Evaluation of critical thinking skills in undergraduate nursing students in Brazil: a cross-sectional studyABSTRACT
Objective: To evaluate critical thinking skills among undergraduate nursing students.
Methods: A cross-sectional design was used, and the study included 98 undergraduate nursing students. Data were collected using the Health Sciences Reasoning Test and a sociodemographic questionnaire. Descriptive and inferential statistical analyses were performed, with categorical variables presented as absolute and relative frequencies and continuous variables as means, standard deviations, medians, and quartiles.
Results: Participants demonstrated a moderate General score in the assessment of skills and a weak score in 5 of the 8 domains of critical thinking. No significant relationship was observed between the critical thinking scores of undergraduates who participated in extracurricular internships and those who did not. However, students with prior experience as nursing technicians or assistants had significantly lower mean scores across all domains and overall scores.
Conclusion: The findings highlight the need to strengthen educational strategies aimed at developing critical thinking skills in undergraduate nursing education, supporting improvements in training aligned with the demands of clinical practice.
Keywords:
Thinking; Students, nursing; Education, nursing; Learning
Highlights
■Undergraduate nursing students demonstrated a moderate overall level of critical thinking, with weak performance in five of the eight Health Sciences Reasoning Test domains.
■Participation in extracurricular internships for three months or more was not associated with significant differences in nursing undergraduates’ critical thinking scores.
■Students with prior professional experience as nursing assistants or technicians exhibited significantly lower critical thinking scores across all domains compared with those without such experience.
■The findings underscore the need for intentional, structured educational strategies to foster critical thinking aligned with clinical decision-making demands.
In Brief
Critical thinking skills are essential for accurate clinical decisionmaking and the effective resolution of problems in patient care. Systematic evaluation of critical thinking skills and the adaptation of teaching strategies according to identified learning needs are therefore essential. Katayama et al. evaluated critical thinking skills among undergraduate nursing students, including the potential influence of extracurricular activities. Building on this evidence, the present study emphasizes the importance of measuring critical thinking skills to enable evidence-based adjustments in educational strategies aimed at developing critical thinkers.
INTRODUCTION
Nurse education has undergone changes over the years due to the increasing demands of the complex health system and rapid technological advancements. Consequently, nurses are required to continuously develop critical thinking (CP) knowledge and skills to support accurate clinical decision-making, with the aim of anticipating outcomes, enhancing patient safety, and improving patient satisfaction.(1)
In this context, critical thinking is defined as a reflective process that involves the accurate evaluation of statements and focuses on making decisions about what should or should not be accepted as true.(2) It entails analytical inquiry into situations, phenomena, questions, or problems to generate hypotheses or conclusions that integrate available information and can be appropriately substantiated.(3)
Given the fundamental role of CP in clinical practice, this study adopts the definition established in the Delphi Report of the American Philosophical Association.(4) Within this framework, undergraduate education is considered essential, as it shapes the knowledge, skills, and competencies required for professional nursing practice.(5)
This investigation is further grounded in classical conceptual frameworks of Paul et al,(6) and Alfaro-Lefevre et al,(7) and Scheffer et al.(8) These authors conceptualize critical thinking as an analytical and reflective process intrinsically linked to clinical decision-making, integrating cognitive skills and affective dispositions such as analysis, inference, curiosity, and intellectual integrity. Their contributions emphasize that critical thinking in nursing extends beyond theoretical reasoning, encompassing contextual judgment in complex clinical environments, ethical deliberation, and the ability to interpret and respond to patients’ needs with precision and accountability. This perspective aligns with the demands of contemporary nursing practice, where the development of clinical reasoning and sound judgment is essential for patient safety and high-quality care.(9)
Building on this conceptual foundation, encouraging students to actively participate in the learning process is one of the key strategies for developing CP. Accordingly, educators should design questions and learning activities that foster critical thinking skills and require accurate interpretation, careful analysis, evidence-based justification, precise evaluation, and accurate explanation. In this context, the pedagogical and scientific competence of educators plays a decisive role in the adoption and implementation of innovative teaching methodologies. To effectively foster CP, educators must master these skills to design, adapt, and implement pedagogical strategies that develop and assess critical thinking.(10–12)
To operationalize these objectives, a range of complementary educational strategies has been widely recommended, including case studies, group discussion with reflective practice, problem-based learning, clinical case analysis, simulation-based scenarios, mind mapping, Socratic questioning, and the use of interactive and multimedia tools such as online learning platforms and discussion forums. These approaches align with the recommendations of the American Philosophical Association, which conceptualizes CP as an intentional and self-regulatory judgment grounded in interpretation, analysis, evaluation, and inference, supported by evidential, conceptual, methodological, and criteriological foundations.(1,12–15)
Beyond the formal curriculum, extracurricular activities offered by educational and healthcare institutions during undergraduate programs provide additional opportunities for students to broaden their knowledge and skills in areas of interest, while also facilitating more direct engagement with professional care settings.(16) Extracurricular internships, in particular, may positively influence students’ technical and behavioral development and support a smoother transition into professional practice. These experiences often enable students to become familiar with institutional workflows and, in some cases, contribute to subsequent employment opportunities within the same organization.(16)
Extracurricular internships represent complementary learning activities that contribute to the development and training of undergraduate students’ technical and behavioral competencies, as well as in the transition from academic to professional life and, in some cases, future recruitment into institutional roles.(17)
Despite the recognized importance of critical thinking in supporting clinical decision-making, enhancing patient safety, and promoting high-quality care, evidence remains limited regarding the level of development of these skills among undergraduate nursing students.
OBJECTIVE
The present study aims to evaluate the critical thinking skills of undergraduate nursing students, contributing to a better understanding of this essential competency in nursing education and informing strategies to strengthen its development.
METHODS
This was a cross-sectional study with a quantitative design conducted at a private higher education institution in the state of São Paulo, Brazil, and followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines to ensure methodological rigor and transparent reporting.
The study population consisted of 98 out of 145 undergraduate nursing students enrolled between the 5th and 8th semesters.
Eligibility criteria included students who were regularly enrolled and attending the course from the 5th semester onwards, when extracurricular internships became available. Exclusion criteria comprised students on leave (e.g., medical or maternity leave) during data collection, those who responded to fewer than 60% of the test questions, or those who completed the test in less than 15 minutes, to minimize bias caused by incomplete or inconsistent responses. A minimum of three months of prior professional experience is the criterion for defining relevant prior professional experience in this study.
Data collection was carried out with the support of faculty teachers who were accompanying the undergraduate students during their curricular internship at the hospital. The researcher was granted a 1-hour and 30-minute time slot, either before or after the internship shift. During this period, the students were gathered in a meeting room, where the study was explained, and those who agreed to participate were provided with the informed consent form and the research questionnaires.
The Health Sciences Reasoning Test (HSRT) was used for data collection in an online Brazilian Portuguese version, together with a sociodemographic questionnaire. The HSRT is a standardized instrument designed to assess critical thinking in health sciences education and practice. It contains 38 multiple-choice items, provides an overall critical thinking score, and evaluates eight domains: interpretation, analysis, inference, explanation, evaluation, induction, numeracy, and deduction. Average completion time ranges from 45 to 60 minutes.(18)
The HSRT, developed by Insight Assessment, is conceptually based on the California Critical Thinking Skills Test (CCTST). The CCTST has previously been translated and validated for the Portuguese language, which supports the theoretical and methodological foundation for the use of the HSRT in Brazil. However, it is important to highlight that the HSRT itself did not undergo a formal transcultural adaptation process for use in the Brazilian context and is currently undergoing cultural adaptation and validation. Its selection in this study is justified by its conceptual alignment with the CCTST, secure and proctored online administration, and increasing use in national research initiatives. The assessment was administered through an individualized link provided by Insight Assessment, ensuring confidentiality, traceability, and data integrity.(19)
The HSRT (Figure 1), which assesses critical thinking performance across eight domains: analysis, interpretation, inference, evaluation, explanation, induction, deduction, and numeracy, using a 100-point scale. The scale is qualitatively classified into five categories: Not Manifested (50-62 points), Weak (63-71 points), Moderate (72-80 points), Strong (81-88 points), and Superior (89-100 points).
The instrument was administered to students participating in an institutional, optional extracurricular internship program. This internship is available to all students beginning from the fifth semester of the undergraduate nursing program onwards. The program has a duration of 12 months, with the possibility of extension until the eighth semester, which explains the higher concentration of participants in the final semesters of the course. Admission occurs through an institutional selection process. Approved students undergo a formal onboarding period, during which they are introduced to the institution's mission, vision, values, and key clinical care protocols. Throughout the internship, each student is assigned a preceptor (practice supervisor), responsible for providing guidance and monitoring their development. In addition, periodic performance evaluations that focus on clinical competencies are conducted at intervals of 1 to 3 months. The extracurricular internship program requires a workload of 30 hours per week.
Data collection took place following approval by the Research Project Management System (SGPP) and the Research Ethics Committee of Hospital Israelita Albert Einstein between September and November 2023 (CAAE: 55589322.3.0000.0071; # 5.540.841.
Information on the study population was obtained from the undergraduate course coordinator, who provided the researcher with a list of the eligible students by e-mail, derived from the institutional database of those enrolled from the 5th semester onwards.
The HSRT scores were calculated by Insight Assessment and transferred to the researcher for storage in a database via the Research Electronic Data Capture (REDCap) platform, along with sociodemographic data.
Data were analyzed using absolute and relative frequencies for categorical variables, and means, standard deviations, medians, quartiles, minimum, and maximum values for numerical variables. Distributional assumptions were assessed using histograms, boxplots, and quantile comparison graphs, and Shapiro-Wilk normality tests.(20)
Students who enrolled only in curricular internships and those in extracurricular internships, as well as students with and without previous experience, were compared using the Student's t-test or the Mann-Whitney non-parametric test. Test selection was based on group-specific distributional characteristics identified in descriptive analyses. The analyses were conducted using SPSS at a 5% significance level.
RESULTS
A total of 145 undergraduate nursing students were eligible for inclusion, based on enrollment between the 5th and 8th semesters. After applying eligibility criteria, including regular enrollment and exclusion of students on leave, those who completed fewer than 60% of HSRT items, or those who completed the test in under 15 minutes, 98 participants were included in the final sample. All participants completed the HSRT and a sociodemographic questionnaire, composing the dataset used for the analyses.
Participants were aged between 19 and 44 years (median: 22); 6 men and 92 women (6.1% and 93.9% respectively). Regarding ethnicity, 74 (75.5%) were white, five (5.1%) black, 13 (13.3%) brown and six (6.1%) yellow. With regard to marital status, 92 (93.9%) were single, 4 (4.1%) were married, and 2 (2.0%) were divorced. At the time of the survey, 18 (18.4%) participants were 5th semester students, 28 (28.6%) were 6th semester students, 18 (18.4%) were 7th semester students, and 34 (34.7%) were 8th semester students. Overall, 24 (24.5%) graduated from public institutions and 74 (75.5%) from private institutions. A total of 25 participants (25.5%) reported previous experience in the health sector, of whom seven (7.1%) had worked as nursing assistants, 14 (14.3%) as nursing technicians, and 4 (4.1%) in other healthcare-related roles.
According to the information reported by the participants, 16 students (16.3%) had previous professional experience in the health sector, having worked as nursing assistants or technicians for a minimum period of three months. Regarding extracurricular internships, 44 participants (44.9%) reported current or prior participation, with 18 (18.4%) in surgical medicine, 7 (7.1%) in critical care, 2 (2.0%) in maternal-child health, 1 (1.0%) in the operating room, 4 (4.1%) in emergency care, 3 (3.1%) in oncology, and 9 (9.2%) in other areas. The duration of these internships ranged from one to 24 months, with a median of nine months. When restricted to those with a minimum of three months’ experience, 39 participants (39.8%) met this criterion. One participant was excluded due to the lack of information regarding internship duration.
Participants completed between 63% and 100% of HSRT items, with a median of 97.0%, and the time taken to complete them varied between 17 and 57 minutes, with a median of 55 minutes. Regarding the General score of the HSRT (Table 1), we observed values between 62 and 85, with a median of 73 and compared to the reference population, the participants’ scores were between the 1st and 75th percentiles, with the median at the 14th percentile.
According to the classification criteria defined in the HSRT manual, overall critical thinking was classified as not expressed in 2 participants (2.0%), weak in 45 (45.9%), moderate in 45 (45.9%), and strong in 6 (6.1%) (Table 2). Across domains, at least 50% demonstrated moderate to very strong performance (between 72 and 100) in Induction (median 79), Explanation (median 77), and Inference (median 75) domains.
Distribution of overall and domain-specific scores of HSRT among undergraduate nursing students
Percentages calculated on the total of 98 participants, adding up to 100% in each line.
Undergraduate students with and without at least three months of extracurricular internship experience were compared with respect to mean overall and domain-specific HSRT scores (Table 3), and no statistically significant differences were observed between groups (p>0.05 in all comparisons).
Mean values and 95% confidence intervals for overall and domain-specific HSRT scores according to participation in extracurricular internships lasting at least three months during their undergraduate studies
The groups of undergraduates who had no experience and those who had previous work experience in the health sector, working as nursing technicians or assistants for a period of three months or more, were compared in relation to the means of the General and Domain scores of the HSRT (Table 4) and there is evidence of significant differences between them in all scores (p<0.05 in all comparisons). The averages of all the scores of the participants with previous experience are significantly lower than the averages of the participants without previous experience.
Mean values and 95% confidence intervals for overall and domain-specific scores of HSRT according to prior healthcare work experience of at least three months
DISCUSSION
This study aimed to assess the critical thinking skills of undergraduate nursing students at a private educational institution in São Paulo using the HSRT. Regarding sociodemographic characteristics, the data showed a diverse distribution in terms of age, gender, ethnicity, and marital status.
The participants ranged in age from 19 to 44 years, with a median of 22 years, which reflects a broad spectrum of ages within the group studied. A study carried out in Salvador showed that 23.4% of the group studied were between 30 and 40 years. This age distribution may be associated with various considerations, such as the different stages of life, individual goals and motivations, and possible cultural or economic influences that shape educational and professional trajectories, demonstrating that older adults are increasingly entering higher education.(21)
Regarding high school education, there is a split between public and private institutions, with the majority of participants (75.5%) having attended private institutions. This disparity may raise questions about access to education and the socio-economic influences of the participants. The preference for education in private institutions may be related to various factors, such as the perceived quality of teaching, available resources, location of the institutions, among others.(22,23) Another point to highlight is the relatively low competitiveness in the selection process to enter undergraduate nursing programs, especially in private institutions, due to the rapid and disorganized growth in the number of places.(24)
In the results obtained from the analysis of the participants’ previous experiences, we observed that about 25.5% of the sample had some form of previous experience in the health area that was not restricted to a single function. Some participants had accumulated experience in multiple functions, which corroborates studies that show that nursing technicians and assistants have sought a degree in nursing as a way of professional and salary growth.(25,26)
With regard to the extracurricular internship activities carried out during graduation, all in private hospitals, the results showed a diversity of specialties. The Nursing Internship Program is one of the differentials offered by the educational institution in this study.
The median duration of extracurricular internships was 9 months, which indicates that students actively engage in this type of practical experience and that they value and recognize the importance of these opportunities to complement their academic training.
Regarding the questions on the HSRT, most of the participants were committed to completing the instrument, with a median of 97% of the questions answered, which suggests that the participants were willing to invest time and effort in their contribution, important factors for the validity and reliability of the results obtained.
The variation in the percentage of questions completed by participants was relatively small, with the first quartile indicating 82% and the third quartile reaching 100%. This suggests a consistent response behavior, with few participants showing very low or very high adherence. This uniformity in the response rate may indicate a good understanding of the questions on the part of the participants, as well as an effort to complete the questionnaire.
As far as completion time is concerned, the data reveal a wider variation, with participants taking between 17 and 57 minutes to complete the HSRT. The median of 55 minutes indicates that most participants spent a substantial amount of time on the task. However, it is important to note that the time taken to complete the questionnaire can be influenced by a number of factors, including the complexity of the questions, the individual's approach to answering, and the degree of thought devoted to each question. The time taken to complete the HSRT in other studies was not found in the literature.
Considering the results presented, it can be argued that the participants showed significant involvement with the study, both in terms of response rate and time invested. These aspects are essential to the quality and reliability of the data collected, suggesting that the study was conducted carefully and that the results obtained can be considered representative of the group of participants.
In the general assessment of CP skills, the results showed a moderate score from the participants (average 72.7), but no domain assessed reached a strong score or higher, with 5 of the domains assessed showing a weak score: numeracy (65.0), deduction (65.6), evaluation (66.9), interpretation (67.4), and analysis (70.4).
Similar results with regard to the overall CP skills score were found in a Brazilian study conducted with 89 participants from 28 public and 30 private universities. The aim of the study was to map the level of critical thinking of undergraduate nursing students using the HSRT and to investigate the correlation between sociodemographic data and CP domains. The results showed a moderate level of CP in the participants and identified low performance in 5 of the 8 domains assessed: numeracy (63.1), deduction (64.6), interpretation (66.0), evaluation (67.8) and analysis (69.1). This study concluded that Brazilian nursing undergraduates have unsatisfactory levels in most of the domains assessed by the HSRT and suggests further studies to investigate the reason for this low score so that teaching strategies are appropriate to improve CP scores.(19)
One hypothesis for these results may be related to the use of active methodologies from the first semester of undergraduate studies, as well as the introduction of curricular internships in the first year. Studies show that the application of active teaching-learning methodologies, when applied from the start of academic activities and at various times during training, contributes to the development of technical, cognitive, and behavioral skills needed for practical work.(27,28)
A study involving 98 students from a dentistry course at the University of Southern California, which used the Problem Based Learning (PBL) method, measured the performance of the CP skills of students from the first to the third year and the results also showed no significant difference in the overall performance of the HSRT score with the exception of the inductive reasoning score, which was more consistent in relation to the other subscale scores. Some aspects, such as gender, race, language, and degree level (undergraduates and postgraduates), showed significant differences in the overall score (evaluation, deduction, and induction).(29)
Another comparison made in this study was between undergraduates who had no previous work experience in the health sector and those who had worked as nursing technicians or assistants for a period of three months or more. They were compared in relation to the means of the General and Domain scores of the HSRT, and there was evidence of significant differences between them in all scores. The mean scores of all the participants with previous experience were significantly lower than the mean scores of the participants without previous experience. A study from Australia reports that nursing assistant roles probably do not provide the opportunity to develop higher level skills and that there are differences in the development of those who carry out basic care and procedures, such as in nursing homes and home care from those who work in general hospitals.(30)
The significant difference found in the comparison between these two groups tells us that technical level activities do not develop higher level skills, suggesting that practice time and the execution of procedures and tasks are not sufficient for the development of critical thinking, as well as the overload of stress and working hours having a negative influence on learning and educational results.
Another study on the subject was carried out at a university in southern Brazil, with 40 nursing students enrolled in the 6th, 7th, and 8th semesters. The aim was to identify the students’ levels of critical thinking based on the application of a virtual simulator, as well as to verify the students’ perspective of their level in this category. Knowledge gaps were identified regarding clinical reasoning, showing deficiencies in critical thinking since no student was identified at the strong level by the simulator. The authors found no significant correlation between the variables when comparing students with nursing technician training and those without. The critical thinking scores of the two groups evaluated were similar in terms of performance, unlike the findings of this study.(31)
Although it is challenging to teach and develop critical thinking skills, the relationship between the educational institution and the health service unit is the weakest link within the reality of the internship, requiring high compliance from both parties, as well as greater participation from the educational institution, facilitating the partnership between nurses, teachers, and students.(32)
In this context, it is believed that the training of critical nurses begins in nursing education, where one of the main challenges is to develop CP skills by adapting pedagogical strategies based on the identification of the skills to be developed, as well as the costs involved in evaluation due to the limited existence of validated and available instruments.
The findings of this study align with the Brazilian National Curriculum Guidelines for Nursing, which establish critical thinking as an essential competency for graduates.(33)
At the institution where the research was conducted, the Nursing Program Curriculum incorporates this competency transversally, integrating it into theoretical activities and clinical placements. The curriculum includes collaborative active learning methods, such as team-based learning, and the use of high-fidelity simulation, both of which are recognized strategies for enhancing critical thinking. By demonstrating that the development of critical thinking in practice depends on pedagogical intentionality and structured reflective support, the results highlight the need for educational strategies that integrate clinical reasoning, decision-making, and systematic reflection, thereby strengthening training for complex care environments.(19)
In-service training experiences, such as curricular and extracurricular internships, are foundational components for the development of critical thinking in undergraduate nursing education; however, their effectiveness depends on pedagogical intentionality, institutional conditions, and qualified supervision. In environments structured predominantly around operational demands and task-centered routines, there is a tendency to reinforce a mechanistic view of care and to limit opportunities for analysis, inference, and self-regulation. Conversely, when internship experiences are anchored in close supervision, guided reflection, and effective academic-practice integration, there is increased likelihood of cognitive advancement. This tension is reflected in the literature: in a quasi-experimental study with nursing students, a structured clinical internship program improved caring behaviors but did not significantly change critical-thinking disposition, suggesting that clinical exposure alone – without an instructional design deliberately oriented toward reflection – is insufficient to promote sustained cognitive development.(34)
This study reveals that isolated practice, without structured reflective support, does not promote improved performance in critical thinking and may even reinforce technicist approaches. The literature suggests that models grounded in guidelines and self-regulated learning strategies are more effective in developing clinical reasoning. Moreover, differences between students from private and public institutions should be interpreted with caution, given the heterogeneity of higher education in Brazil, suggesting that observed variations likely reflect pedagogical and internship conditions rather than institutional type.(35) Thus, it is recommended that internship programs be structured with clear cognitive objectives, formal opportunities for reflection and formative assessment, and practices aligned with current evidence, in order to strengthen critical thinking development in nursing education.
This study has some limitations. First concerns the size of the sample, the cost of purchasing the instrument, and the fact that it was only applied to one educational institution. Second, the HSRT has not yet undergone a complete transcultural adaptation process for use in the Brazilian context. Although its conceptual foundation is aligned with the CCTST and supports its theoretical applicability, the absence of formal cultural and linguistic adaptation may introduce measurement bias, as certain items may not fully capture nuances of reasoning, interpretation, or linguistic comprehension specific to the target population. This limitation should be considered when interpreting the results, as it may influence score variability and potentially affect the comparability of findings with studies conducted in contexts where the instrument has been fully validated.
Future studies should employ longitudinal designs to monitor changes in undergraduates’ critical thinking scores over time and assess the long-term impact of different teaching strategies on skill development. Extending this line of investigation to other educational institutions may also strengthen the evidence base and improve the generalizability of the findings.
CONCLUSION
This study demonstrated that undergraduate nursing students exhibit a moderate level of critical thinking, with domain-specific variability. These findings underscore the need for intentional and structured educational strategies aimed at strengthening critical thinking development throughout nursing education. Enhancing this competency is essential to support clinical decision-making, promote patient safety, and prepare nurses to manage the complexities of professional practice.
DATA AVAILABILITY
The content will be made available upon the article's publication.
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Source: Health Sciences Reasoning Test (HSRT) User Manual (2021).