Critical thinking in the clinical practice tutors for the Nursing degree

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Bonilla Aguilar I. El pensamiento crítico en las tutoras de práctica clínica del grado de Enfermería. Metas Enferm jun 2022; 25(5):3-6. Doi:


Inma Bonilla Aguilar


Adjunta enfermera de Diagnóstico por la Imagen. Hospital Universitari de Bellvitge. Barcelona (España). PhD Student. Grupo GRIN-IDIBELL.

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Critical thinking (CT) is a frequently researched term of interest for the nursing discipline; most of the scientific evidence is focused on promoting CT in Nursing students or novel nurses (1). The conclusion of the analysis of the different definitions of CT in scientific literature is that it is not a method to be learnt; it is transformative process which requires skills, knowledge, and a series of attitudes or dispositions, it is contextual and it has a purpose, and most of all, it looks for the self-improvement of professionals (2). For Alfaro-LeFevre (2021) (3), CT represents a complex process, subject to changes according to context, which requires an active process of reflection, making clinical judgments, problem resolution and decision making. Alfaro-LeFevre defines the CT construct as the integration of four components: knowledge, intellectual skills and competences, interpersonal and self-management competences, technical skills and competences. It puts forward a series of CT indicators or behaviour descriptions which promote CT in clinical practice.

Critical thinking incorporates the attributes of reflection, context, dialogue and time, helping the nurse in practices to solve undetermined problems of the profession. Therefore, in clinical practice CT is not only focused on a linear manner, achieving a means to an end; instead, the thought process is dynamic and integrates each attribute within the real scenarios of clinical practice. It is required to reflect, interpret and discuss the context, in order to understand our past, present and future actions (4).

The Nursing profession has not yet adopted a standard for evaluating CT, and this makes it difficult to compare the results of studies on the effect of certain interventions associated with CT development (2). The populations where CT has been more widely studied have been nurses or Nursing students. Dr Zuriguel et al. (1) states that only 3.3% of articles have studied CT in Nursing Professors. The instruments more commonly used in the Nursing educational research are the California Critical Thinking Disposition Inventory (5) and the California Critical Thinking Skills Test (6), but these do not have a theoretical basis specific to Nursing. The Nursing Critical Thinking in Clinical Practice (N-CT-4 Practice) questionnaire, designed by Dr Zuriguel, implements the nursing model by Alfaro-LeFevre. The questionnaire was validated in a sample of nurses in the clinical setting, and obtained excellent psychometric characteristics (2).

In the practical framework of the learning process of Nursing Degree students, theory and practice converge in the clinical practice setting, and this is defined as the training period spent by students in work settings of the Nursing profession, in this case and out of university, training with professionals of their sector in real work settings. Royal Decree 592/2014 of July 11th regulates the external academic practices of university students; its article 10 refers to tutorships and the requirements for their exercise. Students will have an institutional or company tutor from the collaborating entity, and an academic tutor from university. The institutional tutor designed by the collaborating entity is a person linked with said entity, with professional experience and the knowledge required to conduct an effective tutorship. The academic tutor for extracurricular practices will be preferably a university professor (7). In the Nursing Degree setting, the training on the clinical practice subjects will be linked to the university, which will define and coordinate the teaching plan, and select the different hospitals under agreement with the university where the students will conduct their periods of clinical practices. Therefore, we can define academic tutors as those nurses with assistance activity in the health institutions, but also with a contractual relationship with the university. They are involved in training students on subjects of clinical practices, through evidence and reflection on all those clinical scenarios, providing help and support to the building of knowledge. This profile allows a connection between the university and the centre of care, they carry information and documentation both ways. They are actively involved in the process of practical learning for the student, their follow-up and evaluation, jointly with the nurses of the destination units and the academic staff (8). The institutional or company tutor is a nurse with assistance activity and acts as the professional of reference during the practical learning of the student. They represent an essential component who guides, potentiates, and creates positive learning environments for students. They convey curricular practical knowledge, as well as that relative to understanding the physical and social environment, and also the values of the nursing profession. (8).

The challenge for educators is to put into practice those methodologies based on information and participation which will prepare students for a successful practice (4). The profile of the preceptor is very important in clinical practice, because it links thought with action through the attributes of critical thinking, helping to bestow wisdom in practice (9). The preceptor can be defined as that experienced nurse who will orientate new professionals in practice, which in our teaching clinical setting is known as an institutional tutor.

We are currently working on a multicentre study to validate the N-CT-4 Practice in the teaching setting, in order to evaluate the current situation of CT in those agents involved in clinical practice: both institutional and academic tutors in the Nursing Degree. The results are expected to represent a scientific finding and an increase in the current evidence regarding the matter of study. As a measure to improve CT, specific strategies of multilevel intervention could be implemented, targeting academic and institutional tutors, for the promotion of CT skills.

It is necessary to create more evidence regarding the need to evaluate CT in institutional and academic Degree tutors. Why is it necessary to incorporate CT and which would be its impact on students and future Nursing professionals? That is to say, CT is expected to help students to achieve their academic goals, but in the future it will also translate into an improvement in quality care and patient safety in aspects such as: empowerment of the patient and/or the family, optimization of the care transition process, early detection of the acute deterioration of patients, and improvement in the quality of life. Therefore, the CT will have impact on all patient care settings, because care will be based on critical, scientific and holistic reflection, and this will help to encourage the autonomy of the nursing discipline, as well as the visibility of our profession, and could have an impact on the socio-political context of the health system in our country (10).


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