healthcare training programs come from various backgrounds. This is both a strength for the program and a challenge for the educator. The strength is recognized in the diversity the varied backgrounds bring to the class and ultimately the profession. The challenge for the educator is attempting to provide each student with the material and a learning approach that will fit their individual ability and knowledge level. The educator can provide prerequisite objectives that identify the basic knowledge required before the student attempts the more advanced curriculum. Scaffolding questions can also be provided that allow students to determine their mastery of these prerequisite objectives. Briefly, scaffolding questions are categorized based on complexity. Simple, factual questions are identified with a subscript “0” (i.e. 1. 0 , 2. 0 , etc.). Advanced questions have a subscript suggesting the estimated number of basic concepts that must be included/combined to derive the answer.

Using technology to provide these individual learning opportunities online allows each student to address his or her own potential deficits. Obviously, those who find their knowledge lacking will need to spend additional time learning this information; however, using technology, this can be accomplished without requiring additional class time. This approach will decrease learning gaps for students, while excluding unnecessarily repeating material known by others.

The curriculum is divided into two parts: (1) content and (2) critical thinking/problem-solving skills. The basic knowledge and factual content can be provided online. Students are expected to learn this by actively engaging the material during independent study. This saves classroom or small-group sessions for interaction where students can actively learn critical thinking/problem-solving skills.

The curriculum should be designed so that students can start at their own level of understanding. The more advanced students can identify the level appropriate for themselves and/or review the more rudimentary information as needed. As shown by previous investigators, experts omit non-relevant information so that they can focus on appropriate problem-solving. Requiring students to learn by solving problems or exploring case studies will be emphasized when possible.

Technology can be used to deliver the “content” portion of the curriculum. Voice-over PowerPoints and/or video clips made available online through WebCT or PodCast will allow each student to study separately or in groups at their own rate, starting at their own level of knowledge. The content delivered in this fashion will complement the handout and/or textbook information recommended to the students. This will provide the needed basic information that will be used as a foundation for the development of critical thinking and problem-solving. The flipped classroom and/or team-based learning can both be used to help facilitate this type of learning. [ 15 ]

Student Assessments

It is imperative for students to know whether they have mastered the material to the extent needed. This can be accomplished by providing online formative evaluations. These will not be used to determine student performance; however, the results will be provided to the educator to determine the class’s progress and evaluation of the curriculum.

Developing Critical Thinking Skills in the Classroom or Small-Group Setting

Critical thinking skills are essential to the development of well-trained healthcare professionals. These skills are not “taught” but must be “learned” by the student. The educator provides learning experiences through which the students can gain the needed skills and experience. Mastery of the content should be a responsibility placed on the student. Information and assistance are given to the students, but students are held accountable for learning the content. This does not indicate that the educator is freed from responsibility. In fact, the educator will most likely spend more time planning and preparing, compared to when didactic lectures were given; however, the spotlight will be placed on the student. Once the learning modules are developed, they can be readily updated, allowing the educators to improve their sessions with each evaluation.

Curriculum designed to help student students develop critical thinking/problem-solving skills should be learned in context. During the introductory portions of the training, this can be accomplished by providing problem-based scenarios similar to what will be expected in the later clinical setting. The transition to competency-based evaluation in many disciplines has made this a virtual necessity. Critical thinking/problem-solving skills should emphasize self-examination. It should teach an individual to accomplish this using a series of steps that progress in a logical fashion, stressing that critical thinking is a progression of logical thought, not an unguided process.

The methods of teaching critical thinking can be traced back to the dialectic methods used by Socrates. Helping the students learn by posing questions remains an effective tool. Accomplishing this in a group setting also provides each student with the opportunity to learn, not only from their mistakes and accomplishments, but from the mistakes and accomplishments of others. Scenario questions can be presented in a manner similar to those found in many board and licensure exams. This exposes students to material in a format relevant to the clinical setting and to future exams. In larger groups, PowerPoint presentation of scenario questions can be used. Team-based learning (TBL) is useful in encouraging individual self-assessment and peer-peer instruction, while also providing an opportunity for the development of critical thinking and problem-solving skills. After the Individual Readiness Assurance Test (iRAT) exam, students work together to answer the Group Readiness Assurance Test (gRAT). Following this, relevant material is covered by clinicians and basic scientists working together and questions asked using an audience response system. This has been useful in encouraging individual self-assessment and peer-peer instruction while also providing an opportunity for the development of critical thinking and problem-solving skills.

Formative assessment of the students will be given in the class session. This can be accomplished using an audience response system. This gives each individual a chance to determine their own critical thinking skill level. It will prevent the “Oh, I knew that” response from students who are in denial of their own inabilities. Summative assessment in the class will be based on the critical thinking skills presented in the classroom or small-group setting. As mentioned earlier, the students will be evaluated on their ability to think critically and to problem-solve. This will by necessity include evaluation of content knowledge—but only as it pertains to the critical thinking and problem-solving skills. This will be made clear through the use of objectives that describe both content and critical thinking.

Enhancing Critical Thinking Skills in Simulation Centers and Clinics

The development of critical thinking skills in healthcare is somewhat unique. In chess, students can start playing using the same tools employed by the experts (the chess board); however, in healthcare, allowing students to make medical decisions is ethically inappropriate and irresponsible. Simulations centers allow students to gain needed experience and confidence without placing patients at risk. Once the students have mastered simulation center experiences and acquired the needed confidence, they can participate in patient diagnosis under the watchful eye of the expert healthcare professional.

The student’s curriculum now becomes the entire knowledge base of each healthcare discipline. This includes textbooks and journal articles. Students are required to come well prepared to the clinics and/or hospital having developed and in-depth understanding of each patient in their care.

Each day, the expert healthcare provider, serving as a mentor, will provide formative evaluation of the student and his/her performance. Mentors will guide the student, suggesting changes in the skills needed to evaluate the patients properly. In addition, standardized patients provide an excellent method of student/resident evaluation.

Summative evaluation is in the form of subject/board exams. These test the student’s or resident’s ability to accurately describe and evaluate the patient. The objective structured clinical examination (OSCE) is used to evaluate the student’s ability to correctly assess the patient’s condition. Thinking aloud had been previously shown as an effective tool for evaluating expert performance in such settings [ 16 ]. Briefly, think aloud strategies require the student to explain verbally the logic they are using to combine facts to arrive at correct answers. This approach helps the evaluator to determine both the accuracy of the answer and if the correct thought process was followed by the student.

If the time required to develop an expert is a minimum of ten years, what influence can education have on the process?

Education can:

• Provide the student with a foundation of knowledge required for the development of future knowledge and skills.
• Introduce the student to critical thinking and problem-solving techniques.
• Require the student to actively engage the material instead of attempting to learn using rote memory only.
• Assess the performance of the student in a formative manner, allowing the lack of information of skills to be identified early, thus reducing the risk of failure when changes in study skills are more difficult and/or occur too late to help.
• Provide learning in a contextual format that makes the information meaningful and easier to remember.
• Provide training in forward reasoning and backward reasoning skills. It can relate these skills to the problem-solving techniques in healthcare.
• Help students develop the qualities of an expert healthcare provider.

Authors’ Contributions

The authors wrote and contributed to the final manuscript.

Data Availability

Compliance with ethical standards.

The authors declare that they have no conflict of interest.

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

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• Jonathan M Sharples , professor 1 ,
• Andrew D Oxman , research director 2 ,
• Kamal R Mahtani , clinical lecturer 3 ,
• Iain Chalmers , coordinator 4 ,
• Sandy Oliver , professor 1 ,
• Kevan Collins , chief executive 5 ,
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• Correspondence to: J M Sharples Jonathan.Sharples{at}eefoundation.org.uk

Critical thinking is just one skill crucial to evidence based practice in healthcare and education, write Jonathan Sharples and colleagues , who see exciting opportunities for cross sector collaboration

Imagine you are a primary care doctor. A patient comes into your office with acute, atypical chest pain. Immediately you consider the patient’s sex and age, and you begin to think about what questions to ask and what diagnoses and diagnostic tests to consider. You will also need to think about what treatments to consider and how to communicate with the patient and potentially with the patient’s family and other healthcare providers. Some of what you do will be done reflexively, with little explicit thought, but caring for most patients also requires you to think critically about what you are going to do.

Critical thinking, the ability to think clearly and rationally about what to do or what to believe, is essential for the practice of medicine. Few doctors are likely to argue with this. Yet, until recently, the UK regulator the General Medical Council and similar bodies in North America did not mention “critical thinking” anywhere in their standards for licensing and accreditation, 1 and critical thinking is not explicitly taught or assessed in most education programmes for health professionals. 2

Moreover, although more than 2800 articles indexed by PubMed have “critical thinking” in the title or abstract, most are about nursing. We argue that it is important for clinicians and patients to learn to think critically and that the teaching and learning of these skills should be considered explicitly. Given the shared interest in critical thinking with broader education, we also highlight why healthcare and education professionals and researchers need to work together to enable people to think critically about the health choices they make throughout life.

Essential skills for doctors and patients

Critical thinking …

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Nurturing Leadership: 4 Key Strategies for Reflective Practice in Nursing

5 min read • February, 21 2024

Nursing leaders play a pivotal role in guiding change to enhance patient care and improve professional practice environments. Reflective practice stands out as a cornerstone for effective leadership, allowing nursing professionals to evaluate their experiences critically and foster continuous improvement. This article delves into four key reflective practices that can empower nursing leaders to drive meaningful change.

The Power of Reflection in Nursing Change

Reflective practice is more than a method; it's a mindset that enables nursing leaders to learn from their actions, make informed decisions, and engage their teams in the journey towards excellence. By incorporating reflective practices into their leadership approach , nurses can better navigate the complexities of healthcare, adapt to challenges, and implement strategies that align with their goals and values.

Understanding Your Change Goals

Q: What did you say you were going to do? A: Begin by revisiting your initial objectives. Clear articulation of your goals lays the foundation for accountability and sets the stage for impactful change. Reflect on the scope of the changes you envisioned and the outcomes you aimed to achieve. This honest appraisal is your first step towards meaningful progress.

Assessing Your Actions

Q: What did you actually do? A: Reality often diverges from our plans. Assessing your actions with candor enables you to identify discrepancies between your intentions and your actual practices. Acknowledge both your achievements and the areas where you fell short. This recognition is crucial for realistic self-assessment and sets the groundwork for authentic growth.

Learning from Experience

Q: What did you learn? A: Every step in the change process offers valuable lessons. Reflect on the insights gained from your experiences and how they can inform future strategies. These lessons are the silver lining, providing clarity and direction for your next moves.

Planning Your Next Steps

Q: What do you need to do next? A: Armed with new knowledge, plan your forward strategy. Consider who needs to be involved, the resources required, and the timeline for implementation. This step is about translating insights into actionable plans that drive further change.

Incorporating Reflective Practice into Your Routine

Integrating reflective practice into your leadership routine doesn't have to be daunting. Start small with regular reflection sessions, encourage team discussions that foster collective learning, and set aside time for personal and professional development. Embracing reflection as a habit can transform your leadership approach and significantly impact your team's performance and well-being.

Reflective practice is an invaluable tool for nursing leaders seeking to navigate the complexities of healthcare and drive positive change. By focusing on these four essential aspects of reflection, you can enhance your leadership effectiveness, improve patient care , and foster a culture of continuous learning and improvement . Start today by taking a moment to reflect on your practice and empower yourself and your team for the challenges and opportunities ahead.

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Recognise, reflect, resolve: the benefits of reflecting on your practice.

Working in health and care is rewarding but it is also fast paced, and can be challenging and stressful at times. Creating the space to reflect on your practice, by yourself, with a colleague or as part of a group, can help you to deal with high levels of pressure and share lessons learned to strengthen the important bonds within and across teams.

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A critical Exploration of Theoretical Frameworks for Reflective Learning: Reflections from a Faculty Development Workshop

• Published: 24 September 2024

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• Chew-Fei Sow   ORCID: orcid.org/0000-0003-2482-2781 1 ,
• Supathiratheavy Rasiah 2 &
• Hui Meng Er   ORCID: orcid.org/0000-0001-9835-4840 3  

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Faculty training in reflective practice is essential, given the importance of this skill for health professionals. There are several reflective practice frameworks available; however, facilitators’ experiences with these frameworks vary depending on the learning context (i.e. various types of teaching and learning activities). This commentary discusses the practicality of four reflective learning frameworks, i.e. Kolb’s experiential learning framework, Gibbs’ reflective cycle, Schön’s reflective practice model, and the “What” model. Integrating the “What” model into the Gibbs’ reflective cycle or Kolb’s experiential learning framework is recommended to enhance learners’ comprehension and application of the reflective process through a simple and practical approach.

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Sow, CF., Rasiah, S. & Er, H.M. A critical Exploration of Theoretical Frameworks for Reflective Learning: Reflections from a Faculty Development Workshop. Med.Sci.Educ. (2024). https://doi.org/10.1007/s40670-024-02173-y

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CRITICAL THINKING, PROBLEM-BASED LEARNING, AND REFLECTIVE PRACTICE

Chapter 18 CRITICAL THINKING, PROBLEM-BASED LEARNING, AND REFLECTIVE PRACTICE OBJECTIVES • Define the key terms/concepts • Explain the purpose of clear language, intuition and reflection • Contrast the traditional methods of learning with problem-based learning in nursing • Discuss the purpose of reflective practice in nurse education • Discuss how critical social theory can help develop the nursing profession • Explain different writing styles that may be used for logs and journals for reflecting on practice KEY TERMS/CONCEPTS clear language critical thinking experiential learning intuition log keeping problem-based learning (PBL) reflection reflective practice CHAPTER FOCUS Students are presented with a vast amount of theory that needs to be processed and retained if they are to practise safely as nurses. Some of the methods that are used to pass on this knowledge are problem based, or reflective practice models of learning, or even critical thinking as a distinct study. The main purpose of each is to integrate practice and theory to develop nurses’ understanding during the learning experience, and develop thinking and learning as lifelong processes. LIVED EXPERIENCE So far this year I have been to two different clinical facilities. In the first one we worked as a team, and in the second one I was allocated residents to look after, as I am able to look after them totally and can plan my shift and then document in the care plan and progress notes. I feel like I can give holistic care! Nicholas, Enrolled Nurse student This chapter introduces student nurses to different approaches in the development of professional practice. While critical thinking, problem-based learning (PBL), and reflective practice have some components in common, they present different ways of acquiring knowledge and skills necessary for effective client care. CRITICAL THINKING Thinking and learning are interrelated lifelong processes. As a person selects a career path, it is important for them to become more aware and skilled in thinking. Over time, the knowledge and practical experiences gained help individuals to broaden their ability to make thoughtful observations and judgments. Critical thinking is the active, organised, cognitive and mental process used to carefully examine one’s thinking and the thinking of others. It involves the use of the mind in forming conclusions, making decisions, drawing inferences and reflecting. It means taking nothing for granted. A critical thinker identifies and challenges assumptions, considers what is important in a situation, imagines and explores alternatives, applies reason and logic, and then makes informed decisions. For a new student nurse, critical thinking begins when the student seriously questions and in a continuing way tries to answer again and again: ‘What do I really know about this nursing care situation and how do I know it?’ Critical thinking presupposes a certain basic level of intellectual humility (e.g. acknowledging one’s own ignorance) and a commitment to think clearly, precisely and accurately and to act on the basis of genuine knowledge. When nurses direct critical thinking towards understanding and assisting clients in finding solutions to their health problems, the process becomes purposeful and goal oriented. Through critical thinking a person addresses problems, considers choices and chooses an appropriate course of action. It is clear that critical thinking requires not only cognitive and mental processing skills but a person’s habit to ask questions, to remain well informed, to be honest in facing personal biases, and to be always willing to reconsider and think clearly about issues ( Alfaro-LeFevre 1999 ). Nurses who are good critical thinkers face problems without forming a quick, single solution and instead focus on the options of what to believe and do. This requires discipline to avoid premature decision making. Learning to think critically helps a nurse to care for clients as their advocate and to make better informed choices about their care. Critical thinking is more than just solving problems — it is an attempt to continually improve. Nurses learn to focus on preventing problems and maximising a client’s potential. A critical thinker learns from each clinical experience and pursues each new opportunity with an openness and renewed purpose to excel in practice. CLEAR LANGUAGE An important aspect of critical thinking is the use of language. Thinking and language are closely related processes. The ability to use language is closely associated with the ability to think meaningfully. To become a critical thinker, a nurse must be able to use language precisely and clearly. When language is vague or inaccurate it reflects similar thinking. As nurses care for clients it becomes important not only to communicate clearly with clients and families but also to be able to clearly communicate findings to other health professionals. When a nurse uses incorrect terminology, jargon or vague descriptions, communication is ineffective. Critical thinking requires a framing of one’s thoughts so that the focus and resultant message are clear. It is helpful to reflect on your language and consider whether what you communicate expresses an idea, position or judgment precisely and clearly ( Alfaro-LeFevre 1999 ). INTUITION Expertise in nursing involves the ability to think critically about the knowledge required for a client’s care and the knowledge the nurse brings to a nursing care situation. The expert nurse practises intuitively on a deep knowledge base that is applied in daily practice, and each clinical experience is a lesson for the next one. Intuition is the immediate feeling that something is so, without the benefit of conscious reasoning. It is a common experience that all people have after interacting repeatedly with their environment ( Hood & Leddy 2005) . A nurse gains intuitive knowledge by learning to describe accurately in precise nursing language the common client responses in nursing care situations. However, it is important to remember that quality nursing practice does not depend solely on intuition. Just as it is critical for nurses to know what knowledge they have, it is even more critical to know what knowledge they do not have. If nurses do not recognise how much they do not know in relation to what they do know, they are endangering the health and wellbeing of their clients. Each clinical situation must be carefully thought through. Even if a nurse believes intuitively that a client is experiencing an expected change, it is important to confirm that finding through appropriate clinical observations and measurements. Thoughtful analysis of what the nurse knows, plus a review of the most current clinical data, allows the nurse to make an accurate and sound clinical decision. Prejudices, biases and failure to acknowledge one’s limitations do not result in thoughtful professional practice ( Hood & Leddy 2005) . REFLECTION One important aspect of critical thinking is reflection. This is a process of thinking back or recalling an event to discover the meaning and purpose of that event. For a nurse, reflection involves thinking back on a client situation or experience to explore the information and other factors that influenced the handling of the situation. Reflection requires adequate knowledge and is necessary for self-evaluation, to review one’s successes and mistakes. The process of reflection helps nurses seek and understand the relationships between concepts learned in the classroom and real-life clinical incidents. Reflection also helps the nurse judge personal performance and make judgments about standards of practice. It is a process that helps make sense out of an experience and facilitates the incorporation of the experience into the nurse’s view of themself as a professional ( Rolfe, Freshwater & Jasper 2002) . Engaging in reflection is very individualised. Not everyone reflects in the same way. Some people make mental pictures of the information they contemplate; some prefer quiet thought whereas others may prefer to reflect on new knowledge by discussing it with others. Learning to be reflective takes practice. A nurse who chooses to reflect on a clinical experience must be open to new information and be able to look at the client’s perspective as well as their own. Reflecting on experience reveals behaviour significant to the nurse’s professional development. Through reflection the nurse recognises that the actions were either successful or unsuccessful. The next time a similar experience arises, the nurse uses approaches that were successful or revises an approach to ensure a successful outcome ( Crisp & Taylor 2005) . PROBLEM-BASED LEARNING Growing numbers of nursing faculties around the world believe that new models of education are required for nurses to develop the knowledge, skill and abilities to be critical thinkers, independent decision makers, lifelong learners, effective team members and competent users of information technologies. Problem-based learning (PBL) has emerged as the most promising approach to pursue when implementing a major shift in the philosophy, structure and process of nurse education curricula ( Rideout 2001 ). PBL is a teaching–learning model that may take a variety of forms but which essentially places the student at the centre of the learning process and is aimed at integrating learning with practice. In a normal lecture-based course an academic stands out front and ‘teaches’ students, that is, gives them information. Lecturers assume that students copy and learn from this information, which they are then able to regurgitate at examinations, as well as carry away to apply to work situations. PBL is different because it is based in the practical-work-type situation, where the onus is put on the students. Students need to identify what they need to know. Usually in small groups (about 10 students), students are given problem situations (usually case studies) and in that group students will discuss, research, process the material to work effectively, solve the problem, produce a report, and may sometimes make a verbal presentation for the benefit of other PBL student groups ( Clinical Interest Box 18.1 ). CLINICAL INTEREST BOX 18.1 A problem-based learning scenario Information for students In groups of five, read each step carefully. Before moving on, consult with your facilitator at the end of each step. Step 1: Preoperative assessment Mrs Brown, 55, is admitted to the surgical ward at 0700 hours for a total abdominal hysterectomy. Her history is as follows: • Dysmenorrhoea for 10 years • Menorrhagia for 2 years • Insulin-dependent diabetes mellitus since age 3 • Current medications: aspirin, medroxyprogesterone acetate (the oral contraceptive pill), Actrapid/Protophane insulin 20/80. 1. Explain each of the above mentioned medical conditions. 2. Formulate a list of questions that you would need to ask Mrs Brown. 3. Make a list of all the preoperative procedures that you may need to undertake and why you are performing them. 4. List eight potential complications (physical and psychological). Step 2: Postoperative assessment Mrs Brown has returned from theatre at 1530 hours. She is currently nil by mouth, has a dressing over her lower abdomen, intravenous therapy (IVT) is in progress, and she has an indwelling catheter on free drainage and antiembolitic stockings on. 1. What vital signs will you undertake and why do you perform each of these?

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Reflective practice

Reflective practice is a process of thinking clearly, honestly, deeply, and critically about any aspect of our professional practice. It requires committing to creating space to reflect on one's work and has long been recognised as an integral part of safety and quality.

Reflective practice is considered good practice and is foundational to processing the challenges of high stress and high risk associated with healthcare work.

For example, reflective practice directly strengthens our work in patient safety and quality using structure reflective processes to consider things such as:

• Process the factors underpinning failures,
• Identify opportunities for learning,
• Distinguish accountability,
• See the interplay of culture and
• Strengthen teamwork.

CEC has developed a suite of resources to support the development of reflective practice skills. This includes tools and tips sheets that guide the application of reflective skills in different contexts e.g., as an individual; with peers; or within your supervision.

Download the CEC Reflective practice workbook.

• Print friendly edition

Key qualities to build a reflective practice mindset (PDF)

Use this tip sheet to develop a reflective mindset when joining a reflective practice session either as a host or practitioner.

Creating reflective space (PDF)

Use this tip sheet if hosting a reflective practice session (1:1 or in a group) and want to create a safe space to reflect.

Getting in-sync (PDF)

Use this tip sheet when hosting a reflective practice session (1:1 or in a group).

Empathetic listening (PDF)

Use this tip sheet to deepen your listening skills.

Asking impactful questions (PDF)

Use this tip sheet to consider the types of questions you might ask to help you reveal new insights and deepen understanding.

Question bank (PDF)

These questions can be used to help guide individual reflective practice such as when journalling or preparing to bring a topic to a reflective practice session.

Considering multiple perspectives (PDF)

The tip sheet can help a person better understand someone else’s view or feelings before acting.

Building a shared understanding (PDF)

Use this tip sheet when building a shared understanding of the issue being raised in a reflective practice session.

Resetting our state (PDF)

Use this tip sheet as a stepped guide for generating a feel of 'The Third Space'.

Emotional regulation (PDF)

Use this tip sheet to help you take control of intense emotions.

Positive reframing to shift mindset (PDF)

Use this tip sheet when helping someone in a reflective practice session move beyond automatic negative thoughts to more constructive ways of thinking.

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12 Reflective practice prompts for health professionals

March 22, 2018 by Anne Marie Liebel

This episode was almost titled “Reflective practice prompts for people who can’t stand reflective practice.”

Reflective practice is a term that elicits groans. And sadly, that reputation is more than a little justified.

If this echoes your feelings about reflective practice, you’re not alone. Here are 12 ways to get yourself thinking that won’t bore you to tears. And you might even learn something about yourself, your context, your patients, or your practice.

EPISODE TRANSCRIPT

Hi this is 10 Minutes to Better Patient Communication. I’m Dr. Anne Marie Liebel.

I have heard “reflective practice” mentioned a few times, in the years I have been talking with physicians, medical educators, and public health professionals.

I was talking recently about reflective practice with Dr. Tasha Wyatt from the Education Innovation institute at the Medical College of Georgia. She said,

“Physicians are trained–very much so–to gather data, to make decisions.  And reflective practice is a way to slow down that process.”

Reflective practice is certainly a term that gets thrown around.

If I could say one thing about the term “reflective practice” in my experience as an educator…it would not be a nice thing to say.  If reflective practice has largely been a waste of your time, this episode is for you.

Let me be clear: I am a reflective practitioner.

I have spent most of my time in higher education trying to rescue “reflective practice” from its own bad reputation in my students’ imaginations.

That’s not to say this reputation is undeserved. From where I stand, there are some punitive, reductive, top-down things going on under the guise of “reflective practice.”

If this describes some of your experiences, I don’t blame you for groaning.

Reflective practice is a broad umbrella term that covers many different understandings of and approaches to reflection (and practice).

In the health sector, there seems to be support of reflection as a skill.

Health professionals all require critical-thinking and problem-solving skills, and reflective practice has been used to support these.

Reflection is used to increase metacognition. It is sometimes invoked as a way to connect theory to practice, or to enhance communication. Professionals reflect in classes, in continuing education, or in communities of practice; alone, in dyads, or in small groups.

One   literature review points out the variation in what reflective practice means, and how it is facilitated and assessed, in medical education. This literature review finds similar results in pharmacy education, pointing out the conflicting interpretations and applications of the term ‘reflective practice.’

I highly recommend both these literature reviews for references on reflective practice in health professions. Citations of course in the show notes.

Both also cite Donald Schön, whose highly-influential books The Reflective Practitioner and Educating the Reflective Practitioner describe and analyze reflection-in-action across multiple professions and professional contexts.

In Educating the Reflective Practitioner , Schön explains why this is important:

[T]he problems of real-world practice do not present themselves to practitioners as well-formed structures.  Indeed, they tend not to present themselves as problems at all but as messy, indeterminate situations.  Often, situations are problematic in several ways at once.  These indeterminate zones of practice—uncertainty, uniqueness, and value conflict—escape the canons of technical rationality.  It is just these indeterminate zones of practice, however, that practitioners and critical observers of the professions have come to see with increasing clarity over the past two decades as central to professional practice.  (p. 4)

What I want to share here is a key tool in reflective practice: questioning or problem-posing as a way to begin to investigate and address the ‘problems of real-world practice.’

If I hear ‘what could you have done differently’ posed as a ‘reflective practice’ question one more time, I’ll scream.

So instead, I’m going to give you twelve prompts that you can ask yourself when you wish to engage in some critical reflection.

These questions are designed to get at your taken-for-granted beliefs and actions. Things that tend to slide by, invisible, barely noticed. They encourage you to question structures, processes, and practices (as these authors do), accepting current arrangements not as given or natural but as politically and historically situated (as these authors point out).

These questions are aimed at those times when you are educating—a patient, a client, or a student. But they can have broader applicability. Overall, they are designed to encourage you to take a critical view of the customary practices and conventional roles enacted during education in your practice context.

After each, there always is a follow-up question: what implications does your answer have for your practice?   In other words, why might this matter to you and your work with patients, clients, or students?

Now I’m going to refer to patients but please understand I mean students and clients as well.

• Which patients tend to draw your attention? Why do you think this is? Which patients tend to escape your notice? Why do you think this is?
• Are there patients you find it difficult to get along with , or relate to, or reach? How do you feel about this?
• What information or knowledge are you assuming patients have when they meet with you? Where would they have acquired this knowledge or information? How have you responded when they do not appear to have this knowledge or information ?
• What’s presenting a challenge to you recently when it comes to patient education, that you did not think would present a challenge?
• Did anything a patient did or said surprise you this week? What was it? Why was it surprising to you? What would it be like if patients surprise you more often? Have you surprised yourself lately? How?
• What’s going on around you that piques your curiosity this week? That you’d like to give more time and attention to, if you could?
• The next time you meet with a patient, how are you talking to this person?  What do you tend to think of people from that social group ? How might your conversational dynamics be reflecting some unconscious biases and stereotypes?
• If you broke down the time you spent this week on different tasks and put it on a chart or graph, what would it look like? To what extent does this match your idea of a successful or productive use of your time?
• What have you done this week that you were proud of, no matter how simple it might sound?
• Are there times you are unsure of what you are communicating to a patient or colleague? How do you deal with this?
• If you could wave a magic wand and give yourself the insights, knowledge, dispositions or skills you need in order to succeed this week, what would you give yourself?
• What clever hacks , little-known tricks, or productivity boosts have you discovered lately? What might these be telling you about yourself, or your context?

Again, the important question at the end of each set is always: what implications does this have for your practice?   

Reflection is an important process for any profession. It’s important to acknowledge that health care providers are held to such high expectations that reflection can seem risky, as recent events in the UK illustrate.

As Dr. Wyatt and I were talking, she wondered aloud, “Is reflection safe? If so, under what conditions? If not, under what conditions?”

Of course, no one can eliminate the stress and messiness of practice. Reflection, when critically oriented, is designed to press into the stress and messiness of practice. And not deny it.

Whether you reflect with others, or alone in your thoughts, intentional and systematic reflection is an irreplaceable, powerful tool that invites professionals to imagine other possible practices, roles, and relationships.

If you are interested in reflecting on your language, why not start with your metaphors ? I have written a workshop just for you, that shows you how to break down the metaphors you use, understand their cognitive and affective aspects, and evaluate them in use. It’s fast, it’s On demand, and it’s right on  health communication partners.com .

This has been 10 minutes to Better Patient Communication. I’m Dr. Anne Marie Liebel. Thanks for listening.

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Using reflection in nursing practice to enhance patient care

Affiliation.

• 1 The Open University, Milton Keynes, England.
• PMID: 37005865
• DOI: 10.7748/ns.2023.e11598

The ability to reflect on, and learn from, practice experiences is essential for nurses when seeking to provide effective person-centred care. This article outlines the various types of reflection that nurses can use, such as reflection-in-action and reflection-on-action. It also details some of the main models of reflection and explains how nurses might develop their skills in reflection to enhance the quality of patient care. The article provides examples of cases and reflective activities to demonstrate how nurses can use reflection in their practice.

Keywords: continuing professional development; education; nursing models and theories; professional; professional issues; reflection.

© 2023 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.

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None declared

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• Published: 27 September 2024

Relationship between hospital ethical climate, critical thinking disposition, and nursing task performance

• Seul-Ki Park   ORCID: orcid.org/0000-0003-0151-4161 1 &
• Yeo-Won Jeong   ORCID: orcid.org/0000-0003-3824-5209 2  

BMC Nursing volume  23 , Article number:  696 ( 2024 ) Cite this article

Metrics details

As ethical conflicts increase in the ever-changing healthcare field, nursing task performance, which is the overall ability of a nurse’s professional knowledge, attitude, and skills, is important for patient health and safety, the provision of quality nursing care, and the appropriate resolution of nursing ethical problems. This study aimed to evaluate the mediating effect of critical thinking disposition on the relationship between hospital ethical climate and nursing task performance.

A cross-sectional study was conducted. A total of a convenience sample of 200 clinical nurses from two Korean cities were recruited between November and December 2021. Direct questionnaires and online surveys were used to collect the data. The study variables were analyzed using descriptive statistics, correlations, and a model tested using the Hayes PROCESS macro (Model 4) mediation model.

The mean scores for hospital ethical climate, critical thinking disposition, and nursing task performance were 91.86 ± 11.29, 97.74 ± 10.70, and 138.58 ± 14.95, respectively. Hospital ethical climate and critical thinking disposition were positively correlated with nursing task performance. In the mediation test model, hospital ethical climate was found to be positively and significantly associated with nursing task performance (ß = 0.46, p  < .001) with the mediation of critical thinking disposition (ß = 0.70, p  < .001).

Conclusions

Hospital ethical climate and critical thinking disposition may be important determinants of task performance among clinical nurses. Hospital administrators should make efforts to create a more positive ethical climate in hospitals and conduct education and campaigns on a positive hospital ethical climate for hospital staff to improve nurses’ performance.

Peer Review reports

Introduction

Owing to changes in disease structure and the rapidly aging population, nurses face ethical issues and ethically difficult situations in their daily work. The frequent triggers of ethical dilemmas in nursing practice are conflicting interpersonal relationships (patient, co-workers, or physicians), lack of trust of the patient or family member, workload affecting quality of nursing, poor organization of working process, and conflicts related to the health service and management system [ 1 , 2 ]. Haahr et al. reported that balancing harm and care is one of the ethical dilemmas, that refers to nurses’ values practice conflict leading them to perform nursing actions that are against their personal and professional values [ 1 ]. Moreover, the complexity of ethical situations in healthcare environments and nursing is increasing, affecting not only nurses but also the quality of nursing [ 3 , 4 ]. The Korean nursing community has adopted the Nursing Code of Ethics [ 5 ], emphasizing the significance of ethical environments and nurses’ ethical behavior in the field of nursing [ 6 ]. Ethical behavior of organizational members occurs among individuals; however, an individual’s unethical behavior may be condoned or aided depending on the organization’s ethical environment [ 6 ]. Therefore, the ethical climate of an organization influences the behavior or practice of members in the work environment.

Hospital ethical climate and nursing task performance

Hospital ethical climate refers to nurses’ perceptions of how ethical issues are handled in their work setting [ 7 , 8 ]. Different researchers mention multiple constructs of hospital ethical climate [ 7 , 9 ]; among them, our study adopted Olson’s conceptualization of hospital ethical climate with five dimensions related to colleagues, patients, managers, hospital/organization, and physicians [ 7 ]. Many studies on hospital ethical climate have focused on its association with work-related factors, such as job satisfaction, moral distress, and turnover intentions [ 4 , 6 ]. In South Korea, the variables commonly found in jobs and organizations are job stress, supervisor trust, and organizational commitment rather than personal [ 6 ]. In particular, the hospital ethical climate reflects organizational practices and values in care issues and is an important factor that affects the professional performance and ethical practices of nurses in that organization [ 8 ]. However, most previous studies did not address nursing professional practices as a personal variable, such as nursing task performance, when investigating hospital ethical climate [ 4 , 6 , 10 , 11 , 12 ]. In addition, Noh and Lee suggested expanding the research to evaluate the relationship between hospital ethical climate and various variables such as nursing tasks and nursing outcomes [ 6 ].

Nursing task performance refers to the ability to perform tasks that require the nursing process and provide effective patient care [ 13 , 14 , 15 ]. Nursing task performance has a significant impact on the quality of nursing and nursing competency [ 15 , 16 ]. Nursing competency—an integrated or effective performance required for nurses’ roles in the work setting [ 17 , 18 ]—is positively affected by ethical climate [ 8 ]. Numminen et al.’s study of 318 newly graduated nurses showed that the hospital ethical climate is positively correlated with nurse competency [ 8 ]. However, some studies have reported that nurses with less than one year of work experience are susceptible to hospital ethical climates [ 8 , 19 ]. Thus, this study included nursing task performance as a variable in our exploration of hospital ethical climate with nurses who had been working for more than one year to compare our work with previous findings.

Hospital ethical climate, nursing task performance, and critical thinking disposition

Critical thinking disposition can be defined as a person’s consistent internal motivation to solve problems and make decisions by thinking critically [ 20 ], and a measure to a tendency towards critical thinking [ 20 , 21 ]. Critical thinking disposition is an attitude to actively engage in critical thinking in situations that require critical thinking [ 21 ]. Nurses with a higher critical thinking disposition solve clinical problems to search for the cause and make decisions with careful consideration based on clinical evidence [ 22 ]. In particular, in rapidly changing clinical settings, nurses experience ethical dilemmas in the relationships with patients, colleagues, and organization, which are key elements of the hospital ethical climate, and this has been shown to be a factor that causes difficulties in nursing task performance and inhibiting nurse’s professional decision-making [ 1 ]. In addition, owing to the emergence of new infectious diseases such as COVID-19, nurses face more complex and high-level ethical challenges including fear of infection, disappointing results of treatment, and high mortality rate [ 23 ], and they are required to think critically to make decisions appropriate for these ethical situation. In Yuxiu Jia et al.’s qualitative study, nurses were reported to develop nursing strategies rooted in critical thinking to cope with ethical challenges [ 23 ], influenced by the hospital ethical climate [ 1 , 8 ]. Furthermore, some studies reported that critical thinking disposition is significantly associated with nursing task performance [ 24 , 25 ]. Choi & Cho's study targeting 419 nurses in a general hospital, critical thinking disposition and problem-solving processes were found to be factors that significantly affect nursing task performance [ 24 ]. In rapidly changing clinical setting, the study reported that critical thinking disposition of nurses is the one of the most important ability in resolving various ethical issues or dilemmas that arise during the process of nursing to patients from diverse cultural, social, and religious backgrounds [ 24 ]. Based on existing findings, we theorized that hospital ethical climate and nursing task performance may be related in a pathway through critical thinking disposition among nurses with one year of experience in a clinical setting.

Despite the need to consider hospital ethical climate, in a scoping review on ethical climate in the nursing environments, South Korea has the least amount of research compared to other countries [ 4 ], and interest in nurses’ perception of the ethical climate has not sufficiently spread in South Korea [ 6 ]. Moreover, the higher the critical thinking disposition, the higher the nurses’ decision making [ 22 ]. Therefore, to provide quality care to patients through accurate judgment in clinical settings, a disposition toward critical thinking and nursing task performance is important for nurses. However, to the best of our knowledge, no previous studies have examined the relationship between these three variables. Thus, we addressed this gap in the literature by investigating the relationship between hospital ethical climate, critical thinking disposition, and nursing task performance.

Research design

We conducted a cross-sectional survey. This study aimed to investigate the association between hospital ethical climate, critical thinking disposition, and nursing task performance, and confirm the mediating effect of critical thinking disposition on these relationships (Fig.  1 ).

Study model

Settings and participants

Nurses working in cities in Ulsan, South Korea were recruited using convenience sampling. Based on prior studies, nurses with less than one year of work experience were susceptible to the hospital ethical climate [ 8 , 19 ]; therefore, in this study, the inclusion criteria for the participants were nurses with more than one year of experience working in a general hospital. For regression analysis, the sample size was calculated using G*Power 3.1.9.7. The minimum number of participants needed for a statistical power of 0.95, a significance level of 0.05, and 12 predictors based on an effect size of 0.15, was 184. Considering an expected dropout rate of 20%, 220 printed questionnaires with consent forms were distributed and returned. A total of 200 valid questionnaires were used in the final analysis, after excluding 20 questionnaires with missing data.

Instruments

Hospital ethical climate.

Hospital ethical climate was measured using the Korean version of the Hospital Ethical Climate Survey (HECS) for Nurses developed by Olson [ 7 ]. Hwang and Park translated and validated the scale [ 26 ]; it comprises 26 items across five components: relationship with peers (four items), relationship with patients (four items), relationship with managers (six items), relationship with physicians (six items), and relationship with hospital/organization (six items). The responses are assessed on a 5-point Likert scale (ranging from 1 = “almost never true” to 5 = “almost always true”). A higher score indicated a more positive the perception of the hospital ethical climate. Cronbach’s alpha was 0.91 in Olson’s study, 0.95 in Hwang and Park’s study, and 0.92 in this study.

Critical thinking disposition

The Critical Thinking Disposition Scale, developed by Yoon [ 21 ] and validated by Shin, Park, and Kim [ 27 ] was used to measure critical thinking disposition. The scale comprises 27 items and seven categories: intellectual eagerness/curiosity (five items), prudence (four items), self-confidence (four items), systematicity (three items), intellectual fairness (four items), healthy skepticism (four items), and objectivity (three items). Each item is rated on a 5-point Likert scale (1 = do not agree at all, 5 = absolutely agree), and a higher score with a total score ranging from 27 to 135. Higher total or item scores indicate a higher critical thinking disposition. Two negatively worded items were reverse scored. Cronbach’s alpha was 0.84 in Yoon’s study and.90 in this study.

Nursing task performance

The Nursing Task Performance Scale developed by Paik, Han, and Lee was used to measure task performance among clinical nurses [ 28 ]. The scale comprises 35 items in four categories: knowledge-related nursing task performance (eight items), attitude evaluation regarding passion on nursing task performance (13 items), skills for nursing task performance (seven items), and evaluation of nursing ethics levels (seven items). Each item is rated on a 5-point Likert scale (1 = not at all, 5 = always). The higher total and item scores indicating higher nursing task performance. Cronbach’s alpha was 0.97 in Pack, Han and Lee’s study, and 0.96 in this study.

The measured covariates included age, sex, marital status, religion, education level, total duration of clinical experience, department, recognition of the Korean code of ethics for nurses, and education on nursing ethics.

Survey data collection and procedure

Survey data were collected between November and December 2021. First, permission for the study was obtained from the chief nursing department of each hospital. Thereafter, one of the researchers contacted the nurses directly at each hospital and explained the study’s purpose, procedure, and questionnaire content. Moreover, nurses were informed that participation was voluntary and that they could withdraw at any time during the study without any negative consequences. The questionnaires were then distributed along with a consent form, and those who did not understand the items in the questionnaires could ask the researcher for help to fill them out. One of the researchers collected the completed questionnaires. In the case of another hospital, we provided the URL for the survey using Google Surveys owing to the risk of COVID-19. We uploaded the same questionnaires to a Google survey, and the first page of the survey contained the purpose, procedure, voluntary nature, and withdrawal from the study. In addition, at the bottom of the first page, a button (“I agree”) was created, and clicking it would denote that the participants has agreed to participate in the study. For those who did not understand the items in the questionnaire, the contact number and email were provided on the first page, and the researchers responded and explained the study whenever the participants requested.

Data analysis

Data were analyzed using SPSS (version 25.0; IBM Corp., Armonk, NY, USA) and the SPSS PROCESS macro v3.4. Skewness and kurtosis for each main variable (critical thinking disposition, hospital ethical climate, and nursing task performance) were checked to determine whether the data were normally distributed (skewness range of all main variables -0.121 to 0.347, kurtosis range of all main variables -0.357 to 0.330). The main variables and covariates were analyzed using descriptive statistics. Correlations between the study variables were analyzed using Pearson’s correlation coefficients. PROCESS macro for SPSS (Model 4) was used to evaluate the mediating effect of hospital ethical climate on the relationship between critical thinking disposition and nursing task performance [ 29 , 30 ]. A 95% bias-corrected confidence interval from 5,000 resamples was generated using the bias-corrected bootstrapping method. The bootstrapping size was 5,000. Significant indirect effects were identified as p < 0.05 when the confidence interval (CI) did not include zero [ 29 , 30 ]. For analysis of correlations and mediating effect, main study variables was used the item scores.

Ethical consideration

This study was approved by the Institutional Review Board of Dongguk University, to which the authors belong (DGU IRB 20210040). This study was conducted on human participants in accordance with the Declaration of Helsinki and its subsequent amendments. The purpose, procedures, and rules of the study were explained to all the participants. In addition, the voluntary nature and confidentiality of the study were highlighted, and participants’ personal information was not revealed. Informed consent was obtained from all the subjects.

General characteristics

Of the 200 participants, 92.0% (184) were female, and the mean age was 30.50 years (range 23–64). A total of 142 (71.0%) participants were unmarried and 27.5% (55) were religious. A total of 141 (70.5%) participants held a bachelor’s degree or higher. The mean total period of clinical experience was 7.38 years (range 1–32), about half of the participants had worked in a general ward (56%), and 163 participants responded that their positions were staff nurses. A total of 117 participants were aware of the Korean code of ethics for nurses (58.5%), and 69.5% of the participants responded that they had experience receiving nursing ethics education (Table  1 ).

Descriptive statistics and correlations between hospital ethical climate, critical thinking disposition, and nursing task performance

The total score of hospital ethical climate was 91.86 ± 11.29. The mean scores of hospital ethical climate and critical thinking disposition were 3.53 ± 0.43 and 3.62 ± 0.40, respectively (Table  2 ). The mean nursing task performance score was 3.96 ± 0.43. The higher mean score for hospital ethical climate was peer and manager, 3.92 ± 0.47 and 3.80 ± 0.53, respectively. Hospital ethical climate was positively correlated with critical thinking disposition (r = 0.37, p  < 0.001) and nursing task performance (r = 0.57, p  < 0.001). In addition, nursing task performance was positively correlated with critical thinking disposition (r = 0.64, p  < 0.001).

Mediating effect of critical thinking disposition on the relationship between hospital ethical climate and nursing task performance

As shown in Table  3 , the direct association between hospital ethical climate and nursing task performance was significant (ß = 0.34, p  < 0.001). In the mediation analysis, hospital ethical climate was positively associated with critical thinking disposition (ß = 0.30, p  < 0.001), and critical thinking disposition was positively associated with nursing task performance (ß = 0.54, p  < 0.001). The indirect pathway of hospital ethical climate on nursing task performance through critical thinking disposition was significant (index = 0.16; Boot SE = 0.04; Boot CI:0.09, 0.25). Figure  2 shows the indirect pathway for critical thinking disposition on the relationship between hospital ethical climate and nursing task performance.

The indirect pathway of hospital ethical climate on the relationship between critical thinking disposition and nursing task performance (*** p  < .001)

The findings of this study show that hospital ethical climate has a positive association with nursing task performance and that critical thinking disposition has a mediating effect on this relationship. This study makes an important contribution to the literature, given that it is the first to evaluate the association between hospital ethical climate, critical thinking disposition, and nursing task performance, and the mediating effect of critical thinking disposition on the relationship between hospital ethical climate and nursing task performance in nurses in Korea.

Participants in this study evaluated the hospital ethical climate positively and higher than neutral with a total sum of 91.86, which is in accordance with previous studies [ 8 , 19 , 31 ]. In addition, domains that were positively perceived in the hospital ethical climate were particularly related to peers and managers rather than patient, hospital/organization and physicians. The results of this study are consistent with earlier studies [ 24 ]. Nurse managers are commonly appointed from among the nursing staff in the hospital, and most have a long-term clinical background and a good understanding of the hospital’s ethical climate in the field [ 11 ]. This makes managers willing to listen and support staff nurses in decision-making when they face ethical dilemmas regarding a nursing situation. Through this process, staff nurses come to trust and respect their managers, which has a crucial impact on creating and maintaining positive perceptions of the hospital’s ethical climate. Moreover, their leadership and support to staff nurses are related to the hospital’s ethical climate and, consequently, how ethical issues are dealt with for the benefit of patients [ 8 ]. The previous study reported that access to knowledgeable peers for decision support on ethical issues is important resources for preventing and handling ethical conflicts [ 32 ]. In addition, it is reported that after particularly difficult events, when reflecting whit colleagues, action, feeling, and new perspectives on ethical conflicts are made visible, processed, and normalized [ 32 ]. Thus, the exchange of experience and judgements between peers contribute to self-confidence and the ability to act in ethical conflicts.

The relationship among hospital ethical climate, critical thinking disposition, and nursing task performance

In this study, nurses with a positive perception of their hospital’s ethical climate showed increased nursing task performance. Although it is difficult to compare our results with those in currently published literature, few studies have examined the relationship between hospital ethical climate and nursing task performance. Numminen et al. showed that newly graduate nurses who had a positive perception of hospital ethical climate had significantly higher nursing competency [ 8 ]. In addition, nurses with a more positive perception of the “patient” dimension of hospital ethical climate were less likely to have made medical errors [ 26 ]. Considering job satisfaction and turnover as factors affecting nursing competency, including nursing task performance, a previous study reported that hospital ethical climate was positively correlated with job satisfaction [ 10 ]. Other studies found that nurses with more negative perceptions of hospital ethical climate were highly inclined to leave the hospital or their previous position [ 19 , 33 ]. Moreover, a negative or poor ethical climate can contribute to burnout [ 12 ]. Job satisfaction, intent to leave, and burnout are associated with lower nursing task performance or nursing competency correlated with hospital ethical climate [ 8 , 34 , 35 ] and result in poor patient safety and quality of care [ 34 ]. Therefore, hospital administrators should pay attention to a more positive institutional ethical climate.

Critical thinking disposition was significantly positively associated with nursing task performance, and this is consistent with previous findings [ 24 , 25 ]. In a study by Mohamed et al., critical thinking disposition was significantly correlated with nursing performance in patients undergoing hemodialysis [ 25 ]. Moreover, in Park et al.’s study of 188 nurses with more than 13 months of clinical experience, critical thinking disposition was a major factor influencing nurses’ competency as measured using the nursing performance appraisal tool [ 36 ]. Dispositions are the tendency to do something, and critical thinking disposition is included in the concept of critical thinking [ 37 ]. In addition, critical thinking does not occur or may be substandard without critical thinking disposition [ 38 ]. In nursing, nurses with higher critical thinking or critical thinking dispositions, are able to perform their professional work efficiently and provide effective nursing care [ 24 , 36 , 39 ]. Thus, helping nurses increase their critical thinking disposition enables them to engage proactively in job performance.

Critical thinking disposition mediated the relationship between hospital ethical climate and nursing task performance. It was confirmed that a more positive perception of the hospital’s ethical climate was associated with increased critical thinking disposition, which subsequently increased nursing task performance. In addition, nurses who perceived the hospital’s ethical climate as more negative decreased nursing task performance with decreasing critical thinking disposition. This suggests that critical thinking disposition is an important factor in the hospital ethical climate and nursing task performance, which can be explained by several factors. Given that the hospital ethical climate sets standards for how problems should be addressed, focusing on interactions with colleagues and patients [ 7 ], when nurses perceive a more positive hospital ethical climate, their communication self-efficacy increases [ 40 ], and when communication competency increases, critical thinking disposition increases [ 41 ]. In other words, nurses perceived the hospital’s ethical climate positively and actively communicated with other professionals, including managers or physicians, about patient care, treatment, or further treatment plans, and an increase in critical thinking disposition in the process of exchanging opinions. The higher the critical thinking disposition, the higher the nurse’s critical decision-making [ 22 ] and the nursing task performance [ 36 , 39 ]. Therefore, in order to improve nurses’ task performance, the first step would be to improve the hospital ethical climate more positively. Organizations can improve their hospital ethical climate through ethics training, support, and information exchange within the nursing team [ 4 ]. Moreover, the code of ethics for nurses is to be built upon in combination with the laws, regulation and professional standards [ 42 ], and culture plays an important role in giving shape to nursing professional ethical values [ 43 ]. Therefore, to develop ethical training/education for nurses, there should be mandated and customized by the local law and culture. Together with this, critical thinking disposition is also an important factor to consider improving nurses’ task performance, and it is important to provide various training or education programs to improve critical thinking disposition. Hospital policymakers or administrators should identify the characteristics of the hospital ethical climate and create a positive hospital ethical climate, as well as increase nurses’ critical thinking disposition and improve task performance. It also enhances quality of care and patient safety.

Limitations

This study had some limitations. First, the findings have limited generalizability because the nurses were conveniently sampled. Second, this was a cross-sectional study, which limits the interpretation of causality. Hence, future research can be improved through longitudinal studies. Third, as some responses were made through an online self-report questionnaire, participants may have exaggerated or reduced their performance and perceptions according to their understanding. Additionally, we did not consider the number of hospitals or universities involved in nursing ethics education. This may have affected nurses’ perceptions of the hospital’s ethical climate. Future research should test this hypothesis, including the number and places of nursing ethics education. Finally, numerous factors influenced nursing task performance, and only hospital ethical climate and critical thinking dispositions were included in this study. Hospital ethical climate and critical thinking disposition could explain a limited portion of nursing task performance. Hence, further research is recommended to explore various factors affecting nursing task performance.

The results of this study indicated that nursing task performance was significantly influenced by hospital ethical climate, and the “hospital/organization and physicians” domain was lower than other domains in the hospital ethical climate. To improve a hospital’s ethical climate, small meetings or conferences should be held periodically to exchange opinions and experiences with physicians and nurses regarding patient care and ethical issues. Increasing the number of nursing staff may also be considered to address patients’ needs and health expectations. In addition, there are different action proposed related on other domains, e.g., the workshop, seminars, or periodic counseling to develop leadership competencies among nurse [ 44 ], in-service training which adjusted for the hospital/organization to enhance nurses’ perception of the ethical climate [ 31 ]. Moreover, sufficient publicity and related education should be provided so that nurses can be aware of the ethical ideology pursued by the organization and achieve ideological alignment [ 32 ]. Critical thinking disposition mediates the relationship between hospital ethical climate and nursing task performance. Therefore, to enhance nursing task performance, hospital administrators should provide training programs or education related to critical thinking while making efforts to create a positive ethical hospital climate.

Availability of data and materials

The datasets analyzed during the current study are not publicly available because of privacy or ethical restrictions but are available from the corresponding author upon reasonable request.

The authors declare no competing interests.

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This study is a reanalysis of the data from the first author’s master’s thesis.

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Conceptualization, P.S.K. and J.Y.W; methodology, P.S.K. and J.Y.W.; investigation, H.Y.R.; data curation, software, and formal analysis, J.Y.W.; writing – original draft preparation, P.S.K. and J.Y.W.; writing – review and editing, J.Y.W. All authors have read and agreed to the published version of the manuscript.

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Park, SK., Jeong, YW. Relationship between hospital ethical climate, critical thinking disposition, and nursing task performance. BMC Nurs 23 , 696 (2024). https://doi.org/10.1186/s12912-024-02366-1

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Education & Student Experience

Student engagement with reflective practices: is this the answer in the era of generative ai.

By Dr Cherie Lucas (UNSW School of Population Health), Associate Professor Anita Heywood (UNSW Associate Dean Education (Quality)), Dr Husna Razee (UNSW School of Population Health) and Dr Ben Harris-Roxas (UNSW School of Population Health)

Dr Cherie Lucas is a #UNSWNexus Fellows – learn more about the program here .

Published 25 September 2024

Higher-education teachers face unprecedented challenges in assessing how students arrive at answers, given the accessibility of generative AI. These tools can often produce reasonable responses, blurring the distinction between genuine understanding and algorithmic output. Reflective practice can play a pivotal role in encouraging authentic learning and providing additional artefacts for educators to assess learning. Reflection on one’s practice or learning focusses on the process of learning, revealing new insights and understandings that are relevant to developing critical thinking and problem-solving skills, improving learning and developing lifelong learning skills.

Assessment drives student learning, and sometimes students do not engage in meaningful metacognition through reflection in favour of arriving at an assessable outcome. 

Reflective practice, although not a novel concept, holds renewed significance in contemporary education, particularly as professional bodies increasingly expect graduates to develop reflective-practitioner skills. 

Western practices of reflecting about “how we think” originated in the early 20th century, driven by seminal philosopher John Dewey, and have evolved into pedagogical strategies aimed at fostering deeper learning and intellectual growth. At its core, reflective practice encourages individuals to introspectively examine their thought processes, actions, values, biases and approaches to learning to make better-informed decisions. This enhances their ability to navigate the complexities and uncertainties inherent in academic and professional domains. 

The essence of reflective practice lies in its emphasis on understanding the journey, rather than fixating solely on the destination.

By dedicating time and attention to articulating and unravelling thought processes, learners can uncover invaluable insights into their problem-solving approaches, analytical reasoning and decision-making strategies.

This nuanced approach not only highlights areas of strength and improvement but also nurtures a more profound engagement with and application of subject matter to real-life contexts.

Further, in an era of increasingly sophisticated large language models, reflective practice takes on heightened relevance. Generative AI can yield responses that mimic human comprehension but may also harbor biases or inaccuracies — referred to as flaws, “ hallucinations " or plausible fabricated “ confabulations ”. Engaging students in critical reflection on these outputs encourages them to scrutinise the underlying assumptions, biases and limitations of AI technologies. This process not only sharpens their judgement but also cultivates a healthy scepticism and curiosity, essential for using generative AI responsibly.

Generative AI has been used to produce effective writing, including reflections; depending on the types of prompts used, these can be of a high standard.

Reconceptualising the task so that students reflect on the processes (rather than focusing on the final output) may make the tasks less vulnerable to AI.

For instance, educators may incorporate structured reflection exercises where students analyse their decision-making during problem-solving tasks. For example, in an  Engineering course, educators may ask students to reflect on their team dynamics and its impact on their design activity . By prompting students to articulate the reasoning behind their choices, educators can gain deeper insights into the students’ cognitive processes and can provide targeted feedback to enhance learning outcomes. Alternatively, tasking students to write reflections as a formative task to support summative learning may enhance learning. 

Furthermore, integrating reflective practice into curriculum design can scaffold students' development of metacognitive skills – the ability to monitor and regulate one's own thinking. This metacognitive awareness is crucial for lifelong learning and empowers students to adapt to evolving challenges in their academic and professional journeys.

While generative AI technologies offer unprecedented opportunities for enhancing educational experiences, the importance of reflective practice in nurturing critical thinking and problem-solving skills is more important now than before generative AI’s emergence. By prioritising the understanding of students' cognitive processes over mere outcomes, educators can foster a learning environment that values inquiry, creativity and intellectual rigor. Reflective practice not only equips students to navigate the complexities of generative AI but also cultivates a mindset of continuous growth and inquiry – one that is essential for a lifelong learning process.

Is reflective practice the answer to enhancing critical thinking skills in the era of generative AI?

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 Dr. Cherie Lucas is a   UNSW Nexus Fellow .  

• Learn about the #UNSWNexus program from the Nexus Director  here .  
• UNSW colleagues can also visit the internal info page  here  (SharePoint).

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