critical thinking in nursing video

What is Critical Thinking in Nursing? (With Examples, Importance, & How to Improve)

Successful nursing requires learning several skills used to communicate with patients, families, and healthcare teams. One of the most essential skills nurses must develop is the ability to demonstrate critical thinking. If you are a nurse, perhaps you have asked if there is a way to know how to improve critical thinking in nursing? As you read this article, you will learn what critical thinking in nursing is and why it is important. You will also find 18 simple tips to improve critical thinking in nursing and sample scenarios about how to apply critical thinking in your nursing career.

What Is Critical Thinking In Nursing?

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• Ask relevant questions • Justify opinions • Address and evaluate multiple points of view • Explain assumptions and reasons related to your choice of patient care options

5. Can I Be a Nurse If I Cannot Think Critically?

• Pre-Nursing
• Nursing School
• After Graduation

How to Apply Critical Thinking in Nursing

Harnessing the power of critical thinking can be the key to becoming a successful and competent nurse. 

Developing and refining your critical thinking skills is crucial as you embark on your nursing journey. By doing so, you’ll enhance your ability to provide high-quality care, advance your professional growth, and contribute to the ever-evolving nursing field.

What is critical thinking in nursing?

Critical thinking is an essential cognitive process that enables nurses to analyze, evaluate, and synthesize information to make informed decisions. In the context of nursing, it involves observing, interpreting, and responding to patient needs effectively. 

Critical thinking allows nurses to go beyond memorized facts and apply logical reasoning to address patient problems holistically.

As a nurse, you’ll encounter multifaceted healthcare scenarios, each presenting its unique challenges. Critical thinking enables you to approach these situations systematically, evaluate the available data, identify relevant factors, and understand the patient’s condition comprehensively.

By employing critical thinking skills, you can differentiate between urgent and non-urgent issues, prioritize care, anticipate potential complications, and adapt your interventions accordingly. This analytical approach helps minimize errors, promote patient safety, and achieve positive patient outcomes.

Why is critical thinking important in nursing?

Critical thinking serves as the backbone of nursing practice. You’ll encounter various uncertainties, changing conditions, and ethical dilemmas as a nurse. Developing critical thinking abilities empowers you to navigate these challenges confidently and provide optimal patient care.

In nursing, critical thinking is crucial for the following reasons:

• Enhanced Clinical Judgment: Critical thinking enables assessing complex situations, analyzing available information, and drawing logical conclusions. It enhances your clinical judgment, allowing you to make informed decisions based on the best available evidence and expert consensus.
• Effective Problem Solving: Nursing involves encountering problems and finding effective solutions. Critical thinking equips you with the tools to identify underlying issues, explore alternative options, and implement interventions that address the root cause of the problem.
• Patient Advocacy: Critical thinking empowers you to advocate for your patients’ needs. By actively engaging in critical inquiry, you can challenge assumptions, question policies, and promote patient-centered care.
• Adapting to Changing Environments: Healthcare is constantly evolving, with new research findings, technologies, and treatments emerging regularly. Developing critical thinking skills helps you adapt to these changes, ensuring you stay updated and deliver evidence-based care.

Examples of Critical Thinking in Nursing

Let’s dive into some real-life examples that highlight how critical thinking plays a crucial role in nursing practice:

• Prioritization: Imagine working in an emergency department where multiple patients arrive simultaneously with varying degrees of severity. Utilizing critical thinking, you can assess each patient’s condition, prioritize care based on the urgency of their needs, and allocate resources effectively.
• Medication Administration: When administering medication, critical thinking prompts you to cross-check the prescribed dose, assess potential drug interactions or allergies, and evaluate the patient’s response to the medication. This proactive approach ensures patient safety and minimizes medication errors.
• Ethical Dilemmas: Critical thinking helps you navigate complex ethical dilemmas by analyzing the values at stake, considering legal and ethical principles, and collaborating with the healthcare team to make decisions that align with the patient’s best interests.

Supplement Your Nursing Studies and Boost Your Grades

At SimpleNursing , we understand the significance of critical thinking in nursing education. Our comprehensive digital study tools are designed to enhance your critical thinking abilities, providing you with interactive case studies, practice questions, and simulated patient scenarios. 

Boost your confidence and excel in your nursing studies with SimpleNursing’s innovative study resources.

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The Value of Critical Thinking in Nursing

• How Nurses Use Critical Thinking
• How to Improve Critical Thinking
• Common Mistakes

Some experts describe a person’s ability to question belief systems, test previously held assumptions, and recognize ambiguity as evidence of critical thinking. Others identify specific skills that demonstrate critical thinking, such as the ability to identify problems and biases, infer and draw conclusions, and determine the relevance of information to a situation.

Nicholas McGowan, BSN, RN, CCRN, has been a critical care nurse for 10 years in neurological trauma nursing and cardiovascular and surgical intensive care. He defines critical thinking as “necessary for problem-solving and decision-making by healthcare providers. It is a process where people use a logical process to gather information and take purposeful action based on their evaluation.”

“This cognitive process is vital for excellent patient outcomes because it requires that nurses make clinical decisions utilizing a variety of different lenses, such as fairness, ethics, and evidence-based practice,” he says.

How Do Nurses Use Critical Thinking?

Successful nurses think beyond their assigned tasks to deliver excellent care for their patients. For example, a nurse might be tasked with changing a wound dressing, delivering medications, and monitoring vital signs during a shift. However, it requires critical thinking skills to understand how a difference in the wound may affect blood pressure and temperature and when those changes may require immediate medical intervention.

Nurses care for many patients during their shifts. Strong critical thinking skills are crucial when juggling various tasks so patient safety and care are not compromised.

Jenna Liphart Rhoads, Ph.D., RN, is a nurse educator with a clinical background in surgical-trauma adult critical care, where critical thinking and action were essential to the safety of her patients. She talks about examples of critical thinking in a healthcare environment, saying:

“Nurses must also critically think to determine which patient to see first, which medications to pass first, and the order in which to organize their day caring for patients. Patient conditions and environments are continually in flux, therefore nurses must constantly be evaluating and re-evaluating information they gather (assess) to keep their patients safe.”

The COVID-19 pandemic created hospital care situations where critical thinking was essential. It was expected of the nurses on the general floor and in intensive care units. Crystal Slaughter is an advanced practice nurse in the intensive care unit (ICU) and a nurse educator. She observed critical thinking throughout the pandemic as she watched intensive care nurses test the boundaries of previously held beliefs and master providing excellent care while preserving resources.

“Nurses are at the patient’s bedside and are often the first ones to detect issues. Then, the nurse needs to gather the appropriate subjective and objective data from the patient in order to frame a concise problem statement or question for the physician or advanced practice provider,” she explains.

Top 5 Ways Nurses Can Improve Critical Thinking Skills

We asked our experts for the top five strategies nurses can use to purposefully improve their critical thinking skills.

Case-Based Approach

Slaughter is a fan of the case-based approach to learning critical thinking skills.

In much the same way a detective would approach a mystery, she mentors her students to ask questions about the situation that help determine the information they have and the information they need. “What is going on? What information am I missing? Can I get that information? What does that information mean for the patient? How quickly do I need to act?”

Consider forming a group and working with a mentor who can guide you through case studies. This provides you with a learner-centered environment in which you can analyze data to reach conclusions and develop communication, analytical, and collaborative skills with your colleagues.

Practice Self-Reflection

Rhoads is an advocate for self-reflection. “Nurses should reflect upon what went well or did not go well in their workday and identify areas of improvement or situations in which they should have reached out for help.” Self-reflection is a form of personal analysis to observe and evaluate situations and how you responded.

This gives you the opportunity to discover mistakes you may have made and to establish new behavior patterns that may help you make better decisions. You likely already do this. For example, after a disagreement or contentious meeting, you may go over the conversation in your head and think about ways you could have responded.

It’s important to go through the decisions you made during your day and determine if you should have gotten more information before acting or if you could have asked better questions.

During self-reflection, you may try thinking about the problem in reverse. This may not give you an immediate answer, but can help you see the situation with fresh eyes and a new perspective. How would the outcome of the day be different if you planned the dressing change in reverse with the assumption you would find a wound infection? How does this information change your plan for the next dressing change?

Develop a Questioning Mind

McGowan has learned that “critical thinking is a self-driven process. It isn’t something that can simply be taught. Rather, it is something that you practice and cultivate with experience. To develop critical thinking skills, you have to be curious and inquisitive.”

To gain critical thinking skills, you must undergo a purposeful process of learning strategies and using them consistently so they become a habit. One of those strategies is developing a questioning mind. Meaningful questions lead to useful answers and are at the core of critical thinking .

However, learning to ask insightful questions is a skill you must develop. Faced with staff and nursing shortages , declining patient conditions, and a rising number of tasks to be completed, it may be difficult to do more than finish the task in front of you. Yet, questions drive active learning and train your brain to see the world differently and take nothing for granted.

It is easier to practice questioning in a non-stressful, quiet environment until it becomes a habit. Then, in the moment when your patient’s care depends on your ability to ask the right questions, you can be ready to rise to the occasion.

Practice Self-Awareness in the Moment

Critical thinking in nursing requires self-awareness and being present in the moment. During a hectic shift, it is easy to lose focus as you struggle to finish every task needed for your patients. Passing medication, changing dressings, and hanging intravenous lines all while trying to assess your patient’s mental and emotional status can affect your focus and how you manage stress as a nurse .

Staying present helps you to be proactive in your thinking and anticipate what might happen, such as bringing extra lubricant for a catheterization or extra gloves for a dressing change.

By staying present, you are also better able to practice active listening. This raises your assessment skills and gives you more information as a basis for your interventions and decisions.

Use a Process

As you are developing critical thinking skills, it can be helpful to use a process. For example:

• Ask questions.
• Gather information.
• Implement a strategy.
• Evaluate the results.
• Consider another point of view.

These are the fundamental steps of the nursing process (assess, diagnose, plan, implement, evaluate). The last step will help you overcome one of the common problems of critical thinking in nursing — personal bias.

Common Critical Thinking Pitfalls in Nursing

Your brain uses a set of processes to make inferences about what’s happening around you. In some cases, your unreliable biases can lead you down the wrong path. McGowan places personal biases at the top of his list of common pitfalls to critical thinking in nursing.

“We all form biases based on our own experiences. However, nurses have to learn to separate their own biases from each patient encounter to avoid making false assumptions that may interfere with their care,” he says. Successful critical thinkers accept they have personal biases and learn to look out for them. Awareness of your biases is the first step to understanding if your personal bias is contributing to the wrong decision.

New nurses may be overwhelmed by the transition from academics to clinical practice, leading to a task-oriented mindset and a common new nurse mistake ; this conflicts with critical thinking skills.

“Consider a patient whose blood pressure is low but who also needs to take a blood pressure medication at a scheduled time. A task-oriented nurse may provide the medication without regard for the patient’s blood pressure because medication administration is a task that must be completed,” Slaughter says. “A nurse employing critical thinking skills would address the low blood pressure, review the patient’s blood pressure history and trends, and potentially call the physician to discuss whether medication should be withheld.”

Fear and pride may also stand in the way of developing critical thinking skills. Your belief system and worldview provide comfort and guidance, but this can impede your judgment when you are faced with an individual whose belief system or cultural practices are not the same as yours. Fear or pride may prevent you from pursuing a line of questioning that would benefit the patient. Nurses with strong critical thinking skills exhibit:

• Learn from their mistakes and the mistakes of other nurses
• Look forward to integrating changes that improve patient care
• Treat each patient interaction as a part of a whole
• Evaluate new events based on past knowledge and adjust decision-making as needed
• Solve problems with their colleagues
• Are self-confident
• Acknowledge biases and seek to ensure these do not impact patient care

An Essential Skill for All Nurses

Critical thinking in nursing protects patient health and contributes to professional development and career advancement. Administrative and clinical nursing leaders are required to have strong critical thinking skills to be successful in their positions.

By using the strategies in this guide during your daily life and in your nursing role, you can intentionally improve your critical thinking abilities and be rewarded with better patient outcomes and potential career advancement.

Frequently Asked Questions About Critical Thinking in Nursing

How are critical thinking skills utilized in nursing practice.

Nursing practice utilizes critical thinking skills to provide the best care for patients. Often, the patient’s cause of pain or health issue is not immediately clear. Nursing professionals need to use their knowledge to determine what might be causing distress, collect vital information, and make quick decisions on how best to handle the situation.

How does nursing school develop critical thinking skills?

Nursing school gives students the knowledge professional nurses use to make important healthcare decisions for their patients. Students learn about diseases, anatomy, and physiology, and how to improve the patient’s overall well-being. Learners also participate in supervised clinical experiences, where they practice using their critical thinking skills to make decisions in professional settings.

Do only nurse managers use critical thinking?

Nurse managers certainly use critical thinking skills in their daily duties. But when working in a health setting, anyone giving care to patients uses their critical thinking skills. Everyone — including licensed practical nurses, registered nurses, and advanced nurse practitioners —needs to flex their critical thinking skills to make potentially life-saving decisions.

Meet Our Contributors

Crystal Slaughter, DNP, APRN, ACNS-BC, CNE

Crystal Slaughter is a core faculty member in Walden University’s RN-to-BSN program. She has worked as an advanced practice registered nurse with an intensivist/pulmonary service to provide care to hospitalized ICU patients and in inpatient palliative care. Slaughter’s clinical interests lie in nursing education and evidence-based practice initiatives to promote improving patient care.

Jenna Liphart Rhoads, Ph.D., RN

Jenna Liphart Rhoads is a nurse educator and freelance author and editor. She earned a BSN from Saint Francis Medical Center College of Nursing and an MS in nursing education from Northern Illinois University. Rhoads earned a Ph.D. in education with a concentration in nursing education from Capella University where she researched the moderation effects of emotional intelligence on the relationship of stress and GPA in military veteran nursing students. Her clinical background includes surgical-trauma adult critical care, interventional radiology procedures, and conscious sedation in adult and pediatric populations.

Nicholas McGowan, BSN, RN, CCRN

Nicholas McGowan is a critical care nurse with 10 years of experience in cardiovascular, surgical intensive care, and neurological trauma nursing. McGowan also has a background in education, leadership, and public speaking. He is an online learner who builds on his foundation of critical care nursing, which he uses directly at the bedside where he still practices. In addition, McGowan hosts an online course at Critical Care Academy where he helps nurses achieve critical care (CCRN) certification.

How To Critically Think (Nursing)

Clinical , Study Tips and Getting Organized

Are you SUPER confused on what critical thinking means in nursing school?

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In this video, I’ll walk you through what critical thinking is and how you can do it in nursing school.

Here’s what we’ll talk about:

There are 2 parts to critical thinking: 1. Connecting the dots with everything you’re learning 2. Planning ahead

I’ll also walk you through 9 critical thinking questions to ask to help you critically think while you study or take care of patients at clinical during nursing school.

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What is Critical Thinking in Nursing? (Explained W/ Examples)

Last updated on August 23rd, 2023

Critical thinking is a foundational skill applicable across various domains, including education, problem-solving, decision-making, and professional fields such as science, business, healthcare, and more.

It plays a crucial role in promoting logical and rational thinking, fostering informed decision-making, and enabling individuals to navigate complex and rapidly changing environments.

In this article, we will look at what is critical thinking in nursing practice, its importance, and how it enables nurses to excel in their roles while also positively impacting patient outcomes.

What is Critical Thinking?

Critical thinking is a cognitive process that involves analyzing, evaluating, and synthesizing information to make reasoned and informed decisions.

It’s a mental activity that goes beyond simple memorization or acceptance of information at face value.

Critical thinking involves careful, reflective, and logical thinking to understand complex problems, consider various perspectives, and arrive at well-reasoned conclusions or solutions.

Key aspects of critical thinking include:

• Analysis: Critical thinking begins with the thorough examination of information, ideas, or situations. It involves breaking down complex concepts into smaller parts to better understand their components and relationships.
• Evaluation: Critical thinkers assess the quality and reliability of information or arguments. They weigh evidence, identify strengths and weaknesses, and determine the credibility of sources.
• Synthesis: Critical thinking involves combining different pieces of information or ideas to create a new understanding or perspective. This involves connecting the dots between various sources and integrating them into a coherent whole.
• Inference: Critical thinkers draw logical and well-supported conclusions based on the information and evidence available. They use reasoning to make educated guesses about situations where complete information might be lacking.
• Problem-Solving: Critical thinking is essential in solving complex problems. It allows individuals to identify and define problems, generate potential solutions, evaluate the pros and cons of each solution, and choose the most appropriate course of action.
• Creativity: Critical thinking involves thinking outside the box and considering alternative viewpoints or approaches. It encourages the exploration of new ideas and solutions beyond conventional thinking.
• Reflection: Critical thinkers engage in self-assessment and reflection on their thought processes. They consider their own biases, assumptions, and potential errors in reasoning, aiming to improve their thinking skills over time.
• Open-Mindedness: Critical thinkers approach ideas and information with an open mind, willing to consider different viewpoints and perspectives even if they challenge their own beliefs.
• Effective Communication: Critical thinkers can articulate their thoughts and reasoning clearly and persuasively to others. They can express complex ideas in a coherent and understandable manner.
• Continuous Learning: Critical thinking encourages a commitment to ongoing learning and intellectual growth. It involves seeking out new knowledge, refining thinking skills, and staying receptive to new information.

Definition of Critical Thinking

Critical thinking is an intellectual process of analyzing, evaluating, and synthesizing information to make reasoned and informed decisions.

What is Critical Thinking in Nursing?

Critical thinking in nursing is a vital cognitive skill that involves analyzing, evaluating, and making reasoned decisions about patient care.

It’s an essential aspect of a nurse’s professional practice as it enables them to provide safe and effective care to patients.

Critical thinking involves a careful and deliberate thought process to gather and assess information, consider alternative solutions, and make informed decisions based on evidence and sound judgment.

This skill helps nurses to:

• Assess Information: Critical thinking allows nurses to thoroughly assess patient information, including medical history, symptoms, and test results. By analyzing this data, nurses can identify patterns, discrepancies, and potential issues that may require further investigation.
• Diagnose: Nurses use critical thinking to analyze patient data and collaboratively work with other healthcare professionals to formulate accurate nursing diagnoses. This is crucial for developing appropriate care plans that address the unique needs of each patient.
• Plan and Implement Care: Once a nursing diagnosis is established, critical thinking helps nurses develop effective care plans. They consider various interventions and treatment options, considering the patient’s preferences, medical history, and evidence-based practices.
• Evaluate Outcomes: After implementing interventions, critical thinking enables nurses to evaluate the outcomes of their actions. If the desired outcomes are not achieved, nurses can adapt their approach and make necessary changes to the care plan.
• Prioritize Care: In busy healthcare environments, nurses often face situations where they must prioritize patient care. Critical thinking helps them determine which patients require immediate attention and which interventions are most essential.
• Communicate Effectively: Critical thinking skills allow nurses to communicate clearly and confidently with patients, their families, and other members of the healthcare team. They can explain complex medical information and treatment plans in a way that is easily understood by all parties involved.
• Identify Problems: Nurses use critical thinking to identify potential complications or problems in a patient’s condition. This early recognition can lead to timely interventions and prevent further deterioration.
• Collaborate: Healthcare is a collaborative effort involving various professionals. Critical thinking enables nurses to actively participate in interdisciplinary discussions, share their insights, and contribute to holistic patient care.
• Ethical Decision-Making: Critical thinking helps nurses navigate ethical dilemmas that can arise in patient care. They can analyze different perspectives, consider ethical principles, and make morally sound decisions.
• Continual Learning: Critical thinking encourages nurses to seek out new knowledge, stay up-to-date with the latest research and medical advancements, and incorporate evidence-based practices into their care.

In summary, critical thinking is an integral skill for nurses, allowing them to provide high-quality, patient-centered care by analyzing information, making informed decisions, and adapting their approaches as needed.

It’s a dynamic process that enhances clinical reasoning , problem-solving, and overall patient outcomes.

What are the Levels of Critical Thinking in Nursing?

The development of critical thinking in nursing practice involves progressing through three levels: basic, complex, and commitment.

The Kataoka-Yahiro and Saylor model outlines this progression.

1. Basic Critical Thinking:

At this level, learners trust experts for solutions. Thinking is based on rules and principles. For instance, nursing students may strictly follow a procedure manual without personalization, as they lack experience. Answers are seen as right or wrong, and the opinions of experts are accepted.

2. Complex Critical Thinking:

Learners start to analyze choices independently and think creatively. They recognize conflicting solutions and weigh benefits and risks. Thinking becomes innovative, with a willingness to consider various approaches in complex situations.

3. Commitment:

At this level, individuals anticipate decision points without external help and take responsibility for their choices. They choose actions or beliefs based on available alternatives, considering consequences and accountability.

As nurses gain knowledge and experience, their critical thinking evolves from relying on experts to independent analysis and decision-making, ultimately leading to committed and accountable choices in patient care.

Why Critical Thinking is Important in Nursing?

Critical thinking is important in nursing for several crucial reasons:

Patient Safety:

Nursing decisions directly impact patient well-being. Critical thinking helps nurses identify potential risks, make informed choices, and prevent errors.

Clinical Judgment:

Nursing decisions often involve evaluating information from various sources, such as patient history, lab results, and medical literature.

Critical thinking assists nurses in critically appraising this information, distinguishing credible sources, and making rational judgments that align with evidence-based practices.

Enhances Decision-Making:

In nursing, critical thinking allows nurses to gather relevant patient information, assess it objectively, and weigh different options based on evidence and analysis.

This process empowers them to make informed decisions about patient care, treatment plans, and interventions, ultimately leading to better outcomes.

Promotes Problem-Solving:

Nurses encounter complex patient issues that require effective problem-solving.

Critical thinking equips them to break down problems into manageable parts, analyze root causes, and explore creative solutions that consider the unique needs of each patient.

Drives Creativity:

Nursing care is not always straightforward. Critical thinking encourages nurses to think creatively and explore innovative approaches to challenges, especially when standard protocols might not suffice for unique patient situations.

Fosters Effective Communication:

Communication is central to nursing. Critical thinking enables nurses to clearly express their thoughts, provide logical explanations for their decisions, and engage in meaningful dialogues with patients, families, and other healthcare professionals.

Aids Learning:

Nursing is a field of continuous learning. Critical thinking encourages nurses to engage in ongoing self-directed education, seeking out new knowledge, embracing new techniques, and staying current with the latest research and developments.

Improves Relationships:

Open-mindedness and empathy are essential in nursing relationships.

Critical thinking encourages nurses to consider diverse viewpoints, understand patients’ perspectives, and communicate compassionately, leading to stronger therapeutic relationships.

Empowers Independence:

Nursing often requires autonomous decision-making. Critical thinking empowers nurses to analyze situations independently, make judgments without undue influence, and take responsibility for their actions.

Facilitates Adaptability:

Healthcare environments are ever-changing. Critical thinking equips nurses with the ability to quickly assess new information, adjust care plans, and navigate unexpected situations while maintaining patient safety and well-being.

Strengthens Critical Analysis:

In the era of vast information, nurses must discern reliable data from misinformation.

Critical thinking helps them scrutinize sources, question assumptions, and make well-founded choices based on credible information.

How to Apply Critical Thinking in Nursing? (With Examples)

Here are some examples of how nurses can apply critical thinking.

Assess Patient Data:

Critical Thinking Action: Carefully review patient history, symptoms, and test results.

Example: A nurse notices a change in a diabetic patient’s blood sugar levels. Instead of just administering insulin, the nurse considers recent dietary changes, activity levels, and possible medication interactions before adjusting the treatment plan.

Diagnose Patient Needs:

Critical Thinking Action: Analyze patient data to identify potential nursing diagnoses.

Example: After reviewing a patient’s lab results, vital signs, and observations, a nurse identifies “ Risk for Impaired Skin Integrity ” due to the patient’s limited mobility.

Plan and Implement Care:

Critical Thinking Action: Develop a care plan based on patient needs and evidence-based practices.

Example: For a patient at risk of falls, the nurse plans interventions such as hourly rounding, non-slip footwear, and bed alarms to ensure patient safety.

Evaluate Interventions:

Critical Thinking Action: Assess the effectiveness of interventions and modify the care plan as needed.

Example: After administering pain medication, the nurse evaluates its impact on the patient’s comfort level and considers adjusting the dosage or trying an alternative pain management approach.

Prioritize Care:

Critical Thinking Action: Determine the order of interventions based on patient acuity and needs.

Example: In a busy emergency department, the nurse triages patients by considering the severity of their conditions, ensuring that critical cases receive immediate attention.

Collaborate with the Healthcare Team:

Critical Thinking Action: Participate in interdisciplinary discussions and share insights.

Example: During rounds, a nurse provides input on a patient’s response to treatment, which prompts the team to adjust the care plan for better outcomes.

Ethical Decision-Making:

Critical Thinking Action: Analyze ethical dilemmas and make morally sound choices.

Example: When a terminally ill patient expresses a desire to stop treatment, the nurse engages in ethical discussions, respecting the patient’s autonomy and ensuring proper end-of-life care.

Patient Education:

Critical Thinking Action: Tailor patient education to individual needs and comprehension levels.

Example: A nurse uses visual aids and simplified language to explain medication administration to a patient with limited literacy skills.

Adapt to Changes:

Critical Thinking Action: Quickly adjust care plans when patient conditions change.

Example: During post-operative recovery, a nurse notices signs of infection and promptly informs the healthcare team to initiate appropriate treatment adjustments.

Critical Analysis of Information:

Critical Thinking Action: Evaluate information sources for reliability and relevance.

Example: When presented with conflicting research studies, a nurse critically examines the methodologies and sample sizes to determine which study is more credible.

Making Sense of Critical Thinking Skills

What is the purpose of critical thinking in nursing.

The purpose of critical thinking in nursing is to enable nurses to effectively analyze, interpret, and evaluate patient information, make informed clinical judgments, develop appropriate care plans, prioritize interventions, and adapt their approaches as needed, thereby ensuring safe, evidence-based, and patient-centered care.

Why critical thinking is important in nursing?

Critical thinking is important in nursing because it promotes safe decision-making, accurate clinical judgment, problem-solving, evidence-based practice, holistic patient care, ethical reasoning, collaboration, and adapting to dynamic healthcare environments.

Critical thinking skill also enhances patient safety, improves outcomes, and supports nurses’ professional growth.

How is critical thinking used in the nursing process?

Critical thinking is integral to the nursing process as it guides nurses through the systematic approach of assessing, diagnosing, planning, implementing, and evaluating patient care. It involves:

• Assessment: Critical thinking enables nurses to gather and interpret patient data accurately, recognizing relevant patterns and cues.
• Diagnosis: Nurses use critical thinking to analyze patient data, identify nursing diagnoses, and differentiate actual issues from potential complications.
• Planning: Critical thinking helps nurses develop tailored care plans, selecting appropriate interventions based on patient needs and evidence.
• Implementation: Nurses make informed decisions during interventions, considering patient responses and adjusting plans as needed.
• Evaluation: Critical thinking supports the assessment of patient outcomes, determining the effectiveness of intervention, and adapting care accordingly.

Throughout the nursing process , critical thinking ensures comprehensive, patient-centered care and fosters continuous improvement in clinical judgment and decision-making.

What is an example of the critical thinking attitude of independent thinking in nursing practice?

An example of the critical thinking attitude of independent thinking in nursing practice could be:

A nurse is caring for a patient with a complex medical history who is experiencing a new set of symptoms. The nurse carefully reviews the patient’s history, recent test results, and medication list.

While discussing the case with the healthcare team, the nurse realizes that the current treatment plan might not be addressing all aspects of the patient’s condition.

Instead of simply following the established protocol, the nurse independently considers alternative approaches based on their assessment.

The nurse proposes a modification to the treatment plan, citing the rationale and evidence supporting the change.

This demonstrates independent thinking by critically evaluating the situation, challenging assumptions, and advocating for a more personalized and effective patient care approach.

How to use Costa’s level of questioning for critical thinking in nursing?

Costa’s levels of questioning can be applied in nursing to facilitate critical thinking and stimulate a deeper understanding of patient situations. The levels of questioning are as follows:

• 15 Attitudes of Critical Thinking in Nursing (Explained W/ Examples)
• Nursing Concept Map (FREE Template)
• Clinical Reasoning In Nursing (Explained W/ Example)
• 8 Stages Of The Clinical Reasoning Cycle
• How To Improve Critical Thinking Skills In Nursing? 24 Strategies With Examples
• What is the “5 Whys” Technique?
• What Are Socratic Questions?

Critical thinking in nursing is the foundation that underpins safe, effective, and patient-centered care.

Critical thinking skills empower nurses to navigate the complexities of their profession while consistently providing high-quality care to diverse patient populations.

Reading Recommendation

Potter, P.A., Perry, A.G., Stockert, P. and Hall, A. (2013) Fundamentals of Nursing

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Critical thinking definition

Critical thinking, as described by Oxford Languages, is the objective analysis and evaluation of an issue in order to form a judgement.

Active and skillful approach, evaluation, assessment, synthesis, and/or evaluation of information obtained from, or made by, observation, knowledge, reflection, acumen or conversation, as a guide to belief and action, requires the critical thinking process, which is why it's often used in education and academics.

Some even may view it as a backbone of modern thought.

However, it's a skill, and skills must be trained and encouraged to be used at its full potential.

People turn up to various approaches in improving their critical thinking, like:

• Developing technical and problem-solving skills
• Engaging in more active listening
• Actively questioning their assumptions and beliefs
• Seeking out more diversity of thought
• Opening up their curiosity in an intellectual way etc.

Is critical thinking useful in writing?

Critical thinking can help in planning your paper and making it more concise, but it's not obvious at first. We carefully pinpointed some the questions you should ask yourself when boosting critical thinking in writing:

• What information should be included?
• Which information resources should the author look to?
• What degree of technical knowledge should the report assume its audience has?
• What is the most effective way to show information?
• How should the report be organized?
• How should it be designed?
• What tone and level of language difficulty should the document have?

Usage of critical thinking comes down not only to the outline of your paper, it also begs the question: How can we use critical thinking solving problems in our writing's topic?

Let's say, you have a Powerpoint on how critical thinking can reduce poverty in the United States. You'll primarily have to define critical thinking for the viewers, as well as use a lot of critical thinking questions and synonyms to get them to be familiar with your methods and start the thinking process behind it.

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• v.22(4); 2022 Nov

Effectiveness of an Interactive Educational Video on Knowledge, Skill and Satisfaction of Nursing Students

This study aimed to compare the interactive educational video-based strategy with traditional general demonstration in regard to teaching a basic nursing skill. Nursing education requires innovative teaching strategies for teaching fundamental nursing skills to ensure proficient nurses for the future. However, nursing educators face challenges in teaching and retaining the skill competency and knowledge of the nursing students, given shortages of nursing faculty and scarcity of opportunities for clinical practice.

This cross-sectional comparative study followed 55 nursing students enrolled in the Fundamentals of Nursing Laboratory course, College of Nursing, Sultan Qaboos University, Muscat, Oman, during the Spring 2020 semester. The control group was taught using traditional general demonstration-based teaching of the oral medication procedure, while the experimental group learned the same skill through an interactive educational video. The knowledge, skill competency and satisfaction levels of both groups were assessed post-intervention using standardised questionnaires.

There was no statistical difference between the two groups in knowledge level and skill competency scores. Regarding satisfaction, 92% of the students were satisfied with video learning and 87% with the traditional approach.

The interactive video learning strategy for learning fundamental nursing skills is as effective as the traditional face-to-face general demonstration-based approach.

Advances in Knowledge

• - Using an interactive video as a strategy for learning a nursing skill is as effective as the traditional face-to-face general demonstration-based approach, although further studies are required to confirm this finding .
• - Interactive videos to learn fundamental nursing skills support learning and promote student achievement and satisfaction .

Applications to Patient Care

• - With the spread of COVID-19 still being a threat, using technological strategies such as videos are of utmost importance so nursing students can learn the necessary skills anytime and anywhere .
• - Watching interactive videos before coming to class allows students to better prepare for the class, thus reducing time for lectures and providing more time for practice and feedback .
• - Using interactive videos could enhance nursing clinical skills, which are critical for patient care .
• - Ensuring high levels of competency in learning medication administration skills may reduce medical errors and healthcare costs and enhance patient safety .

Nursing students are equipped with basic nursing skills in the Fundamentals of Nursing Laboratory course. These skills are often reviewed during their course of study and their time as nurses in the clinical setting. The quality of patient care and patient safety can be compromised when basic skills are not learned properly and this compromise can even cause permanent disability or endanger patients’ lives in severe cases. 1

General laboratory-based demonstrations of skills are the most common strategies used to teach basic nursing skills to nursing students. The approach involves explaining the procedure, showing students how to perform it step by step and supporting students in practicing the skill to acquire knowledge and competency. 2 – 4 However, as new teaching methods are evolving, the approaches to training nursing students also must be upgraded. Technology has made everything easier and faster and is attractive to the millennial generation of nursing students. 5 One such technology that is gaining greater attention in the educational field is the use of interactive educational videos.

Using interactive educational videos is an innovative teaching approach to teaching fundamental nursing skills to undergraduate nursing students who live their daily lives equipped with highly advanced mobile technology. 6 Such videos, when used to complement face-to-face education, have been found to improve students’ competencies as well as their learning. 7 Nursing educators are encouraged to use various forms of technology to enhance the learning experiences of nursing students, as emphasised in the Vision Statement of the American National League for Nursing. 8

Educational videos convey information to the learner through aural and visual sensory channels simultaneously, which may result in better learning outcomes. 9 In addition, videos are more consistent (in terms of the steps used in teaching nursing skills) than demonstrations of skills by different nursing faculty. 10 Branigan remarked that an increasing number of educators are embracing video as an instructional tool because of the rise in the number of multimedia-enabled computers at colleges and the lower cost of video-editing equipment and software. 10 A growing trend of active usage of social media for networking and communication has also been observed among today’s youth. 11 A systematic review revealed that highly informative educational videos with authoritative speakers that posed questions had a positive impact on the learning interest of students and their self-reported knowledge gains. 12 Furthermore, students have expressed that educational videos improve their memory of new information and provide better intelligibility. 11 Videos also provide greater opportunities for students with diverse learning styles to learn at their own pace, for instance, when taught in the context of a flipped classroom—an instructional strategy wherein students listen to the lectures at home and engage in active learning during class time. 13

Interactive educational videos can increase the learning-related self-confidence and self-motivation of nursing students. 14 , 15 Student satisfaction and skill competencies were found to have been improved in a study conducted among Korean nursing students that compared the use of educational video with traditional methods. 16 Additionally, nursing students’ knowledge has been shown to improve when educational videos were used for theory and clinical learning. 17 Overall, educational videos are considered an adequate teaching approach for students to learn fundamental skills independently and at their own pace.

Nevertheless, despite the numerous advantages of educational videos, nursing faculty and students have been reluctant to adopt this approach because of a misconception that the traditional method of general demonstration results in better student outcomes. 18 However, the traditional method of teaching nursing skills in a Fundamentals of Nursing course consumes faculty time and other resources. Clinical instructors may need to repeat their explanation many times as students have different levels of understanding. Clinical instructors are also generally restricted to using only a single technique to explain the concept and skill, as they do not have adequate time to deliver the information using multiple methods, which may not ensure the understanding of all students. The use of interactive educational videos can solve most of the problems faced by nursing students and clinical instructors of a Fundamentals of Nursing course, thus saving resources and time.

A review of the literature has revealed a dearth of studies on the use of interactive educational videos for learning fundamental nursing skills in the Middle East. Therefore, this study aimed to compare the knowledge, skill and competency of learning the procedure of administrating oral medication among the fundamentals of nursing students using either an interactive educational video or the traditional general demonstration approach. Moreover, this study sought to describe the satisfaction levels of students with both strategies. The topic was chosen because errors in administering medication are common among nursing students in the clinical setting worldwide. 19

This quantitative study was conducted at the College of Nursing, Sultan Qaboos University, Muscat, Oman, and involved second-year nursing students enrolled in the Fundamentals of Nursing Laboratory course in the Spring 2020 semester. This study used a quantitative comparative design. The college offers the Baccalaureate of Nursing (BSN) and Master of Nursing programmes to students from various parts of Oman. As the college has a multinational faculty, the interactive educational video technology could be beneficial to the new faculty in ensuring uniformity in teaching a skill. Two laboratory groups already existed for this course based on students’ enrolment in the course. The authors randomly assigned one of the two (n = 30) as the control group, which then learned medication administration skills using a traditional demonstration method. Students from the other group (n = 25) were assigned to the experimental group and learned the same procedure by watching an interactive educational video prepared by the faculty. This recruitment meets the requirements of sample size for a study with a 95% confidence interval for a sample size of 50 participants. Using G power analysis, a sample size of 54 students was needed with the medium effect size of d = 0.5 and power of 0.70.

The students in the control group came to the laboratory on two days (Sunday and Monday) of one week for eight hours each day. They were exposed to face-to-face laboratory demonstrations of oral medication administration performed by the Fundamentals of Nursing instructor. The demonstration started with a presentation of an overview of medication administration using a Microsoft PowerPoint 2016 (Microsoft Corporation, Redmond, Washington, USA), followed by a face-to-face general demonstration in the laboratory by an expert course faculty. The demonstration was followed by the faculty answering the students’ questions and clarifying uncertainties. Then, the students performed the procedure in front of their clinical instructors and were evaluated using the procedure checklists.

The experimental group came to the laboratory on two different days from the control group (Wednesday and Thursday) of one week for six hours each day. The students watched an interactive video about the medication administration skill on their own time at home and came to class prepared to perform the procedure. After they had reached the laboratory, an overview of the procedure was presented to the students with the same PowerPoint (Microsoft Corporation) presentation as the control group and their questions were answered for clarification. Then, the students performed the procedure in front of their group clinical instructors and were evaluated using the procedure checklists. After the procedure demonstrations, both groups of students answered a survey on satisfaction using standardised questionnaires.

An interactive educational video is defined as a teaching approach that uses a digital video containing interactions via gestures, voice and touch. 20 In this study, the interactive educational video was developed based on the nine events of instruction for designing an instructional material as outlined by Gagné. 21 Gagné’s events are: (1) to gain attention; (2) to describe the goal; (3) to stimulate prior knowledge; (4) to present the material to be learned; (5) to provide guidance for learning; (6) to elicit performance; (7) to provide feedback; (8) to assess performance; and (9) to enhance retention and transfer. When video materials match these steps, higher levels of achievement in student learning outcomes and learner engagement can be accomplished. 22

The interactive educational video was developed by the experienced course coordinator and uploaded to Moodle, version 3.11.2 (Moodle, Perth, Australia; the learning management system accessed by students), two days before their laboratory session. To ensure consistency, the same faculty performed the face-to-face demonstration and were present in the video. The video was created with the help of the technical support team at the College of Nursing. The video was recorded in the skill laboratory at the College of Nursing, where the faculty performed the administration of oral medications on a trained standardised patient using all the equipment available in the laboratory and following a checklist developed for this course. The video was recorded in one session, which lasted around two hours. In addition, a concise voice narration was recorded to help clarify the demonstration in the video. The technical team used Adobe Premiere Pro (Adobe Stock, San Jose, California, USA) to edit the video and sync it with the voiceover. The video was divided into three parts, each six minutes long. The parts consisted of an overview of medication administration as a recorded PowerPoint (Microsoft Corporation) presentation, a demonstration of the oral medication administration on a standardised patient and a discussion of the aftercare and other policies to be considered while administering oral medications in the clinical setting. The final version of the oral medication video was shared with two professors from the Fundamentals of Nursing course and two clinical instructors to verify the accuracy and the quality of the video, before it was released to the students participating in this study.

A knowledge questionnaire regarding the oral medication administration procedure was developed by the course coordinator based on the National Council Licensure Examination-pattern multiple-choice questions (MCQs) and peer-reviewed by two experts. Five questions were scored, with a score of 5 indicating an excellent level of knowledge, 3–4 a good level of knowledge and 1–2 a poor level of knowledge. The test–retest reliability scores were 0.8, indicating high reliability.

A performance checklist for an oral medication administration was developed for the objective structured clinical examination (OSCE) by the course team based on the textbook for the Fundamentals of Nursing course and approved by the Department Board. 23 The mean inter-rater score was 0.9, indicating high reliability.

Satisfaction with the interactive educational videos was measured with the Evaluation of Satisfaction for the Video-Based Interactive Education Method in Professional Skills Training questionnaire developed by Arslan et al . 24 It comprises 17 items designed to assess every stage of the learning processing, starting with watching the videos. For each item, the participant could choose 1 (disagree), 2 (neutral) or 3 (agree) as their level of satisfaction, with 17 being the minimum and 51 being the maximum possible score. In the study, the total score was converted to a percentage, with a result of 60% or above indicating a high satisfaction level. Cronbach’s alpha was 0.9, indicating very good internal consistency and showing the tool’s high reliability. 24

The Student Evaluation of Educational Quality (SEEQ) questionnaire was used to assess the students’ satisfaction levels after general demonstration of the skill. It is a five-point Likert scale developed by Coffey and Gibbs (5 is strongly agree and 1 is strongly disagree) and consists of 12 items enquiring about the classroom demonstration. 25 The resulting scores were converted to percentages and a score above 60% was considered satisfactory. The SEEQ questionnaire has a high level of reliability, with Cronbach’s alpha ranging from 0.88 to 0.97. 26

The control group had general demonstration and hands-on practice of the procedure on the first day. Re-demonstration of the procedure in OSCE was evaluated by two nursing faculty with the help of the checklist after the students had answered the knowledge quiz. Finally, the participants were asked to complete the SEEQ survey to evaluate their satisfaction levels.

The experimental group watched the interactive educational video recording of the oral medication procedure, then came to the laboratory to practice. They completed a knowledge quiz after a brief review of the procedure in the video. The students performed the procedure in the laboratory, which was evaluated by two teams of faculty. The questionnaire regarding satisfaction with the video-based interactive education was completed by the students at the end of the laboratory session, during the scheduled laboratory hours and with the permission of the course coordinators. They could complete it in six hours as they had saved some time otherwise spent on demonstration by watching the interactive educational video.

The collected data were checked for completeness, and scores were calculated and entered by two investigators to ensure the accuracy of the entered data. Data analysis was performed with the Statistical Packages for Social Sciences (SPSS), Version 24 (IBM, Armonk, New York, USA). Independent sample t and Chi-squared tests were used to compare the scores of skill competency and knowledge of both groups of students. Levels of satisfaction for both groups were calculated and presented as frequency, percentage and mean scores, but they were not compared as the two questionnaires were different.

Ethical approval was obtained from the Research and Ethics Committee at the College of Nursing (CON/GP/2020/04) and permission was received from the Fundamentals of Nursing Laboratory course coordinators. The procedure was explained to the students in detail and written informed consent was provided by the participants in both groups. Data confidentiality was maintained. Names and identification numbers of the students were coded and the collected data were stored in a locked cabinet. Permission to use the questionnaires was obtained from their respective authors. The interactive educational video on oral medication administration was shared with both groups after the completion of the study period so that both could benefit equally from the interactive educational video.

A total of 55 nursing students were included in this study. The study participants were enrolled from the College of Nursing’s BSN programme and had registered in the Fundamentals of Nursing Laboratory course for the Spring 2020 semester. A total of 34 (61.81%) students were females and 21 (38.19%) were males and aged between 19 and 21 years.

The first objective was to compare the knowledge of both groups (control and experimental) regarding appropriate oral medication administration procedures. Knowledge was assessed using five MCQs developed by the course experts. Scores were assigned as 1 or 2 (poor), 3 or 4 (good) and 5 (excellent). The majority of students (36, 65.45%) had a good level of knowledge regarding oral medication administration and there was no significant difference between the control and experimental groups (χ 2 [2,55] = 2.626; P = 0.269) [ Table 1 ].

Comparison of medication administration knowledge scores between the control and experimental groups (N = 55)

The second objective was to compare the skill competency scores of both groups. Skill competency of the participants in performing oral medication procedure was evaluated by two evaluators using a standardised checklist; the average was the final score of the participants. Scores <40% were classified as poor performance, 40–80% as good performance and >80% as excellent performance. The majority of students (n = 35, 63.64%) displayed good performance scores and none were in the poor performance category. There was no significant difference in the skill performance of both groups (χ 2 [1,55] = 0.262; P = 0.609) [ Table 2 ].

Competency scores of oral medication administration skill for the control and experimental groups (N = 55)

The third objective was to describe the satisfaction level of the students who learned the procedure by the traditional demonstration method (control group). These students were asked to rate their satisfaction with the general demonstration using a five-point Likert scale anchored by 1 (strongly disagree) and 5 (strongly agree). The students in the control group were satisfied with the demonstration, with mean scores >3.5 for all items and 26 (86.70%) students in the control group considered traditional demonstration as highly satisfactory [ Table 3 and Figure 1 ].

Students’ satisfaction with the skill general demonstration and the interactive educational video approach.

Control group satisfaction scores with the general demonstration (n = 30)

SD = standard deviation.

The fourth objective was to describe the satisfaction level of the students who learned the procedure by the interactive educational video (experimental group). These participants rated the videos using a three-point Likert scale. A mean score of 2.5 and above on the items indicated a high level of satisfaction. The video recordings were reported to be very important in understanding the procedure steps (mean = 2.56). The procedure steps in the videos were very clear (mean = 2.64), with students agreeing that ‘I can control the video easily (to watch the steps again, to advance, to rewind’ (mean = 2.48), ‘The use of different learning materials (video) increased my learning’ (mean = 2.48) and ‘The video showing advanced my learning’ (mean = 2.56) [ Table 4 ]. Furthermore, 23 (92%) students were highly satisfied with the interactive educational video learning strategy [ Figure 1 ].

Experimental group satisfaction scores with the interactive educational video (n = 25)

The advanced technologies accessible to the new generation of nursing students have created opportunities for nursing educators to use interactive educational video recording as a teaching approach to help students learn and practice nursing skills. The current study aimed to assess the effectiveness of using an interactive educational video over traditional demonstration on students’ knowledge gain, clinical skills competency and levels of satisfaction. The results revealed no statistical differences between the knowledge, skill competency scores and satisfaction levels of the study groups, indicating that both teaching approaches have similar student outcomes. This is similar to the findings of the studies on video learning for basic nursing skills among Turkish nursing students as well as on teaching the subcutaneous injection administration procedure using face-to-face demonstration versus computer-assisted learning among Turkish nursing students. 24 , 27 Vicdan used Instagram (Meta Platforms, Menlo Park, California, USA) to teach intramuscular injection administration to students enrolled in the Fundamentals of Nursing course. 4 The results showed no statistical difference of knowledge and competency scores between groups. In all these studies, the results indicate that the outcomes of interactive video learning for teaching nursing skills were as good as the traditional face-to-face demonstration method. This is a positive sign, suggesting interactive videos may appropriately be integrated into fundamental nursing skills courses. Indeed, another study revealed that educational video learning was better than traditional general demonstration for learning a urinary catheterisation procedure, with a significant improvement in knowledge and competency scores. 14

Nursing students in the experimental group were satisfied with all aspects of the experience and indicated higher satisfaction levels with several items, including clarity of the procedure’s steps, feasibility to watch at their own pace or many times and the enhancement of their interest to learn through advanced technology. These findings are similar to those of studies carried out among nursing students learning web-based medication application skills. 16 , 28 , 29 Another study conducted among students on antenatal examination revealed significantly higher levels of knowledge and competency scores in groups of students subjected to online videos, suggesting that this approach may be appropriately implemented in other courses. 30

Nevertheless, the control group students who witnessed the traditional general demonstration also exhibited high satisfaction levels. Since they were second-year nursing students and it was their first experience of learning skills, they may have appreciated face-to-face student–faculty interactions and valued the opportunity to ask questions in the classroom. While students preferred the social presence of the faculty during the demonstration of skills, they were satisfied with the encouragement they received in their discussion at the end of the sessions. This may encourage faculty to introduce a flipped classroom approach among Fundamentals of Nursing course students when learning basic skills. This approach may improve their critical thinking, clinical judgement, learning motivation, communication and teamwork skills. 13 Moreover, in this study, the experimental group had a six-hour laboratory session each day for two days, while the control group had eight-hour laboratory sessions. As the nursing students in the experimental group watched the interactive educational videos at home, a total of four hours was gained and reduced from the face-to-face laboratory session. Thus, interactive educational videos could be used to save time in the classroom, which can then be utilised to build on the previously acquired knowledge.

This study is not without its limitations. First, the results cannot be generalised, as the study was conducted at a single institution in Oman and on a single nursing fundamental skill. Furthermore, research should be done among different courses in the BSN programme with larger sample sizes and including more than one institution. A more rigorous research design, such as a randomised controlled trial, is recommended to control the effect of confounding variables on the findings of future studies.

This study shows that an interactive educational video approach can be easily adopted for undergraduate nursing students learning basic nursing skills, as it is as effective as traditional methods in achieving student learning outcomes. In future studies, a combination of technology (using interactive educational videos to demonstrate nursing skills) and face-to-face, hands-on demonstration should be investigated and used to determine if it yields a better outcome. However, this study shows that when face-to-face meetings are not possible (e.g. during lockdowns due to the COVID-19 pandemic), a switch to online interactive educational videos could be made without fear of falling short of necessary programme outcomes.

AUTHORS’ CONTRIBUTION

JN designed the study and supervised the project. ZSS, SSH, DKH, ANK and IMM conducted the experiment and collected the data. JN and MAJ analysed and interpreted the results. MAJ designed and prepared the tables and figures. JN and MAJ drafted the manuscript. All the authors approved the final version of the manuscript.

CONFLICT OF INTEREST

The authors declare no conflicts of interest.

No funding was received for this study.