Exploring the link of educational environment and self-esteem with critical thinking in undergraduate nursing university students: a cross-sectional study

Introduction

Critical thinking (CT) is the cornerstone of high-quality healthcare practice, which plays an essential role in ensuring safe, effective and evidence-based care delivery [1]. CT can be defined as “a purposeful and self-regulatory act of thinking that involves interpretation, analysis, evaluation, inference, and explanation” [2], 3]. High levels of CT enable healthcare professionals to more act effectively towards the complexity of clinical decision-making and diagnostic accuracy [1]. The COVID-19 pandemic has further emphasized the need for healthcare professionals to possess high levels of CT due to the rapid and unpredictable challenges posed by the global health crisis [4], [5], [6]. In nursing, CT is essential for identifying patient needs, evaluating interventions, and anticipating potential complications [1]. However, studies suggest that undergraduate nursing programs often do not foster this critical skill adequately [7], 8]. Consequently, research has indicated the need for the early development of CT in nurses [9].

Literature review

In particular, undergraduate nursing education is considered the optimal period for the development of CT [8], 9], 10]. Nevertheless, improving CT has always been challenging for nurse educators, especially considering that it is a complex skill with numerous modifiable (i.e. educational environment, emotional intelligence, and self-esteem) and unmodifiable (i.e. gender, age, past experiences) factors that could influence its development [8], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19]. Interestingly, among the modifiable factors that influence CT, two prominent examples are the educational environment (EE) and self-esteem (SE).

EE encompasses various aspects that influence student learning, including the physical, psychological, and pedagogical domains [20]. This includes factors such as classroom dynamics, available resources, curriculum design, and teaching strategies [21], 22]. A well-structured educational environment promotes intellectual curiosity, critical inquiry, and engagement, providing nursing students with opportunities to further develop their CT [21], 22]. Effective teaching methods, such as problem-based learning, reflective writing, simulation exercises, and case studies, have been shown promising in promoting CT among nursing students [23], [24], [25]. Problem-based learning, in particular, encourages the application of theoretical knowledge to real-world scenarios, enhancing analytical and collaborative skills [26]. On the other hand, SE has been defined as the “positive or negative attitudes towards oneself, whose positivity is the main feature of self-esteem” [27]. SE seems to play a pivotal role in shaping CT abilities, since higher levels of SE are associated with greater motivation, resilience, and openness to intellectual challenges, all of which are essential for reflective and analytical thinking [16], 18], 19], 28], 29]. Furthermore, nursing students with elevated self-esteem are more likely to actively participate in learning activities, take intellectual risks, and persevere in the face of challenges, contributing to their CT development [16], 18], 29].

Theoretical framework

Studies have examined these factors independently, thus the interaction between EE, SE, and CT remains relatively underexplored, particularly in nursing education [18]. This is important, since EE serves as the structural and contextual framework for learning, providing opportunities for engagement and intellectual growth [20]. Meanwhile, SE provides the psychological foundation for students to more confidently participate in these educational activities [27]. However, despite the theoretical and empirical insights into the importance of EE and SE in the development of CT, there is still a notable gap in understanding how these factors could interact to influence CT among nursing students. This is important, since, previous studies have primarily focused on their individual effects, with limited attention given to their potential synergistic impact. Hence, it is crucial to address this gap in order to develop targeted strategies that optimize nursing education and more effectively improve the CT of nursing students. Consequently, the present study aimed to evaluate CT, SE, and perceptions of EE among undergraduate nursing students in Greece and examine the potential associations between EE and SE with CT in these students.

Methods

Results

A total of 185 nursing students participated in the study, with the majority being female (87.6 %). The mean age of the participants was 21 years, ranging from 18 to 50 years (Table 1). The distribution of participants across the academic semesters was as follows, 30.8 % in the fourth semester, 27.0 % in the sixth semester, and 37.3 % in the eighth semester (Table 1).

The participants exhibited a moderate level of critical thinking disposition (mean score 43.6, SD=5.5) (Table 2). The subscale scores of CTDs were also moderate (Critical Openness, mean score=27.2, SD=3.6; and Reflective Skepticism, mean score=16.4, SD=2.4). The participants also exhibited moderate to high levels of self-esteem (mean score 29.4, SD=5.0) (Table 2). The Positive Dimension of Self-Esteem had a mean score of 15.8 (SD=2.2), while the Negative Dimension had a mean score of 11.4 (SD=3.3). On the other hand, the students perceived the overall educational environment positively (mean score 158.1, SD=28.0). All of the DREEM subscale scores were moderate (Learning, mean score=37.1, SD=8.1, Teachers, mean score=37.5, SD=6.7, Academic, mean score=26.0, SD=5.4, Atmosphere, mean score=37.2, SD=7.8, and Social, mean score=20.6, SD=5.0) (Table 2).

Spearman’s correlation coefficients were calculated to explore the relationships between CT, EE, and SE (Table 3). The overall DREEM score was positively associated with the total CTDS score (ρ=0.34, p<0.01). On the other hand, the overall RSE score was also positively associated with the total CTDS score (ρ=0.31, p<0.01) and the DREEM score (ρ=0.25, p<0.01), respectively. Similarly, significant positive associations were found between the DREEM, RSE, and CTDS subscales.

Robust regression showed that demographic factors, such as sex and semester, were not statistically significantly associated with total CTDS score and its subscales, critical openness and reflective skepticism (Table 4). However, the total score and subscales of the DREEM, showed strong positive associations with CT disposition and its subscale. More specifically, the total DREEM score had a significant association with total CTDS score (β=0.34, p<0.001), critical openness (β=0.34, p<0.001), and reflective skepticism (β=0.38, p<0.001). Furthermore, total RSE was found to be positively associated with total CTDS score (β=0.20, p<0.001), critical openness (β=0.12, p=0.012), and reflective skepticism (β=0.28, p<0.001). Including total RSE score in the model slightly reduced the effects of DREEM while maintaining statistical significance (p=0.012). This finding suggests that part of the association between EE and CT might be explained by SE, as both are likely contributing to the improvement of CT.

SEM was utilized to explore the potential mediating role of SE in the relationship between EE and CT (Figure 1). No significant mediating effect of SE was found between EE with total CTDS score (CI: −0.003, 0.14), and EE with the Critical Openness subscale of CTDS (CI: −0.02, 0.12). However, SEM indicated that SE partially mediates the relationship between EE and the Reflective Skepticism subscale of CTDS (M=0.09, CI: 0.009–0.17). This suggests that a positive educational environment enhances self-esteem, which subsequently improves reflective skepticism, a component of critical thinking disposition.

Figure 1:

Structural equation modeling between DREEM, RES with CTDS, and DREEM, RES with critical openness subscale of CTDS, and DREEM, RES with reflective skepticism subscale of CTDS (IE: Indirect effect, DE: Direct effect, TE: Total effect, 95 % CI were estimated with 5,000 bootstrap iterations).

Discussion

This study aimed to evaluate the levels of EE, SE, and CT of nursing students in Greece, and examine the potential relationships between EE, SE, and CT. Our findings suggested that nursing students had moderate to high levels of EE, SE, and CT. In addition, our results indicated a positive correlation between both EE and SE with CT. Furthermore, SE was identified as a mediator (a variable that explains part of the association) between EE and the Reflective Skepticism subscale of CTDS.

A major finding of the present study was that EE was positively associated with CT. This finding aligns with previous studies that have highlighted the crucial role of the educational environment in improving students’ critical thinking [40], [41], [42], [43], [44], [45], [46], [47], [48]. More specifically, a positive EE, characterized by supportive faculty, active and collaborative learning methods, and an engaging curriculum, has consistently been shown to enhance critical thinking skills in various studies [40], [41], [42], [43], [44], [45], [46], [47], [48]. For example [49], conducted a systematic review that demonstrated how problem-based learning and other interactive teaching methods significantly improve CT among nursing students. Similarly [1], emphasized the positive effect of the educational environment on the development of critical thinking in medical education. [15]; in a meta-analysis, found that non-traditional teaching methods, including simulation and reflective writing, effectively promote CT in nursing education. Additionally [50], showed that simulation with problem-based learning enhances moral sensitivity, empathy, critical thinking and grades in nursing students. Therefore, a potential explanation of our finding could be that the Nursing Department where this study took place is a small department with only 11 professors; however, these professors are using an individualized approach in teaching. Small numbers of professors and students makes active learning techniques a reality. This could have potentially improved students’ critical thinking and self-esteem. Moreover, a well-designed EE could facilitate the development of CT through experiential learning, collaborative problem-solving, and reflective practices [1].

Another important finding of the present study was that SE was positively associated with CT. Other studies have also suggested that higher self-esteem is positively associated to CT [18], 19]. For example, a study suggested that nursing students with higher self-esteem performed better academically and had higher levels of critical thinking [19]. Another study, found that higher CT scores were positively associated with higher SE scores, and lower state anxiety scores; similarly, higher SE scores correlated with lower state anxiety scores [18]. This finding could be explained by Rosenberg’s research, which suggests that individuals with higher SE are more likely to actively engage in their own learning process [36]. Consequently, they may develop higher levels of CT. Moreover, high levels of SE could enhance students’ ability to persevere through complex problem-solving tasks, enabling them to critically analyze information and make sound decisions [16].

A significant finding of the present study was that SE could play a mediating role in the relationship between SE and the reflective skepticism subscale of CTDS. Professor Sosu, the creator of CTDS, suggests that the reflective skepticism subscale measures “the tendency to learn from past experiences (reflection) and question evidence (skepticism)” [32]. Therefore, our finding indicates that a positive educational environment not only directly influences critical thinking, but also enhances SE, which in turn fosters the students’ ability to learn from past experiences and questioned evidence, thus further improving their CT. This aligns with other studies that emphasize the importance of psychological factors, such as SE, in the development of CT [16], 19], 29].

Implications for an international audience

Our study emphasizes the importance of nursing education in fostering a positive EE that supports the development of CT and improves students’ SE. To achieve this, nursing educators could focus on cultivating supportive relationships, promoting collaborative learning, and incorporating reflective practices [21]. Interactive teaching methods, such as problem-based learning, simulations, and case-based discussions, could also be effective in engaging students and applying theoretical knowledge to practical situations, which in turn could enhance the students’ CT [22]. In addition, faculty development programs could be crucial for training nurse educators to create inclusive and supportive classrooms [21], 23], 51]. Educators who are approachable, provide constructive feedback, and encourage participation may have a positive impact on students’ perceptions of their EE, leading to increased engagement and academic performance [21], 23], 51]. On the other hand, targeted interventions, such as workshops on self-awareness, stress management, and resilience training, could improve students’ SE and enhance CT, and professional development [16]. Furthermore, mentorship programs could play a significant role in guiding nursing students through both academic and clinical challenges [52], 53]. Towards that end, experienced mentors could provide valuable support, feedback, and encouragement, which could help nursing students build their confidence and analytical skills [52], 53]. Integrating these strategies into nursing university curriculums could create a comprehensive framework to improve students’ critical thinking, self-esteem, and ultimately, the quality of patient care they will provide as nurses.

Limitations

Our study, to the best of our knowledge, is the first to examine the relationship between CT, SE, and perceptions of the EE in Greek nursing students, and suggest that SE could mediate the relationship of EE and CT, through the reflective skepticism dimension of CT. However, it is important to acknowledge that despite its strengths our study has a few limitations to consider. The cross-sectional design prevents us from making causal inferences between the variables. To establish causality and track changes over time, future research should consider longitudinal designs to investigate critical thinking, self-esteem, and perceptions of the educational environment. Furthermore, the use of self-reported measures in this study may introduce response biases, as participants may provide socially desirable answers rather than accurate reflections of their perceptions and abilities. Additionally, the findings of this study may not be applicable to all nursing students due to the unique cultural and educational context of the sample. Our study was conducted in a single university in Greece, with a predominantly female participant group. Finally, our study only considered two modifiable CT factors (EE and SE), so other factors might also be involved. Consequently, future studies could employ mixed methods designs to mitigate the self-report bias or utilize longitudinal designs to improve our understanding of causality. To better understand how to improve CT for nursing students, future studies should incorporate more modifiable factors, such as emotional intelligence, and utilize larger, more diverse samples, including other healthcare students.

Conclusions

In conclusion, our findings indicate that both EE and SE have a positive association with CT disposition. Additionally, our findings suggest that SE acts as a mediator in the relationship between EE and Reflective Skepticism, a component of CT. The positive correlation between EE and CT emphasizes the significance of establishing a supportive and stimulating educational environment in nursing programs. Educators could concentrate on improving the EE by using effective teaching strategies, promoting collaborative learning, and providing opportunities for critical reflection. This type of environment could not only directly impact students’ CT skills but also enhance their SE, which could further improve their ability to engage in reflective and analytical thinking. Furthermore, nursing educators may consider incorporating activities that promote SE into their curricula. By offering positive feedback, encouraging student participation, and creating a supportive learning atmosphere, students’ self-esteem and, consequently, their critical thinking abilities could be further improved. This is important since students who have adequately developed their CT during their university studies will become highly competent healthcare professionals that provide high-quality care to their patients.