Simple Six-Step Learning Strategy Boosts Critical Thinking in Nursing Students

A structured teaching method that asks students six deceptively simple questions — What do I know? What do I want to know? How will I find out? What have I learned? How can I apply it? What new questions do I have? — has produced striking gains in critical thinking and self-directed learning among nursing students training for one of medicine’s most demanding environments. The findings, published as an open-access research article in BMC Nursing, come from a quasi-experimental trial conducted at the Faculty of Nursing, Alexandria University in Egypt, and they suggest that a low-cost, easily replicable classroom framework may help prepare the next generation of intensive care nurses far better than traditional lectures alone.

The strategy at the heart of the study is known as KWHLAQ, an extended version of the familiar KWL (Know–Want–Learned) chart that many readers will remember from school. The original KWL tool prompts learners to activate prior knowledge, set questions, and consolidate what they have learned. The modified KWHLAQ framework adds three further steps: identifying how the learner will find the needed information, planning how the new knowledge can be applied in practice, and generating new questions that arise from the learning cycle. Each letter of the acronym corresponds to one stage of an iterative inquiry loop, turning passive note-taking into an active, self-monitoring process of questioning, searching, evaluating, and reflecting.

The research team, led by Yasmeen Mohamed Mohamed Shehata of the Nursing Education Department at Alexandria University, together with colleagues from Alexandria University, Prince Sattam Bin Abdulaziz University, and Helwan University, set out to test whether this framework could move the needle on two competencies that educators consider essential for high-acuity clinical work: critical thinking and self-directed learning. Critical care nursing demands rapid, defensible decisions under pressure, where a misjudged interpretation of ventilator data or a subtle change in a patient’s condition can have immediate consequences. Students who cannot evaluate evidence, weigh alternatives, and direct their own learning are at a distinct disadvantage both in training and at the bedside.

To test the intervention rigorously, the researchers employed a quasi-experimental, nonequivalent control group pretest–posttest design. One hundred undergraduate nursing students in their third semester, all enrolled in the Critical and Emergency Nursing Department at Alexandria University’s Faculty of Nursing, participated during the 2025 academic session. Fifty students were assigned to the study group, which received a twelve-week structured intervention built around the KWHLAQ framework, while the remaining fifty formed a control group that received standard lecture-based instruction. Because randomization was not used, the researchers applied statistical covariate adjustment to account for baseline differences between the groups, a standard approach in quasi-experimental educational research.

Both groups completed two validated instruments before and after the intervention period. The Critical Thinking Questionnaire, or CThQ, with an internal consistency of Cronbach’s alpha of 0.80, measured multiple dimensions of critical thinking, including interpretation, analysis, and evaluation of information. The Self-Directed Learning Instrument, or SDLI, also with an alpha of 0.80, assessed four subscales covering the learner’s ability to set goals, seek resources, monitor progress, and evaluate outcomes independently. Using the same measures in both groups at both time points allowed the team to compare change over time and isolate the effect of the teaching strategy.

The results were unambiguous. After covariate adjustment, the study group demonstrated significantly higher post-intervention critical thinking scores than the control group, with a p-value below 0.05 and a Cohen’s d of 0.67, an effect size in the moderate-to-large range. The study group improved significantly in overall critical thinking, with a mean difference of 5.66 points (p < 0.01), while the control group’s scores actually declined over the same period. The most dramatic difference appeared in the evaluating subscale of the CThQ, where the intervention group posted a mean difference of 4.50 points (p < 0.001) and an effect size of Cohen’s d = 2.10 — an exceptionally large gain by educational research standards, and one made more notable by the fact that students receiving conventional instruction moved in the opposite direction.

Self-directed learning showed an even stronger response. The study group improved by a mean difference of 23.06 points on the SDLI (p < 0.001), corresponding to a Cohen’s d of 2.45, and the gains were significant across all four subscales of the instrument. In practical terms, students who had spent twelve weeks working through the KWHLAQ cycle did not merely absorb more content; they became measurably better at organizing their own learning — identifying what they needed to know, planning how to find it, applying what they learned, and reflecting on remaining gaps. That shift from passive recipient to active manager of knowledge is precisely the behavior that lifelong clinical learning requires, particularly in critical care, where guidelines, technologies, and evidence bases evolve continuously.

The authors argue that the strength of the KWHLAQ approach lies in its structure and simplicity. The framework requires no expensive technology, no additional staffing, and no wholesale curriculum redesign; it can be embedded into existing courses as a recurring scaffold around lectures, case discussions, and clinical assignments. Its iterative design also aligns with established learning theory: by asking students to articulate prior knowledge and explicit questions, the strategy works within what educational psychologists call the zone of proximal development, the space between what a learner can do alone and what they can achieve with appropriate support. By closing each cycle with application and new questions, it encourages the reflective reasoning that underpins sound clinical judgment.

The study was approved by the Research Ethics Committee of the Faculty of Nursing at Alexandria University (Approval No. AU-20-9-380) and conducted in accordance with the Declaration of Helsinki, with all participants giving informed consent and retaining the right to withdraw at any time without adverse consequences. The research received no external funding, and the authors declare no competing interests. The article was received on 12 May 2026, accepted on 13 August 2026, and published on 28 September 2026 under a Creative Commons Attribution 4.0 license, making the full methods and findings freely available to educators worldwide.

For nursing schools facing rising enrollment, acute workforce shortages, and curricula already crowded with technical content, the appeal of a twelve-week, low-cost intervention with effects of this magnitude is considerable. The authors conclude that integrating this structured, replicable pedagogical framework into nursing curricula may promote active learning, reflective reasoning, and the clinical decision-making competencies essential for high-acuity practice. As with any quasi-experimental study conducted at a single institution, broader replication across different settings and student populations will be needed to confirm generalizability, and the published version is subject to further editorial refinement. But the core message is already compelling: sometimes the most powerful upgrade to a demanding professional curriculum is not new technology at all, but a better set of questions.

Subject of Research: Effect of the modified KWHLAQ learning strategy on critical thinking and self-directed learning in critical care nursing education

Article Title: Enhancing critical thinking skills and self-directed learning among critical care nursing students: a quasi-experimental study on the impact of the modified KWHLAQ strategy

Article References: Shehata, Y. M. M., Hendawi, N. E., Atta, M. H. R., Aly, M. A., Nagy, A. S. A., & Younis, A. A. A. (2026). Enhancing critical thinking skills and self-directed learning among critical care nursing students: a quasi-experimental study on the impact of the modified KWHLAQ strategy. BMC Nursing, 25(1), Article 895. https://doi.org/10.1186/s12912-026-05254-y

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05254-y

Keywords: critical thinking, self-directed learning, nursing education, KWHLAQ strategy, critical care nursing, quasi-experimental study, problem-based learning, clinical decision making, Alexandria University, BMC Nursing, pedagogy, intensive care