Development of nursing students' critical thinking and clinical decision-making skills

Abstract

Aim
This study aimed to compare the critical thinking and clinical decision-making levels of first-year nursing students studying at two different universities that provide synchronous and asynchronous online distance education.

Methods
This research was applied as a pretest-posttest, quasi-experimental design. The study was conducted with the students taking the course Fundamentals of Nursing at two nursing schools that provided undergraduate education in the west of Turkey (School A and B) between May and June 2020. Seventy-one first-year students from School A and 56 first-year students from School B participated in the study. The Student Descriptive Information Form, Critical Thinking Disposition Scale, and Clinical Decision-Making Scale were used for collecting data.

Results
The study revealed that online distance education methods did not create a difference in the first-year nursing students' critical thinking and clinical decision-making levels. However, a positive significant relationship was found between critical thinking level and clinical decision-making.

Conclusion
In this study, it was concluded that synchronous and asynchronous online distance education was not superior to each other in terms of critical thinking and clinical decision-making levels of first-year nursing students. Based on the results of the research, critical thinking and new research can be done on how to make effective practices in improving the level of thinking and clinical decision-making. Thus, different research results can be compared and it can be decided how to make more effective practices related to distance education practice.

Full text

Research
Development of nursing students' critical thinking and clinical decision-
making skills
Emine
_
Ilaslan, PhD
a,
*, Derya Adıbelli, PhD
b
, Gamze Teskereci, PhD
c
,
¸Seng€
ul
€
Uzen Cura, PhD, BSN
d
a
Department of Internal Medicine Nursing, Akdeniz University Kumluca Health Science Faculty, Antalya, Turkey
b
Department of Public Health Nursing, Akdeniz University Kumluca Health Science Faculty, Antalya, Turkey
c
Department of Obstetric and Gynecologic Nursing, Akdeniz University Kumluca Health Science Faculty, Antalya, Turkey
d
Department of Nursing, School of Health Sciences, ¸Canakkale Onsekiz Mart University, ¸C anakkale, Turkey
ARTICLE INFO
Article History:
Accepted 10 July 2022
ABSTRACT
Aim: This study aimed to compare the critical thinking and clinical decision-making levels of first-year nurs-
ing students studying at two different universities that provide synchronous and asynchronous online dis-
tance education.
Methods: This research was applied as a pretest-posttest, quasi-experimental design. The study was con-
ducted with the students taking the course Fundamentals of Nursing at two nursing schools that provided
undergraduate education in the west of Turkey (School A and B) between May and June 2020. Seventy-one
first-year students from School A and 56 first-year students from School B participated in the study. The Stu-
dent Descriptive Information Form, Critical Thinking Disposition Scale, and Clinical Decision-Making Scale
were used for collecting data.
Results: The study revealed that online distance education methods did not create a difference in the first-
year nursing students' critical thinking and clinical decision-making levels. However, a positive significant
relationship was found between critical thinking level and clinical decision-making.
Conclusion: In this study, it was concluded that synchronous and asynchronous online distance education
was not superior to each other in terms of critical thinking and clinical decision-making levels of first-year
nursing students. Based on the results of the research, critical thinking and new research can be done on
how to make effective practices in improving the level of thinking and clinical decision-making. Thus, differ-
ent research results can be compared and it can be decided how to make more effective practices related to
distance education practice.
© 2022 Published by Elsevier Inc. on behalf of Organization for Associate Degree Nursing.
Keywords:
Clinical decision-making
Clinical reasoning
Critical thinking
Nursing students
Introduction
Nursing education’s purpose is to train competent nurses who can
provide professional nursing care in the rapidly changing field of
nursing practice. Therefore, nursing students should have the neces-
sary knowledge, skills, and attitudes to effectively solve the issues
that arise in diverse situations throughout their education (Lee,
2018). During the nursing education process, students are expected
to have problem-solving, analytical reasoning, critical thinking, writ-
ing, communication, interpersonal relations, teamwork, ethical deci-
sion-making, and information and communication technologies skills
(Kim, 2019;Namadi et al., 2019). Nurses' education should be as
good as thinking, problematic, and clinical reasoning to have the pro-
fessional skills necessary for high-quality and effective care
(Torabizadeh et al., 2019). Critical thinking and clinical decision-mak-
ing are among the major skills that nursing undergraduates need to
acquire or develop in the education process to become nurses who
provide safe and competent nursing care in the 21st century. Clinical
decision-making and critical thinking must be addressed together so
that students can know how to think like nurses and make clinical
decisions about patient care (Benner et al., 2010). Critical thinking
ability is a fundamental element of nursing education (Holland &
Ulrich, 2016). Critical thinking in nursing; it is a thinking process that
includes features such as collecting and organizing the data obtained
from the patient/healthy individual, deciding on the needs in parallel
with these data, choosing one of the possible approaches based on
knowledge and developed with applications, and evaluating the
results of the procedure (G€
unerig€
ok et al., 2020;Kaddoura, 2013).
While many explanations have been reported in the literature, there
is a consensus that critical thinking is oriented thinking involving
reflective reasoning before having a conclusion that leads to a clinical
*Correspondence author. Tel.: 0242 887 09 10; fax: 0242 887 0911.
E-mail address: emineilaslan@akdeniz.edu.tr (E.
_
Ilaslan).
https://doi.org/10.1016/j.teln.2022.07.004
1557-3087/© 2022 Published by Elsevier Inc. on behalf of Organization for Associate Degree Nursing.
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Contents lists available at ScienceDirect
Teaching and Learning in Nursing
journal homepage: www.journals.elsevier.com/
teaching-and-learning-in-nursing

decision. Clinical decision-making, on the other hand, has often been
defined as the process of selecting options (Thompson & Stapley,
2011). Clinical decision-making includes the nurse's evaluation of the
data by observing the patient's condition, investigating the causative
factors, quickly and accurately finding the appropriate option for the
patient's situation by considering various factors, and applying nurs-
ing interventions (Chen et al., 2016).
In nursing education, critical thinking and clinical decision-mak-
ing are significant components of providing safe and effective patient
care and high-quality nursing care. Critical thinking is a necessary,
process for safe, effective, and competent nursing practice. The nurs-
ing schools should accept attitudes that encouraging critical thinking
and mobilize the skills of clinical decision-making (Tønnessen et al.,
2020). The World Health Organization (WHO) recommends, as the
gold standard in professional nurse training, the development of clin-
ical decision-making, problem-solving and critical thinking in nurs-
ing school programs (WHO, 2009). It is highlighted by the National
League for Nursing in the United States that the undergraduate nurs-
ing curriculum should be designed in a way to advance nursing stu-
dents' critical thinking skills and learning synthesis (Simpson &
Courtney, 2002). In our country, "National Competencies of the Nurs-
ing Undergraduate Program" have been determined for the continua-
tion of my nursing education according to the standards (HU¸CEP,
2014). One of the National Competencies of the Nursing Undergradu-
ate Program is a nursing student's "use of lifelong learning, problem-
solving and critical thinking skills". In this context, the student is
expected that they will be able to think critically in nursing care, base
nursing care on the problem-solving process, and operate the deci-
sion-making process in nursing care. Nurses responsible for care in
developing and changing health service delivery are expected to
have the basic competencies specified in the “Basic Competencies
Guide in Nursing”published by the Ministry of Health in Turkey.
These competencies are professionalism, effective communication,
evidence-based practice, care management, quality improvement,
teamwork and collaboration, and professional leadership. One of the
professional competency criteria was the nurse's use of critical think-
ing and problem-solving skills in care (Ministry of Health, 2021).
Various approaches such as problem-based learning, concept
mapping, case studies, and computer-aided teaching are recom-
mended for improving critical thinking skills (Burrell, 2014;Should-
ers et al., 2014). However, which educational strategies are the most
efficient for developing and improving critical thinking skills and
clinical decision-making is still unclear, and nurse educators are
experiencing difficulties in preparing new graduates. However, criti-
cal thinking and clinical decision-making are both intangible and
nominative (Lee et al., 2017). To date, there is no consensus on the
best strategy to recognize or evaluate critical thinking in the clinical
field (Chao et al., 2013). The effects of individual variables such as
academic achievement level, age and experience on critical thinking
and decision-making in nursing students were examined by the
researchers (Chang et al., 2011;Noohi et al., 2013). The importance of
nurses’critical thinking skills for developing clinical decision-making
ability has been well recognized and brought forth worldwide efforts
to incorporate elements of critical thinking in nursing curricula (Lee
et al., 2017;Yu et al., 2013).
Statement of the Problem
Since the late 2000s, many teaching methods have been used to
develop critical thinking and clinical decision-making. However, no
consensus has been reached on which teaching method is the most
effective (Lee et al., 2016). In recent years, students who are geo-
graphically separate from educational centers or instructors have
been offered online distance learning options to ensure that they
make the best possible use of educational resources. Online distance
education processes are performed in two ways: asynchronous and
synchronous distance education (Roopnarinesingh & Whiteman,
2020). Via the tools such as Microsoft teams, Adobe Connect, Google
Hangout, or Skype, synchronous distance education is provided in
real-time through video conference or chat. In synchronous distance
education, students and teachers are not required to be online at the
same time. Asynchronous distance education, on the other hand, is
provided by uploading content such as course videos and course
topics to a Learning Management System (LMS), offering users the
flexibility of being independent of time. Since the WHO declared a
pandemic in March 2020, face-to-face education was suspended and
distance education commenced in all undergraduate programs in
Turkey. Some universities completed the education period by syn-
chronous online distance education, and some universities by asyn-
chronous online distance education. Online distance education has
created visible differences influential on students' achievement and
learning skills. These methods may also have affected students' abil-
ity to make clinical decisions and think critically. In the literature,
there are the studies that are generally conducted with seniors (Caz-
zell & Anderson, 2016;Shin et al., 2015;Weatherspoon et al., 2015)
or second, third, and fourth (Akta¸s & Karabulut, 2016;
€
Ozden et al.,
2018;
€
Ozen et al., 2017) year nursing students. The first aim of this
study is to evaluate the clinical decision-making and critical thinking
dispositions of the nursing students at two nursing schools in the
west of Turkey using different distance education methods. Its other
is to conduct a preliminary study to assess the change in clinical deci-
sion-making and critical thinking levels of the same student group
when they move to the upper grades. For these purposes, answers to
the following questions were researched:
1. Is there a difference between the critical thinking and clinical
decision-making levels of students receiving synchronous and
asynchronous online education?
2. Is there a relationship between clinical decision-making and crit-
ical thinking level?
Method
Purpose of the Study
This study was carried out to compare the critical thinking and
clinical decision-making levels of the first-year nursing students
studying at two different universities that provide synchronous and
asynchronous online distance education.
Design of the Study
This research was applied as a pretestposttest, quasi-experi-
mental design.
Sampling and Setting
The study was conducted with the students taking the course
Fundamentals of Nursing at two nursing schools that provide under-
graduate education in the west of Turkey (School A and B) between
May and June 2020. Seventy-one first-year students from School A
and 56 first-year students from School B joined in the study. Students
in school A were included in group A, and students in school B were
included in group B. This online course was conducted asynchro-
nously in school A and synchronously in school B. In this study, no
sample selection was made, and all students who took the course
Fundamentals of Nursing and volunteered to joined in the study
were included in the study. In this regard, the study was completed
with a total of 127 nursing students. All students of both schools
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participated in this study (participation rate 100%), and no student
left the research.
Conducting the Nursing Fundamentals Course
The course Fundamentals of Nursing is a compulsory course in
which fundamental nursing practices and skills are taught in the first
year of undergraduate programs in our country. This course is a 14
ECTS course with 4 hours theoretical, 4 hours laboratory, and 8 hours
clinical practice. The course Fundamentals of Nursing is a course that
aims to focus on the concepts, theories, principles, and methods con-
stituting the core and fundamental elements of nursing, and to teach
the new nursing students the theoretical concepts such as critical
thinking, ethics, and values, and to enable them to perform the daily
life activities and meet basic human requirements based on an evi-
dence-based, scientific, holistic and humanistic approach. At both
schools where the study was conducted, the curriculum of the course
Fundamentals of Nursing is similar (Box 1). One of the learning out-
comes of this course is to enable students to gain analytical thinking
skills in carrying out the nursing activities by using intellectual, inter-
personal communication skills, and psycho-motor skills to learn the
nursing theories and practices. In-School A included in the scope of
this research, the course was conducted through asynchronous
online distance education, and weekly course presentations and case
presentations were uploaded to the distance education system as
written documents. No synchronous online course was held with the
students who followed the course through written documents. At
School B, the course was conducted through synchronous distance
education by the relevant teaching staff. The lessons were held via
online distance education at the date and time included in the curric-
ulum, and students participated in the lesson through question-
answer/case discussions. The research was conducted over 8 weeks
between April and May 2020. Asynchronous online distance educa-
tion was provided at School A and synchronous online distance edu-
cation at School B for 8 weeks.
Data Collection
The pretest and post-test data of the study were collected using an
online survey prepared by the researchers. On the first day of the
Fundamental of Nursing course, the students were informed about
the purpose, method, and how to use the research results, that partic-
ipation in the research is willing, and they can withdraw from the
research at any time. The data collection form was sent to the stu-
dents who accepted to join in the study online. All participants were
asked to write a code name in the data collection form. The data col-
lection form was sent back to the students at the end of 8 weeks.
They were asked to write the code name they used in the pre-test
and post-test, and it was ensured that the data belonged to the same
person in the evaluation.
Data Collection Instrument
The Student Descriptive Information Form, Critical Thinking Dis-
position Scale, and Clinical Decision-Making Scale were used for col-
lecting data.
Student Descriptive Information Form: The form created by the
researchers includes the questions on gender, age, parents' education
status, the school of graduation, the residence place during education,
the reason for choosing the nursing profession, and the suitability of
the profession.
Critical Thinking Disposition Scale (CTDS): Critical Thinking Dis-
position Scale (CTDS): The scale was developed by Semerci (2000) as
the "Critical Thinking Scale" in Turkey. It was revised as the "Critical
Thinking Disposition Scale" by Semerci (2016). The Cronbach alpha
coefficient of the CTDS scale is 0.96. CTDS defines how students per-
ceive interpretation, analysis, inference, and evaluation from a rea-
soned point of view. It consists of a total of 49 items and five
subscales. The sub-scales, e.g. metacognition consisted of 14 state-
ments, flexibility 11 statements, systematicity 13, perseverance-
patience 8, and open-mindedness 3 statements. The evaluation of the
scale is performed over each sub-scale and the total score of the scale
(Semerci, 2016). The Cronbach alpha reliability coefficient of the scale
was calculated as 0.97 in our study.
Clinical Decision-Making in Nursing Scale (CDMNS): The scale,
which was developed by Jenkins in 1983, defines nursing students'
perceptions of clinical decision-making based on their statements
(Jenkins, 2001). The Cronbach Alpha reliability coefficient of the scale
that was adapted to the Turkish language by Durmaz Edeer and Sarı-
kaya (2015) is 0.78. CDMNS consists of 40 items and 4 sub-scales. The
subscales are “search for alternatives or options,”“canvassing of
objectives and values,”“evaluation of consequences,”and “search for
information and unbiased assimilation of new information”respec-
tively. Each subscale consists of 10 items. 22 items are positively and
18 items are negatively significant on the scale. 18 items of the scale
with negative significance are reversely scored. Each item of the scale
is evaluated as 5 = Always, 4 = often, 3 = Occasionally, 2 = Rarely,
1 = Never. It is possible to obtain a total score between 40 and 200,
and a score between 10 and 50 from each sub-scale, and there is no
cut-off point. A high score obtained from the scale indicates a high
perception of decision-making, and a low score indicates a low per-
ception of decision-making. The evaluation of the scale is performed
over each sub-scale and the total score of the scale (Durmaz Edeer &
Sarıkaya, 2015). The Cronbach alpha reliability coefficient of the scale
was calculated as 0.74 in our study.
Data Analysis
The data analysis was performed using the IBM SPSS Statistics
version 23.0 software for Windows (IBM Corp. Released 2015). The
compliance with normal distribution was tested by the ShapiroWilk
test, and it was determined that the data showed a normal distribu-
tion, and parametric tests were used. In the analysis of the data, a t-
test was used for paired comparisons between two-category varia-
bles in addition to descriptive statistics (mean, standard deviation,
frequency). Paired-sample or dependent sample t-test was used to
test the difference in two different measurement times obtained
from the same individuals, and an independent sample t-test was
conducted to analyze the scale scores between two independent
groups. The correlation coefficient was calculated for the relation-
ships between quantitative variables. The significance level was
accepted as 0.05 for the entire study.
Ethical Considerations
Ethical approval was acquired from University Clinical Research
Ethics Committee for the study (Number: 70904504/389). After
explaining the purpose of the study, the students were informed that
participating in the study was willing, their grades would not be
affected if they did not participate, their personal information would
be kept confidential, and they could withdraw from the study if they
wished. On the first page of the data collection tool, this information
about the study was made, and the students' consent was obtained.
Results
Demographics and Background Data
Table 1 shows the results of the descriptive characteristics of the
students studying at two different schools. Considering the
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descriptive characteristics of the students, it was determined that
66.2% of the students studying at School A and 83.9% of the students
studying at School B were female, and their mean age was 19.18 §
0.93 and 19.40 §1.32, respectively. The study found that mothers
(54.9% and 76.8% respectively for two schools) and fathers (54.9% and
60.7% respectively for two schools) of most of the students of both
schools were primary- school graduates. It was revealed that the
majority of the students of both schools (87.3%, 67.9% respectively)
graduated from Anatolian High School and stayed in the student dor-
mitory (54.9%, 60.7% respectively for two schools). The study discov-
ered that 60.6% of the students of School A and 37.5% of the students
of School B selected the nursing profession to find a job easily.
Around half of the students of both schools noted that they found the
nursing profession “slightly suitable”for them (54.9% and 51.8%
respectively for two schools).
CDMNS Intragroup and Intergroup Comparison
The results of the comparison of the student's total score and
mean scores of the sub-scales of CDMNS by the university are shown
in Table 2. In our study, there was no statistically significant differ-
ence between the CDMNS total score and subscale scores of the two
schools after the intervention (p >0.05). Considering Table 2,itis
seen that there is no significant difference between the pre-test and
post-test CDMNS total and sub-scales mean scores of School A (p >
0.05). In the pre-test and post-test of School B, a significant difference
was found between the sub-scales other than "evaluation of conse-
quences" and the total mean scores (p <0.05) (Table 2).
CTDS Intragroup and Intergroup Comparison
The results of the comparison of the student's total score and
mean scores of the sub-scales of CTDS by the university are shown in
Table 3. In our study, there was no statistically significant difference
between the CTDS sub-scale scores of the two schools after the inter-
vention (p >0.05). Considering Table 3, it is seen that there is a signif-
icant difference between the mean scores of the CTDS sub-scales
except "perseverance-patience" in the pre-test and post-test of
School A (p <0.05). In the pre-test and post-test of School B, there is
no significant difference between the mean scores of the CTDS sub-
scales (p >0.05) (Table 3).
Relationship Between CDMNS and CTDS Mean Scores
The relationship between CTDS and CDMNS total scores of stu-
dents is shown in Table 4. A moderate positive correlation was found
between the CTDS and CDMNS total mean scores (r = .427; p <0.01).
Discussion
Clinical decision-making establishes the foundation of profes-
sional nursing practices, and it is considered a skill that needs to be
developed and evaluated (Jahanpour et al., 2010). Critical thinking is
recognized as an essential component of nurses' professional judg-
ment and clinical decision-making. The importance of nurses' critical
thinking skills in improving clinical decision-making is well known
(Lee et al., 2017;Ludin, 2018). It has been emphasized that critical
thinking and decision-making skills are at the center of all nursing
curricula in nursing education (Lee et al., 2017;Reji & Saini, 2022).
The literature has studies generally conducted with senior nursing
students (Durmaz Edeer & Sarıkaya, 2015;G€
unerig€
ok et al., 2020).
Our study was carried out with the first-year nursing students, and it
was revealed that the students had a high rating for their skills of
"clinical decision-making and critical thinking dispositions." A high
score on critical thinking and clinical decision-making was not
expected at the planning stage of our research, but our results do not
match our expectations. It is known that individual variables may
influence cognitive and affective processes involved in decision-mak-
ing (Kamhalov
a et al., 2013). Nurses with high values of self-esteem,
and self-efficacy, make autonomous intervention decisions, seek
alternative options, examine patient data in detail, evaluate conse-
quences of these interventions (Far
ci
c et al., 2020;
€
Ozden et al.,
2018). Besides, a high score on clinical decision-making can also
mean that students have difficulty giving a realistic response because
they have not encountered a situation requiring clinical decision-
making yet. In some studies conducted in Turkey, the scores of sec-
ond-year students are higher than those of the upper graders (Akta¸s
& Karabulut, 2016;Demir Barutcu, 2019;
€
Ozen et al., 2017). The study
Table 1
Distribution of descriptive characteristics of students
School A n (71) % School B n (56) %
Gender Female 47 66.2 47 83.9
Male 24 33.8 9 16.1
Mean age 19.18 §0.93 (minmax: 1821) 19.40 §1.32 (minmax: 1825)
Mother's educational status Illiterate 18 25.4 2 3.6
Primary-school graduate 39 54.9 43 76.8
High-school graduate 9 12.7 10 17.9
University and higher 5 7.0 1 1.8
Father's educational status Illiterate 5 7.0 1 1.8
Primary-school graduate 39 54.9 34 60.7
High-school graduate 20 28.2 18 32.1
University and higher 7 9.9 3 5.4
Type of high school of graduation Anatolian high school 62 87.3 38 67.9
Vocational/technical high school 2 2.8 16 28.6
Science high school 7 9.9 2 3.6
Place of residence Student dormitory 39 54.9 45 80.4
Home with friend 24 33.8 7 12.5
Other 8 11.3 4 7.1
The reason for selecting the nursing
profession
Ease of finding a job 43 60.6 21 37.5
Voluntarily 9 12.7 4 7.1
Unintentionally 6 8.5 4 7.1
My family's intention 13 18.3 27 48.2
Suitability of the profession Very suitable 31 43.7 24 42.9
Slightly suitable 39 54.9 29 51.8
Unsuitable at all 1 1.4 3 5.4
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performed by Durmaz Edeer and Sarıkaya in 2015 showed that senior
students' clinical decision-making levels were found lower than
those of lower graders. According to the researchers' interpretation,
this situation results from the experience of second-year students in
providing care to one or two patients in clinical practice, and from
there feeling stronger and more competent in having the right deci-
sions for patients' problems. Clinical knowledge is among the most
significant elements of clinical decision-making. The high decision-
making skill, a result obtained from our research, suggests that stu-
dents make decisions based on theoretical knowledge.
In our study, no significant difference was found in the intergroup
comparison of clinical decision levels (p >0.05), but the intragroup
total score and subscale mean scores increased in the posttest, and
there was a significant difference in favor of School B (p <0.05).
Although this study reported that the clinical decision-making levels
of students increased after asynchronous and synchronous distance
education, it wasn't shown that distance education methods were
superior to one other. The synchronous online education at School B
is believed to have a positive effect on the student's decision-making
score by interacting with the students and having the question-
answer session. Some studies conducted on the level of clinical deci-
sion-making in our country have results that (Akta¸s & Karabulut,
2016;Demir Barutcu, 2019) show and do not show (Durmaz Edeer &
Sarıkaya, 2015) differences between grades. In a study conducted by
G€
unerig€
ok et al. (2019), it was found that the practice of internship
had a positive impact on clinical decision-making. The study by
€
Ozden et al. (2018) revealed that variables such as mother's working
status, voluntary selection of profession, fondness of the profession,
positive thoughts about the profession, having no problems in clinical
practice and use of theoretical knowledge in clinical practice had a
positive impact.
This study showed that the critical thinking levels of the schools
increased in the intragroup comparison, but there was no difference
between the groups. It is shown in the literature that the quality of
the relationship and interactions between the educator and the stu-
dent, and allowing students to ask questions and present their ideas,
as well as mutual respect and trust, are highly significant for the
development of critical thinking (Potgieter, 2012). According to a
study, specular writing, concept mapping, and case studies are inter-
ventions that improve critical thinking in the context of nursing edu-
cation (Yu et al., 2013). A systemic review noted that students'
readiness, individual variables, educators' beliefs and attitudes about
critical thinking, and the learning environment can get different edu-
cational effects due to cultural factors. Students in some countries or
cultures make an effort to avoid conflicts, do not question teachers,
and are hip to traditional seniority systems. Such cultural back-
grounds may obstruct students from speaking out and thinking criti-
cally (Chan, 2013). Our study discovered that synchronous online
education was not efficient in increasing students' critical thinking
levels, and even a significant difference was found between pre-test
and post-test at School A where asynchronous online education was
provided. This result does not support the literature. This significant
result suggests that methods reported to be effective in critical think-
ing arise from face-to-face lessons, and synchronous online distance
education conducted in a computer environment does not have the
same effect.
Our study shows that there is a moderate positive relationship
between critical thinking disposition and clinical decision-making.
This result supports some studies conducted with nursing students
(Bowles, 2000;Kora¸sS
€
ozen & Karabulut, 2021;Martin, 2002). In con-
trast, some studies did not show such a correlation between the two
skills (Gorton & Hayes, 2014;Noohi et al., 2012). The systematic
Table 2
Comparison of CDMNS total score and sub-scale total scores by faculties
Pro-test Post-test Test** and p value
Search for alternatives or options
School A 38.38 §5.11 39.40 §4.24 t = -0.355
p = 0.180
School B 38.50 §4.66 40.17 §4.23 t = -2.217
p = 0.031*
Test*** and p value t = 0.691 p = 0.892 t = 0.189 p = 0.312
Canvassing of objectives and values
School A 35.40 §7.22 37.67 §3.34 t = -0.286
p = -.286
School B 34.57 §3.31 36.66 §3.54 t = -3.741
p = 0.000*
Test*** and p value t = 2.774 p = 0.424 t = 0.106 p = 0.111
Evaluation of consequences
School A 38.49 §7.49 39.61 §5.49 t = -1.105
p = 0.273
School B 38.87 §5.89 40.33 §5.45 t = -1.596
p = 0.116
Test*** and p value t = 0.101 p = 0.755 t = 0.008 p = 0.464
Search for information and unbiased assimilation of new information
School A 35.63 §4.14 36.12 §4.25 t = -0.754
p = 0.453
School B 35.46 §3.50 37.30 §3.85 t = -2.849
p = 0.006*
Test*** and p value t = 2.188 p = 0.807 t = 1.681 p = 0.109
Total
School A 147.91 §17.45 150.83 §15.20 t = -1.120
p = 0.266
School B 147.41 §14.80 154.48 §14.60 t = -3.092
p = 0.003*
Test*** and p value t = 1.292 p = 0.863 t = 0.096 p = 0.175
*p <0.05.
** Paired-sample test.
***Independent sample t test.
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review by Lee et al. (2017) noted that the contradictory relationship
between critical thinking and clinical decision-making resulted from
the difference in the design of the studies and the measurement tools
used (Lee et al., 2017). To improve critical thinking and clinical deci-
sion-making, it is considered necessary to organize and develop nurs-
ing education methods for evidence-based research and to do more
research in clinical practice and education.
Conclusion
This study supports the need for different learning methods for
developing the nursing students' critical thinking and clinical deci-
sion-making level. “Our study found that levels of critical thinking
and clinical decision-making increased in both groups. However,
teaching the Fundamentals of Nursing course with "synchronous and
asynchronous online distance education" did not make a difference
between the clinical decision-making and critical thinking levels of
the first year students. This study supports the need for different
learning methods to develop nursing students' critical thinking and
clinical decision-making levels. It is seen that there is a need for
revision in the delivery of education and training in nursing schools,
taking into account extraordinary situations (distance education,
etc.) as in the COVID-19 pandemic. To develop critical thinking, prob-
lem solving and decision-making skills in nursing education; inte-
grating critical thinking strategies into the curriculum, developing
abstract thinking, controversial and questioning education, computer
aided education, analyzing critical events, using reflective techniques,
doing case studies, scripting theory with real events, making student
presentations, using concept maps in the clinic, problem solving
approaches, it is recommended to use self-assessment and peer
assessment. In order to disseminate these strategies, firstly, countries'
determination and implementation of nursing education policies, and
then cooperation with international nurse associations, and the
Table 3
Comparison of CTDS total score and sub-scale total scores by faculties
Pro-test Post-test Test** and p value
Metacognition
School A 3.87 §0.59 4.11 §0.74 t = -2.085
p = 0.041*
School B 4.08 §0.62 4.24 §0.64 t = -0.554
p = 0.582
Test*** and p value t = -2.709 p = 0.008 t = -0.970 p = 0.334
Flexibility
School A 3.87 §0.68 4.19 §0.73 t = -2.523
p = 0.014*
School B 4.08 §0.60 4.18 §0.81 t = -0.678
p = 0.501
Test*** and p value t = -1.769 p = 0.079 t = 0.072
p = 0.943
Systematicity
School A 3.72 §0.70 4.05 §0.71 t = -2.653
p = 0.010*
School B 3.97 §0.60 4.09 §0.79 t = -0.823
t = -0.823
Test*** and p value t = -2.086 p = 0.033 t = 0.388 p = 0.766
Perseverance-patience
School A 3.75 §0.83 3.99 §0.81 t = -1.729
p = 0.088
School B 4.00 §0.63 4.10 §0.81 t = -0.661
p = 0.511
Test*** and p value t = -1.302 p = 0.059 t = -0.778 p = 0.438
Open-mindedness
School A 3.73 §0.90 4.02 §0.73 t = -2.045
p = 0.045*
School B 3.92 §0.78 4.15 §0.65 t = -1.441
p = 0.155
Test*** and p value t = -1.216 p = 0.226 t = -1.033 p = 0.419
Total score
School A 3.79 §0.67 4.07 §0.67 t = -2.370 p = 0.021*
School B 4.15 §0.59 4.15 §0.67 t = -0.947 p = 0.348
Test*** and p value t = -2.089 p = 0.039* t = -0.652 p = 0.516
*p <0.05.
**Dependent sample t test.
***Independent sample t test.
Table 4
Relationship between CTDS and CDMNS total
mean scores (n = 127)
Correlation test results CTDS total score
CDMNS total score 0.427**
**p <0.01.
Box 1
Fundamentals of nursing course content
Weeks Content of course
1st week Parenteral drug applications and intravenous fluid therapy
2nd week Intramuscular drug applications, taking a blood sample, and blood
transfusion
3rd week Respiratory system applications
4th week Digestion and excretory system applications
5th week Urinary system applications, fluid-electrolyte balance, and fluid
monitoring
6th week Physical examination methods in nursing
7th week A bedridden patient care, maintenance of tissue integrity, loss,
mourning, death process
8th week The nursing care planning process
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development of education/training strategies to improve the level of
critical thinking and clinical decision-making can make a significant
contribution in this field. In future, multi-centered studies, in addi-
tion to larger sample size, the curriculum of undergraduate programs
should be supported by content aiming to improve the level of critical
thinking and clinical decision-making.
Limitations of the Study
It is accepted that the study has several limitations. It is accepted
that the study has several limitations. First, the inclusion of only
freshmen and 1825-year-old students with no previous career
experience in this study limits the generalizability of its findings.
Considering the studies showing that students' critical thinking skills
increase as they age (¸Celik et al., 2015;Shinnick & Woo, 2013;Wan-
gensteen et al., 2010) and the grade level of nursing students (Ta¸s¸cı
et al., 2022) increase, the results of this study are valid for first-year
nursing students and students whose age range is 1825. The second
limitation is that synchronous and asynchronous online distance
education used in the research was applied for 8 weeks. Since it
couldn't be predicted at the planning stage of the study that the pan-
demic process would take longer than a year, the research period
was limited to 8 weeks. This period may not be sufficient to change
the perception of critical thinking and clinical decision-making.
Consent for Publication Statement
This manuscript has not been published elsewhere. It is not pend-
ing review by other journals.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Declaration of Competing Interest
They have contributed to, read and approved the manuscript.
There has been no duplicate publication or submission of any part of
the work to another journal. There is no financial arrangement or
other relationship that could be construed as a conflict of interest.
Acknowledgments
We would like to extend our heartfelt gratitude to the nursing
students of the two schools involved in this study for sharing their
time and experience.
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