Nurse Education in Practice 45 (2020) 102783

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Nurse Education in Practice

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Original research

Critical thinking skills in intensive care and medical-surgical nurses and T

their explaining factors
Tayyebeh Ali-Abadia, Hassan Babamohamadib,c,∗, Monir Nobaharb,c,d
a
Student Research Committee, Semnan University of Medical Sciences, Semnan, Iran
b
Nursing Care Research Center, Semnan University of Medical Sciences, Semnan, Iran
c
Department of Nursing, Faculty of Nursing and Midwifery, Semnan University of Medical Sciences, Semnan, Iran
d
Social Determinant of Health Research Center, Semnan University of Medical Sciences, Semnan, Iran

ARTICLE INFO ABSTRACT

Keywords: Critical thinking affects patient safety in critical situations. Nurses, in particular, intensive care unit (ICU) nurses,
Nurse need to develop their critical thinking skills. The present article seeks to compare the level of critical thinking in
Critical thinking medical-surgical and ICU nurses and investigate the factors explaining it. A cross-sectional study was conducted
Intensive care unit on 120 medical-surgical and ICU nurses (60 per group). Data were collected using the California Critical
Medical-surgical ward
Thinking Skills Test and analyzed in SPSS-16 using independent samples t-test, ANOVA, and the regression
Iran
analysis. The mean critical thinking score was 8.68 ± 2.84 in the ICU nurses and 9.12 ± 2.99 in the medical-
surgical nurses. No significant differences were found between the two groups in terms of the critical thinking
score and the scores of its domains. The results of the regression analysis showed that demographic variables
explain only 8% of the variations in critical thinking score, as only gender explains nurses' critical thinking score.
The results revealed poor critical thinking scores in the nurses working in medical-surgical wards. Investigating
the reasons for the poor scores obtained and using educational strategies such as PBL, conceptual map, parti-
cipation in interdisciplinary rounds, the development of clinical guidelines and participation in continuing
education conferences are recommended for developing critical thinking skills in nurses.

1. Introduction abilities and presentation of professional role of a person (Keating,

Critical thinking is a cognitive process in which the individual in-
vestigates the existing reasons and analyzes the available information to
arrive at a conclusion and thus makes a decision and judgement. In
other terms, critical thinking is a self-regulating and purposive process
of judgement that leads to the resolution of problems and proper de-
cision-making (Taheri et al., 2009). The dimensions of critical thinking
include cognitive skills (skills) and emotional aspects (dispositions).
Critical thinking skills include interpretation, inference, explanation,
evaluation, self-regulation, analysis and inductive and deductive rea-
soning (Profetto-McGrath, 2003).
Critical thinking requires cognitive skills, the habit of sincere in-
quisition and willingness to think about different issues. By applying
these skills, the individual needs to experience and thoughtfully in-
vestigate the application of knowledge acquired in the real world;
therefore, there is a relationship between the level of critical thinking
2014).
Critical thinking forms the foundation of nursing knowledge and is a
vital part of performance, establishing rapport, solving problems and
the theoretical and conceptual understanding of responsibilities in this
profession. Professional nurses are thus expected to possess this ability,
which is regarded as an essential part of clinical training (Kashaninia
et al., 2016). Malloch and Porter-O’Grady (2010) wrote that critical
thinking and evidence-based practice complement each other and re-
flect a new approach to clinical performance (Malloch and Porter-
O'Grady, 2010). Another reason for the necessity of critical thinking is
the gap between theory and practice in medical sciences, including
nursing, since critical thinking can put scientific knowledge into prac-
tice. This skill is in fact a means of eliminating the gap between theory
and practice (Pasargadi et al., 2002).
Critical thinking, clinical judgement, clinical reasoning and the
nursing process are all terms used to describe the method by which

Corresponding author. 5 Kilometer of Damghan Road, Education and Research Campus, Semnan University of Medical Sciences, Faculty of Nursing and
∗

Midwifery, Semnan University of Medical Sciences. Semnan, Postal Code: 3513138111, Iran.
E-mail addresses: tayebealiabadi@yahoo.com (T. Ali-Abadi), babamohammady2007@gmail.com, babamohamadi@semums.ac.ir (H. Babamohamadi),
nobahar43@semums.ac.ir (M. Nobahar).

https://doi.org/10.1016/j.nepr.2020.102783
Received 18 April 2019; Received in revised form 19 March 2020; Accepted 2 April 2020
1471-5953/ © 2020 Elsevier Ltd. All rights reserved.
T. Ali-Abadi, et al.
nurses collect and analyze data to design a care program (Dickerson,
2005).
In analyzing the concept of critical thinking in clinical nursing,
Bahmanpour et al. (2017) found six features for this concept, including
the use of the nursing process in dealing with clinical scenarios, holistic
and comprehensive practice, the application of emotional intelligence
skills in dealing with situations, the use of various models for cognition,
the factors conducive to critical thinking and the elements and com-
ponents of critical thinking. Acquiring critical thinking skills will lead
to positive outcomes such as patient-oriented and effective nursing
care, creativity, evidence-based practice and professionalism in nursing
(Bahmanpour et al., 2017).
Nursing process is a cognitive process that includes the use of cri-
tical and creative thinking skills for problem-solving and decision-
making (Chabeli, 2007). The application of critical thinking in the
nursing process enables nurses to meet the complex and diverse re-
quirements of clinical nursing practice. Moreover, there is a significant
relationship between nurses' description of the nursing process and
their level of critical thinking (Chang et al., 2011).
The results of studies conducted by Chang et al. (2011) and Tajvidi
and Moghimi Hanjani (2019) showed a significant and positive corre-
lation between critical thinking and clinical competence in nursing.
Berkow et al. (2008) also reported critical thinking as one of the six
skills of clinical competence in nursing, i.e. communication, clinical
knowledge, critical thinking, responsive management, professionalism
and technical skills. Critical thinking is a requirement of high-quality
nursing care (Scheffer and Rubenfeld, 2000), reducing the gap between
knowledge and practice (Seymour et al., 2003) and performing evi-
dence-based nursing care (Profetto-McGrath, 2005).
Scheffer and Rubenfeld (2006) argued that nurses who use critical
thinking in providing care are more confident in the process of decision-
making and can defend the decisions they have taken. Castledine
(2010) argued that nursing managers also need critical thinking skills to
create an efficient professional environment, improve satisfaction and
discourage employee turnover.
Some studies have shown that nurses' critical thinking can directly
affect the patients’ safety and recovery. Nurses should therefore be able
to understand the patients' condition change, implement individual
nursing interventions, correctly carry out medical instructions and
prioritize nursing procedures (Forneris & Peden-McAlpine, 2007; Agwu
et al., 2007). In the nursing profession, critical thinking also leads to
efficient problem-solving and promotes the ability to make judgements
and provide quality clinical services. Using critical thinking skills con-
tribute to making a proper clinical judgement and patient management
in critical and stressful situations (Babamohamadi and Khalili, 2004).
1.1. Background
Nurses are faced with several complex problems in clinical settings
and making a decision about them requires critical thinking. Critical
thinking improves nurses' ability to make decisions and identify the
patients' needs and choose the best nursing interventions (Kashaninia
et al., 2016).
Medical-surgical wards are a place where new graduates can ex-
perience the skills they have learnt in the nursing school before their
transfer to other roles, such as intensive care nursing, community
health nursing or advanced practice. This issue turns medical-surgical
nurses into a serious thinker and capable trainer for the newcomers of
the nursing profession. The three main domains in which medical-sur-
gical nurses need to implement critical thinking include evaluation,
patient treatment/care management and discharge/treatment out-
comes. In all these domains, nurses should qualify for the following
competencies: Be an independent thinker, evaluate the available evi-
dence and facts, assess consequences before making any decision or
taking any action, evaluate the organizational policy, have self-con-
fidence in decision-making, ask relevant questions, be curious and
2
Nurse Education in Practice 45 (2020) 102783
reject incorrect information (Cohen, 2017).
Alongside these nurses, ICU nurses have very particular work con-
ditions, and like other nurses, they are also faced with many stressful
occupational factors, such as heavy workloads, professional relation-
ship with other nurses and medical team members (Inoue et al., 2014),
providing care to critically-ill patients, prompt responding in emer-
gency situations, and different medical devices and techniques
(Rodrigues and Ferreira, 2011). Consequently, in all hospital wards,
especially the ICU, nurses need to process large volumes of information
and develop critical thinking skills in order to make clinical decisions
(Bastable, 2013). The measurement of nurses' disposition toward cri-
tical thinking and their critical thinking skills is therefore essential.
Acquiring critical thinking skills is not merely concerned with
higher education, and is actually affected by various components, such
as activities of living, including interpersonal and professional re-
lationships, the teacher's manner of asking questions (Widjaja et al.,
2010), personal capabilities including intelligence, knowledge, crea-
tivity, experience, direct understanding and logics (Salehi et al., 2008)
and different personal and circumstantial factors (Madadkhani et al.,
2014). Shields et al. (2012) reasoned that disregarding rationality in
nursing may prevent the development of critical thoughts.
Many studies have been conducted to measure the critical thinking
skills of students in different medical disciplines (Hariri and
Bagherinejad, 2012; Salehi et al., 2008; Widjaja et al., 2010) and
compare them at different academic levels (Gharib et al., 2009;
Kermansaravi et al., 2013) and between undergraduate and post-
graduate students (Babamohamadi et al., 2017a; Hariri and
Bagherinejad, 2012), students and clinical nurses (Eslami-Akbar and
Maarefi, 2010; Kiany et al., 2012), faculty members (Babamohamadi
et al., 2017b) and nursing managers (Zori and Morrison, 2009).
Meanwhile, only a few studies have been conducted on critical thinking
in nurses working in clinical wards or compared the level of critical
thinking in medical-surgical and ICU nurses in Iran and around the
world. In a study entitled “Critical thinking and clinical decision-
making in nurses”, Salehi et al. (2008) reported the mean score of
nurses' critical thinking as 10.67 ± 2.87 in medical-surgical wards and
10.61 ± 2.94 in ICUs, which are not significantly different.
Considering that the review of literature yielded only one relevant
study and given the limited studies on the factors explaining the level of
critical thinking among Iranian nurses, the present study was conducted
to compare critical thinking skills in medical-surgical and ICU nurses
and investigate the factors explaining these skills in the nurses working
in these wards.
2. Methods
In the present cross-sectional study, the samples were selected
through the census method or random cluster sampling from the in-
tensive care units (CCU, medical-surgical ICU) of Kowsar Teaching
Hospital in Semnan, Iran, in 2017. The study inclusion criteria were:
Willingness to participate in the study, no history of participation in
similar studies (i.e. not having completed the California Critical
Thinking Skills Test in the past) and at least six months of work ex-
perience in medical-surgical wards or ICUs. The exclusion criteria were:
Unwillingness to participate in the study and having previously com-
pleted a similar questionnaire.
After obtaining written permission from the research deputy of
Semnan University of Medical Sciences, the researcher visited the ICU
and medical-surgical wards of Kowsar Hospital and conducted sampling
during the morning, afternoon and night shifts. Data were collected
using a two-part questionnaire; the first part inquired about demo-
graphic variables, including type of ward, work experience, education,
marital status, age and gender; the second part consisted of the
California Critical Thinking Skills Test- Form-B (CCTS-FB).
The CCTS-FB consists of 34 multiple-choice items with one correct
answer in five domains of cognitive skills for critical thinking (analysis,
T. Ali-Abadi, et al. Nurse Education in Practice 45 (2020) 102783

evaluation, inference, inductive reasoning and deductive reasoning) to Table 1

specifically assess the level of critical thinking. The time required for Distribution of the demographic characteristics of nurses based on the work
answering the test questions is 45 min (Babamohamadi and Khalili, units.
2004; Khoda-Moradi et al., 2007). This tool appears to be more com- Work units Demographic Medical- Intensive Care Total
prehensive than other critical thinking assessment tools (Facione, Variables Surgical
1992).
N (%) N (%) N (%)
For interpretation, the mean score determined for this test is 15.89,
which means that scores below 15.89 indicate poor critical thinking Age (years)
skills while higher scores suggest strong critical thinking skills (Shin < 20 1 (1.7) 0 (0) 1 (0.8)
et al., 2006). 20–24 10 (16.7) 7 (11.7) 17 (14.2)
25–29 26 (43.3) 19 (31.7) 45 (37.5)
The validity and reliability of this test have been determined and
30–34 9 (15) 12 (20) 21 (17.5)
confirmed in previous studies. As for its construct validity, the factor ≥35 14 (23.3) 22 (36.6) 36 (30)
analysis results showed a positive and high level of correlation between Gendera
the scores of the sub-tests and the total score. Using Kuder Richardson Male 12 (21.1) 3 (5.1) 15 (12.9)
formula-20, the test reliability was found as 0.86 (Hariri and Female 45 (78.9) 56 (94.9) 101 (87.1)
Marital Statusa
Bagherinejad, 2012). In the present study, the reliability of this test was
Single 29 (50.9) 21 (35.6) 50 (43.1)
reassessed, and the Cronbach's alpha coefficient of the test was calcu- Married 28 (49.1) 38 (64.4) 66 (56.9)
lated as 0.87, which suggests a high reliability. Educationa
Associate degree 0 (0) 1 (1.7) 1 (0.9)
Bachelor 43 (75.4) 49 (81.7) 92 (78.6)
2.1. Data collection
Master 13 (22.8) 10 (16.7) 23 (19.6)
Ph.D 1 (1.8) 0 (0) 1 (0.9)
The ethics committee of Semnan University of Medical Sciences Work Experience (month)
approved this study under the code 92/358968. Permission to conduct 6–10 40 (66.7) 41 (68.3) 81 (67.5)
the study was obtained from the hospital authorities, and a list of the 11–15 5 (8.3) 9 (15) 14 (11.7)
16–20 2 (3.3) 3 (5) 5 (4.2)
names of the personnel of the medical-surgical wards and ICU was
20–25 1 (1.7) 1 (1.7) 2 (1.7)
obtained from the hospital's nursing office. Then, with prior arrange- > 25 12 (20) 6 (10) 18 (15)
ment with the head nurses of these wards, the researchers visited the
nurses at an appropriate time and briefed them on the study objectives N: Number; %: Percent.
a
and significance and method of honest and accurate questionnaire Missing data exists.
completion, and ensured them of the confidentiality of the results and
the voluntary nature of participation in the study. The participants then Table 2
gave their consent to participate in the study and filled out the ques- Comparison of critical thinking scores based on the work units.
tionnaires. Critical thinking domains Work unitsa P-valueb

2.2. Statistical analysis Medical-Surgical Intensive Care

Mean ± SD Mean ± SD
Data were analyzed in SPSS-16 using descriptive (frequency and
percentage, mean and standard deviation) and inferential (independent Analytic 2.50 ± 1.52 2.25 ± 1.33 0.34
samples t-test, ANOVA, and regression analysis) statistics. The level of Inference 2.68 ± 1.44 2.73 ± 1.44 0.85
Evaluation 4.14 ± 1.72 4.14 ± 1.71 0.46
statistical significance was set at P < 0.05 for all the tests.
Deductive Reasoning 3.92 ± 1.60 3.70 ± 1.69 0.51
Inductive Reasoning 4.37 ± 1.92 4.53 ± 1.70 0.64
3. Results Total 9.12 ± 2.99 8.68 ± 2.84 0.45

Of the 214 personnel working in different wards of Kowsar Hospital
affiliated to Semnan University of Medical Sciences, 60 nurses were
selected from ICUs by census sampling and 60 from medical-surgical
wards by random cluster sampling based on the study inclusion criteria.
The response rate was 100% for the ICU nurses and 80% for the med-
ical-surgical nurses. According to the results, the mean age of the par-
ticipants was 29.18 ± 6.33 years in the medical-surgical wards and
31.32 ± 6.35 years in the ICU, and the majority of nurses were female
(87.1%). In terms of marital status, 24.1% of the nurses were married in
the medical-surgical wards and 32.8% in the ICUs. The nurses' work
experience was 7.17 ± 5.27 months in the ICUs and 6.62 ± 6.02
months in the medical-surgical wards. No significant differences were
found between the two wards in terms of the demographic variables,
with the exception of gender (P > 0.05). Table 1 presents the fre-
quency distribution of the demographic variables among the nurses.
The mean and standard deviation of the nurses' critical thinking
score was 8.68 ± 2.84 in the ICUs and 9.12 ± 2.99 in the medical-
surgical ward, and the statistical analysis of the results showed no
significant differences between the two wards in terms of the critical
thinking scores (P = 0.45). The results of the ANOVA showed no sig-
nificant differences between the two wards in the scores of the different
domains of critical thinking (P > 0.05) (Table 2).
The multiple linear regression analysis was carried out using the
a
All data presented as Mean ± SD.
b
The Analysis of Variance (ANOVA) test (P < 0.05).
backward method (Chamberlain et al., 2016). First, the multiple linear
regression assumptions were assessed using the normal probability
diagram (p-p plot) and the Kolmogorov-Smirnov test to assess the
normal distribution of the demographic variables and critical thinking
skills, variance stability and the assumption of the independence of the
predictive variables (tolerance, VIF). Based on the Mahalanobis Index,
the data related to participants number 3 and 67 (outlier observations)
were eliminated from the regression analysis and the missing data were
replaced by mean values. The significance of the regression model was
confirmed using the results of the ANOVA table.
The results of the multiple linear regression analysis of the effect of
the demographic variables on the critical thinking score showed that
the demographic variables explained only 8% of the variations in this
score, and only gender explained the nurses' critical thinking score. The
mean score of critical thinking in the medical-surgical wards was
8.54 ± 2.38 in women and 11.50 ± 4.11 in men, such that women's
critical thinking scores were 2.97 lower than men's scores. The critical
thinking score of the nurses in the medical-surgical ward had a sig-
nificant relationship with gender (P < 0.001), and gender had a
greater share in explaining this relationship compared to the other

3
T. Ali-Abadi, et al. Nurse Education in Practice 45 (2020) 102783

Table 3
Multiple linear regression analysis of the effect of demographic variables on the critical thinking score in the work units.
Demographic variable Work unit Beta Standardized Beta Standard Error P-Value 95.0% CI for Beta

Lower bound Upper bound

Medical surgical (n = 58)

Work experience −0.10 −0.21 0.10 0.32 −0.327 0.110
Gendera −2.97 −0.44 0.82 0.001 −4.631 −1.319
Education 0.28 0.04 0.79 0.72 −1.301 1.869
Marital status 0.36 0.06 0.78 0.64 −1.199 1.932
Age 0.10 0.22 0.10 0.32 −0.101 0.304
Constant −6.31 8.67 0.47 −23.714 11.093
Intensive care (n = 60)
Work experience 0.92 0.20 0.10 0.39 −0.124 0.309
Gender 0.64 0.06 1.62 0.69 −2.621 3.907
Education 0.94 0.16 0.98 0.34 −1.038 2.933
Marital status −0.11 −0.002 0.73 0.98 −1.486 1.464
Age −1.35 −0.35 0.08 0.13 −0.312 0.042
Constant 17.42 7.09 0.018 3.169 31.683
Total (n = 118)
Gender −2.17 −0.29 0.66 0.001 −3.493 −0.863

a
Female:(R = 0.29; R Square = 0.08, Adjusted R Square = 0.07, Durbin-Watson = 1.71).

demographic variables. None of the demographic variables explained et al., 2014).

the critical thinking score of the ICU nurses, and in general, gender In general, the mean score of critical thinking skills has been re-
explained the variations in critical thinking score inversely by 0.29% in ported as 10.12 to 11.68 in Iranian studies using the CCTST, while the
the nurses in the medical-surgical wards and ICUs (Table 3). mean score of this test has been reported as 15.89 in the process of
standardization in the US (Eslami-Akbar and Maarefi, 2010;
Babamohamadi et al., 2017a; Babamohamadi and Khalili, 2004;
4. Discussion
Bowles, 2000; Gharib et al., 2009; Naber and Wyatt, 2014; Shin et al.,
2006). According to the present researchers, the differences in the
The results of the present study conducted to compare critical
educational and cultural infrastructure of some advanced countries and
thinking skills and determine the components explaining them in
their vision of knowledge development give them certain advantages
clinical settings showed that nurses in ICUs and medical-surgical wards
over Iran in the process of cultural flourishing and growth and gaining
have poor critical thinking skills and do not differ significantly with
mastery over the tools of personal and social development, and these
each other in terms of their skills, which concurs with the results of
advantages manifest themselves in the assessments made of people
other studies (Babamohamadi et al., 2017a; Kawashima and Petrini,
from these different countries. The educational system in Iran is not
2004). The results of a study conducted by Eslami-Akbar and Maarefi
responsive to the needs of the people, perhaps due to its greater use of
(2010) entitled “Comparing critical thinking abilities in freshman and
old and traditional strategies. Another reason for nurses' poor critical
senior undergraduate nursing students and clinical nurses” using the
thinking abilities could be the atmosphere ruling clinical settings and
Watson-Glaser tool revealed the mean critical thinking ability score as
nurses' passive dealing with problems, lack of self-confidence, inability
44.3 ± 7.7 in clinical nurses, which indicated poor critical thinking
to make decisions, resort to seniors for getting instructions and lack of
abilities. A study by Madadkhani et al. (2014) entitled “Emotional in-
professional autonomy (Eslami-Akbar and Maarefi, 2010). Also in line
telligence and the disposition toward critical thinking in nurses” re-
with this finding, Javadi et al. (2008) argued that nurses can only make
ported a mean critical thinking disposition of 264.45 ± 19.05 in the
decisions under normal circumstances and most of them do not have
nurses and showed that 78% of them had a precarious disposition to-
the power to make independent decisions in complex and unclear si-
ward critical thinking (Madadkhani et al., 2014), and since critical
tuations and simply refer to their personal or other colleagues' (in-
thinking includes emotional (disposition to critical thinking) and skill
cluding general practitioners’) experiences (Javadi et al., 2008).
dimensions and the emotional dimension is a prerequisite for the skill
Some studies have shown a significant and positive correlation be-
dimension (Babamohamadi et al., 2017b; Profetto-McGrath, 2003), a
tween critical thinking and clinical competence in nursing (Chang et al.,
precarious disposition toward critical thinking will result in a decline in
2011; Tajvidi and Moghimi Hanjani, 2019). Critical thinking is a re-
nurses’ critical thinking skills. The study conducted by Salehi et al.
quirement of high-quality nursing care (Scheffer and Rubenfeld, 2000),
(2008) also confirmed that nurses have poor critical thinking abilities.
reducing the theory-practice gap (Seymour et al., 2003) and performing
In their study, critical thinking was measured using the CCTST, and the
evidence-based nursing care (Profetto-McGrath, 2005).
mean critical thinking score was 10.67 ± 2.87 in the medical-surgical
Scheffer and Rubenfeld (2006) argued that nurses who use critical
wards and 10.61 ± 2.94 in the ICUs, with no significant differences
thinking in providing care are more confident in the process of decision-
between the wards, as in line with the present findings. Eslami-Akbar
making and can defend the decisions they have made.
and Maarefi (2010) also argued that, according to studies conducted in
Some studies have shown that nurses' critical thinking can directly
Iran, 98.3% of clinical nurses have poor critical thinking abilities. The
affect the patients’ safety and recovery (Forneris & Peden-McAlpine,
differences in critical thinking scores appear to be associated with the
2007; Agwu et al., 2007). In the nursing profession, critical thinking
different cultural backgrounds (Wangensteen et al., 2010) and the dif-
also leads to efficient problem-solving and promotes the ability to make
ferences in the tools used to assess the emotional and skill dimensions of
judgments and provide quality clinical services. Using critical thinking
critical thinking (Azizi-Fini et al., 2015).
skills contributes to making a proper clinical judgment and patient
The general belief is that nurses perform effectively during their
management in critical and stressful situations (Babamohamadi and
shifts without using critical thinking and that many of their decisions
Khalili, 2004).
are taken according to habits and with the least amount of thinking. As
Moreover, the present study showed no significant relationships
a result, they will use critical thinking only when new ideas and needs
between the critical thinking score and the demographic variables (age,
arise that require decision-making beyond the routine (Papathanasiou

4
T. Ali-Abadi, et al.
marital status, education and work experience), which agrees with the
results of other studies (Babamohamadi et al., 2017a; Salehi et al.,
2008). A study conducted by Ryan& Tatum (2012) entitled “The ob-
jective assessment of critical thinking abilities in registered nurses”
showed that the critical thinking score has no significant relationships
with work experience, education or age. Karimi-naghandar et al. (2010)
and Kiany et al. (2012) found no significant relationships between
critical thinking and age either. The research carried out by Hicks et al.
(2003) on ICU nurses showed that education and work experience have
no significant relationships with critical thinking. A study by Ludin
(2018) showed that the disposition toward critical thinking has a neg-
ligible significant relationship with gender, age, ethnicity, education
and work experience. Ingram (2008) also reported a significant re-
lationship between critical thinking and work experience (Ingram,
2008). The low level of critical thinking and the lack of a significant
relationship between critical thinking skills and work experience in the
present study can probably be attributed to the low work experience
(less than one year) in over 60% of the participants, since critical
thinking abilities are expected to gradually increase as the level of
clinical skills rise from novice to expert (Kiany et al., 2012). The dis-
parate results of the cited studies could be attributed to cultural dif-
ferences (Mangena and Chabeli, 2005), diversity in variables affecting
critical thinking (Ludin, 2018), the study population and the tools used
to assess critical thinking skills (Azizi-Fini et al., 2015).
The present findings also showed that demographic variables are
not predictors of critical thinking in ICUs. Yet, some of these variables
were able to predict critical thinking abilities in medical-surgical
nurses, such that critical thinking skills had a significant relationship
with gender in these wards, as in line with the results of Wangensteen
et al. (2010) study. The results of some studies suggest the absence of a
statistical relationship between the critical thinking score and gender,
including the study by Noshadi (2008) on the students of certain hu-
manities disciplines, including law, history, economics and sociology,
which showed that gender has no significant relationship with critical
thinking (Noshadi, 2008). The results of studies conducted by
Barkhordary et al. (2009) on nursing students, Gharibet al. (2009) on
management students, Madadkhani et al. (2014) as well as Ranjbar and
Esmaili (2006) on the students of nursing and midwifery also showed
no significant relationships between gender and critical thinking skills.
This finding should be interpreted with caution, as the gender ratio of
nurses is not equal in Iranian hospitals (including the setting of the
present study) and the number of female nurses exceeds that of male
nurses.
4.1. Limitations of the study
The limitations of this study include the small sample size and the
difficulty of completing the CCTST-FB for the nurses due to the abstract
nature of some items and potential cultural biases of the tool. More
extensive large-scale studies are therefore recommended to be con-
ducted using other tools for assessing critical thinking skills, such as the
Ritex or Watson and Glaser tools, with larger sample sizes.
5. Conclusion
The present study suggests the poor level of critical thinking in
nurses working in clinical wards and show that in-service training and
the educational facilities and environment of clinical settings have not
been able to help boost critical thinking in clinical nurses. The re-
searchers thus recommend that, in addition to seeking to resolve the
flaws of in-service training from the perspective of nurses, various
strategies also be used, such as conceptual map (Moattari et al., 2014),
simulation (Kaddoura, 2010; Zarifsanaiey et al., 2016), self-reflective
learning (Forneris & Peden-McAlpine, 2007; Swinny, 2010), problem
solving (Kong et al., 2014), peer discussion and sharing experiences of
real clinical situations (Chang et al., 2011), the application of nursing
5
Nurse Education in Practice 45 (2020) 102783
process in clinical settings and the involvement of nurses in evidence-
based research and learning (Kiany et al., 2012), so as to improve
nurses' critical thinking skills. Changing the atmosphere dominating
clinical settings and ensuring nurses' non-passive dealing with pro-
blems, which leads to a sense of self-confidence in them for making
appropriate and timely decisions and paying attention to nurses' pro-
fessional autonomy and motivation and respecting creativity in them as
well as reducing the theory-practice gap are other recommended
measures for enhancing critical thinking skills in nurses.
Source(s) of support
This study was conducted in the form of a project without financial
support of the Student Research Committee of Semnan University of
Medical Sciences, Semnan, Iran.
CRediT authorship contribution statement
Tayyebeh Ali-Abadi: Conceptualization, Data curation, Formal
analysis, Writing - original draft. Hassan Babamohamadi:
Conceptualization, Data curation, Methodology, Supervision, Writing -
original draft, Writing - review & editing. Monir Nobahar:
Conceptualization, Writing - original draft, Writing - review & editing.
Declaration of competing interest
None.
Acknowledgements
We would like to thank Kowsar Hospital research deputy and clin-
ical research development unit of Semnan University of Medical
Sciences for cooperation and providing facilities to this work. We also
thank nursing management, nurses and authorities of the intensive care
unit, medical and surgical wards of Kowsar Hospital.
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