Critical care nurses’ knowledge, confidence, and clinical reasoning in sepsis management: a systematic review

Abstract

Background

Sepsis is a critical condition with high global mortality, accounting for 11 million deaths annually. Nurses are central to sepsis management, and their knowledge, confidence, and clinical reasoning significantly impact patient outcomes.

Aim

This systematic review evaluates critical care nurses’ knowledge, confidence, and clinical reasoning in sepsis management and examines factors influencing these competencies.

Methods

A comprehensive search of PubMed, CINAHL, MEDLINE, Scopus, EMBASE, and the Cochrane Library was conducted, covering studies published from 2014 to 2023. Studies were included if they assessed knowledge, confidence, or clinical reasoning in sepsis management among critical care nurses using quantitative, qualitative, or mixed-methods approaches in clinical settings. Only peer-reviewed studies were considered to ensure academic rigor. The risk of bias was assessed using the JBI Checklist for quantitative studies and the CASP tool for qualitative studies, with discrepancies resolved through discussion or a third reviewer. A total of 70 records were screened, with 25 studies (sample sizes ranging from 28 to 835 nurses) meeting the inclusion criteria. Data extraction focused on study design, tools used, and key outcomes related to knowledge, confidence, and clinical reasoning in sepsis management.

Results

Across 25 studies involving over 5,000 nurses globally, knowledge scores were moderate, with significant gaps in early sepsis recognition (e.g., only 52% of nurses could define sepsis). In three studies, confidence improved with sepsis-specific training, showing a 10–25% increase post-intervention. Clinical reasoning was influenced by organizational factors, experience, and the use of technology, with decision-support tools enhancing timely sepsis recognition and reducing mortality by up to 23%.

Conclusion

This review provides a global perspective on sepsis management among critical care nurses, strengthened by diverse study designs. However, limitations include variability in measurement tools, self-reporting bias, small sample sizes, and language-based selection bias. Continuous education, targeted training, and the integration of AI-driven decision tools are essential to improving sepsis outcomes. Addressing gaps in sepsis knowledge and promoting better clinical reasoning will enhance the overall quality of care in critical settings.

Background

Sepsis is a life-threatening condition resulting from an unregulated immune response to infection, leading to organ dysfunction and systemic inflammation and, causing approximately 11 million deaths annually, accounting for nearly 20% of global mortality [1, 2]. Its pathophysiology is marked by the overwhelming release of pro-inflammatory cytokines that trigger widespread vasodilation, increased vascular permeability, and tissue edema, eventually causing a decline in organ function [3]. The clinical manifestations of sepsis can vary, including fever, tachycardia, tachypnea, and signs of organ failure such as oliguria, hypotension, altered mental status, and elevated lactate levels. Without prompt treatment, sepsis can escalate into septic shock, characterized by persistent hypotension despite fluid resuscitation, requiring vasopressor support [4,5,6]. In low- and middle-income countries, the incidence of sepsis is disproportionately higher due to limited healthcare resources and delayed intervention. In Brazil, for instance, the mortality rate in intensive care units (ICUs) can be as high as 55.6% [7], reflecting the devastating impact of sepsis, particularly when timely diagnosis and management are not achieved [7].

Management of sepsis is guided by evidence-based interventions, with the core components revolving around the early identification of sepsis, prompt administration of antibiotics, fluid resuscitation, and, when needed, vasopressor support [1]. The cornerstone of sepsis treatment is early goal-directed therapy, which aims to restore perfusion, maintain organ function, and address the source of infection. Updated sepsis care guidelines, such as the Surviving Sepsis Campaign, emphasize early detection and intervention through standardized protocols like the one-hour bundle [8]. These aim to address delays in treatment, which significantly increase mortality. However, the complexity of sepsis management often leads to inconsistent adherence, highlighting the need for skilled nursing care [9].

Nurses play a pivotal role in the management of sepsis, particularly in critical care settings, where their responsibilities include monitoring for early signs of clinical deterioration, implementing protocols, and coordinating care with the multidisciplinary team. The role of nurses extends beyond mere task execution; they are essential in identifying and managing sepsis, as they often are the first to detect subtle changes in a patient’s condition [10]. In many instances, nurses are responsible for initiating sepsis protocols, ensuring timely administration of antibiotics and fluids, and performing ongoing monitoring of vital signs and laboratory markers. For example, implementing nurse-led sepsis screening tools such as the Modified Early Warning Score (MEWS) has significantly reduced mortality by enabling earlier intervention [11].

A critical component of nursing practice in sepsis management is clinical reasoning, which involves the cognitive process nurses use to assess and interpret patient data, recognize patterns, and make informed decisions. Nurses’ clinical reasoning in recognizing and responding to sepsis is crucial in preventing progression to septic shock. Harley et al. [12] emphasize the importance of clinical reasoning in emergency department nurses, highlighting that prompt recognition of sepsis symptoms by nurses can improve survival rates by initiating treatment promptly. However, inadequate clinical reasoning can lead to delayed recognition, inappropriate interventions, and worse prognoses for patients with sepsis.

However, effective sepsis management requires that nurses possess adequate knowledge, confidence, and clinical reasoning skills. Knowledge of sepsis is critical, as it equips nurses with the understanding needed to recognize early warning signs, initiate appropriate interventions, and manage complications. Studies have shown that nurses with higher knowledge levels are more adept at identifying early sepsis markers, such as tachypnea and elevated lactate levels, which are crucial for early diagnosis [2]. Confidence, on the other hand, refers to the self-assurance nurses have in their ability to perform tasks related to sepsis management. Nurses who are confident in their skills are more likely to take swift action, collaborate with other healthcare professionals, and adhere to sepsis protocols [1]. Confidence is also linked to clinical experience and continuous education, as [9] found that participation in sepsis educational programs significantly enhanced nurses’ confidence in managing sepsis patients. Lastly, clinical reasoning is the cognitive process nurses use to assess and interpret patient information, make decisions, and implement interventions. Clinical reasoning is essential in sepsis management, as it allows nurses to distinguish between normal and abnormal findings, prioritize interventions, and adjust treatment based on patient response [12]. Without strong clinical reasoning, nurses may struggle to recognize sepsis in its early stages, potentially leading to delayed treatment and poor patient outcomes.

The theoretical underpinning of this systematic review lies in understanding the interplay between nurses’ knowledge, confidence, and clinical reasoning in the management of sepsis [7, 9, 13]. Each of these variables is integral to effective nursing practice, and together, they form a comprehensive framework for improving patient outcomes in critical care settings [14]. In this context, knowledge refers to the understanding of sepsis pathophysiology, risk factors, and management protocols. It encompasses both theoretical knowledge gained through education and practical knowledge acquired through clinical experience [15]. In this review, confidence is defined as the belief in one’s own abilities to perform nursing tasks effectively, particularly in high-stakes environments like critical care. It encompasses both self-efficacy and the willingness to make clinical judgments. Clinical reasoning is defined as the cognitive process through which nurses synthesize patient data, assess clinical situations, and make informed decisions [12]. The knowledge-attitude-behavior (KAB) framework was incorporated to underscore the interplay between these three variables. This model highlights how knowledge influences attitudes (in this case, confidence) and subsequently impacts behavior (clinical reasoning in practice). By using this framework, the review will provide a more coherent structure for understanding how these elements interact to improve patient outcomes in sepsis management. The significance of reviewing these three variables concurrently is underscored by studies like [16], which showed that nurses with higher knowledge, confidence, and clinical reasoning skills had better decision-making abilities in sepsis management, ultimately improving patient outcomes. By exploring these variables in tandem, this review seeks to fill a critical research gap and offer insights into how nursing education and practice can be optimized to enhance sepsis care. Understanding the relationships among these variables can inform the development of targeted interventions, such as specialized sepsis training programs, which can bolster nurses’ competencies and improve the quality of care provided to sepsis patients.

Research gap

Existing literature reveals gaps in understanding how critical care nurses’ knowledge, confidence, and clinical reasoning interplay in improving sepsis management. Limited attention has been given to consolidating qualitative and quantitative insights on these competencies. This review addresses this gap by systematically synthesizing findings to inform future interventions.

Aim of the review

This systematic review evaluates critical care nurses’ knowledge, confidence, and clinical reasoning in sepsis management, identifying associated factors and offering insights for targeted training programs.

Methodology

Study design

The study was designed as a systematic review to evaluate critical care nurses’ knowledge, confidence, and clinical reasoning in sepsis management and identify factors associated with these competencies. The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, which provide a standardized framework for conducting and reporting systematic reviews, ensuring transparency and reproducibility in the research process [17]. Additionally, the methodology was informed by the Joanna Briggs Institute (JBI) approach to systematic reviews [18]. The combination of these guidelines ensured that the review was methodologically sound, comprehensive, and adhered to the highest standards of evidence synthesis.

Search strategy

For this systematic review, a comprehensive search strategy was employed to identify relevant studies. The search was conducted across several key databases, including PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), MEDLINE, Scopus, EMBASE, the Cochrane Library, and Web of Science. These databases were selected for their wide coverage of health and nursing literature, ensuring a thorough exploration of available studies on critical care nurses’ knowledge, confidence, and clinical reasoning in sepsis management. The search strategy incorporated both controlled vocabulary, such as Medical Subject Headings (MeSH) terms, and free-text keywords to capture a broad range of studies. Some of key search terms included “sepsis,” “nursing knowledge,” “nursing confidence,” “clinical reasoning,” “sepsis management,” “critical care nurses,” and “nursing competence.” Boolean operators, including AND/OR, were used to combine these terms, refining the search results to focus on the intersection of these key concepts, ensuring that only the most relevant studies were identified. The detailed search strategy and key terms used was included in the supplementary file.

The search was restricted to studies published in English to maintain consistency in the review and ensure that the included studies could be fully understood and analyzed without translation errors. Furthermore, the search was limited to studies published from 2014 to the present, reflecting the most recent advances in sepsis management and critical care practices. This time frame was selected to ensure that the review captures current trends in nursing practice, particularly in the context of sepsis, which has seen significant updates in guidelines and management strategies over the past decade.

Specific criteria were established to determine the eligibility of studies for inclusion. The inclusion criteria required studies to assess one or more of the variables—knowledge, confidence, and clinical reasoning—among critical care nurses, specifically in the context of sepsis management. Studies that involved adult critical care nurses and employed quantitative, qualitative, or mixed-methods approaches were all considered, allowing for a broad range of data and insights to be incorporated into the review. Additionally, only studies conducted in clinical settings, such as hospitals or intensive care units, were included, as these settings are directly relevant to the experiences of critical care nurses managing sepsis. All studies had to be peer-reviewed, ensuring a high level of academic rigor Fig 1.

Fig. 1

PRISMA flow diagram

Study selection process

The study selection process for this systematic review involved a multi-step approach. First, two independent reviewers screened the titles and abstracts of all retrieved records (n = 70) from databases (n = 100) and registers (n = 20) after removing duplicate records (n = 30), records marked as ineligible by automation tools (n = 10), and other records removed for various reasons (n = 10) (e.g. Insufficient methodological quality). During the title and abstract screening, 30 studies were excluded for not meeting the inclusion criteria. Next, the full texts of potentially eligible reports (n = 40) were sought for retrieval, with five reports not retrieved. The remaining 35 reports were assessed for eligibility, and 11 were excluded—5 for not addressing the review variables (knowledge, confidence, or clinical reasoning), 4 for focusing on a different population, and one due to failing to meet methodological rigor, including vague participant descriptions and insufficient analytical frameworks. Ultimately, 24 studies were included in the review. A PRISMA flow diagram documented this process, including the reasons for exclusion at each stage.

Method for assessing risk of bias

To evaluate the risk of bias in the included studies, two independent reviewers conducted a structured assessment using standardized appraisal tools appropriate for different study designs. For quantitative studies, the Joanna Briggs Institute (JBI) Critical Appraisal Checklist was applied, examining aspects such as sample selection, measurement validity, and confounding factors. For qualitative studies, the Critical Appraisal Skills Programme (CASP) tool was used to assess research credibility, data coherence, and reflexivity. Discrepancies in the assessments were resolved through discussion or consultation with a third reviewer to ensure reliability and minimize subjective bias.

Data extraction

The data extraction process employed an evidence matrix structured into three tables, each focusing on one of the key variables: knowledge, confidence, and clinical reasoning in sepsis management. Each table recorded essential study details, including author, year, country, study design, and sample size, as well as population characteristics like nurses’ experience and education. The extraction form also documented the measurement tools used (e.g., questionnaires, scales), outcomes (knowledge scores, confidence ratings, clinical reasoning metrics), and factors associated with each variable, such as training and experience, allowing for a clear comparison across studies.

Table 1 Critical care nurses’ knowledge of sepsis management and associated factors

Data synthesis

The data synthesis methodology was organized into three main headings, each focusing on one of the key variables: knowledge, confidence, and clinical reasoning, along with the factors associated with these variables. For quantitative data, descriptive statistics such as means, standard deviations, and ranges were used to summarize the scores for each variable. Where data were sufficiently homogeneous, a meta-analysis was considered. Qualitative data were analyzed using thematic synthesis to identify recurring themes related to knowledge, confidence, and clinical reasoning.

Table 2 Nurses’ confidence in sepsis recognition and management and its determinants

Results

Characteristics of the included studies

The 25 studies included in this systematic review utilized a range of research designs, with the majority being cross-sectional (17 studies), along with two quasi-experimental studies, two descriptive studies, two qualitative studies, and one scoping review. Geographically, the studies were distributed across diverse countries, providing a broad international perspective on critical care nurses’ knowledge, confidence, and clinical reasoning in sepsis management. These studies spanned across 20 countries, with Brazil having the highest representation (six studies), followed by the United States and Singapore (two studies each). The remaining countries contributed one study each, highlighting the global relevance of sepsis management across different healthcare settings Table 3.

Table 3 Clinical reasoning skills in sepsis management and influencing factors

Regarding the variables assessed, all 25 studies focused on sepsis knowledge, while confidence was specifically assessed in 7 studies, and clinical reasoning was explored in 5 studies. Study sample sizes varied widely, ranging from 41 [7] to 835 [19] participants. Most studies relied on surveys and validated questionnaires [1, 4, 6]. For example, Delaney et al. [9] and Enongene [13] applied specific scales like the Nurse Competence Scale (NCS) and Critical Appraisal Skill Program (CASP). While others utilized qualitative methods such as semi-structured interviews [12] and participant observation [20]. Advanced tools like Machine Learning, Robot Laura^® [21], and ontology-based annotation [22] were used for decision-making. One study [23] conducted a scoping review of quality improvement projects to explore sepsis management protocols.

In terms of population characteristics, the studies involved a diverse group of participants, primarily focusing on nurses across various healthcare settings, including ICU nurses [2], emergency department nurses [1, 24, 25], and critical care nurses [5, 6, 19]. Sample sizes varied widely, ranging from smaller groups like 14 participants [12] to larger groups such as 835 nurses [19]. Many studies highlighted the experience level of the participants, with some noting that more experienced nurses demonstrated higher knowledge and confidence [2, 6]. For example, Rababa et al. [5] found that nurses with more experience had better sepsis management skills. Education level also emerged as an important factor, with higher education linked to greater sepsis knowledge [1, 14, 15]. Additionally, studies indicated that recent training played a role in improving confidence and knowledge [8, 10]. Some studies included physicians alongside nurses, such as Rababa et al. [5] and Regina et al. [26], while others assessed students or paramedics [12, 26]. Only a few studies mentioned gender, but where it was included, the samples were generally diverse, including both male and female participants. For instance, Schorr et al. [10] conducted their study across 60 hospitals, examining the implementation process of sepsis management protocols rather than reporting specific clinical or knowledge-based outcomes. While both male and female nurses participated, gender-specific results were not detailed. Additionally, variations in work settings were observed across studies, with acute care environments [1, 15, 25] and sepsis-focused units often demonstrating higher levels of knowledge and confidence. This systematic review’s findings reflect a wide variety of methodologies, sample sizes, and geographical contexts, emphasizing the importance of ongoing education and training in enhancing sepsis management skills among critical care nurses globally. Tables 1, 2, and 3 present a summary of the reviewed studies.

Critical care nurses’ knowledge of sepsis management and associated factors

This section consolidates findings from 14 studies (13 quantitative and 2 qualitative) that explored nurses’ knowledge of sepsis management and the factors influencing it (Table 1). Key determinants included educational background, clinical experience, patient exposure, and institutional support.

Formal education and specialized training in sepsis significantly enhanced knowledge. Nurses with advanced degrees or recent training were better at identifying early symptoms of sepsis, whereas those without recent education exhibited knowledge gaps [4, 6]. Similarly, clinical experience played a crucial role. Nurses with over 10 years of experience or frequent encounters with sepsis cases displayed greater proficiency than less-experienced counterparts, who often struggled with early symptom recognition [1, 2, 16].

The work environment also influences nurses’ knowledge, with ICU and ED nurses demonstrating a stronger understanding of sepsis. Additionally, institutions that provided structured sepsis protocols and accessible training improved nurses’ knowledge retention and application. While critical care nurses generally had a baseline understanding of sepsis, gaps remained in translating knowledge into evidence-based practice, emphasizing the need for ongoing education and structured training initiatives [21, 25, 26].

Nurses’ confidence in sepsis recognition and management and its determinants

This section summarizes the outcomes of six studies (four quantitative and two qualitative) that examined factors affecting nurses’ confidence in managing sepsis (Table 2). Confidence was largely shaped by education, clinical experience, and institutional support.

Structured sepsis training programs significantly enhanced confidence, with studies showing nurses who underwent training reported higher self-assurance compared to those without formal training [8]. Interactive learning methods, such as simulations and case-based discussions, were particularly effective [9].

Clinical experience also played a vital role [1, 13]. Nurses in acute care settings or those with extensive experience felt more confident, while newer nurses with limited exposure to sepsis cases faced challenges in building confidence [1, 13]. Mentorship and hands-on training were identified as crucial strategies to bridge this gap.

Institutional backing, including clear sepsis management protocols and the integration of electronic health records [10], further bolstered confidence. For instance, technological interventions such as real-time clinical decision-support tools improved nurses’ ability to manage severe sepsis cases effectively [10].

Clinical reasoning skills in sepsis management and influencing factors

This section consolidates insights from five studies (three quantitative and two qualitative) that examined factors influencing nurses’ clinical decision-making in sepsis treatment (Table 3). Clinical reasoning was shaped by organizational constraints, experience levels, and technology adoption.

Organizational elements, such as patient flow and time limitations, frequently obstructed nurses’ clinical reasoning, leading nurses to prioritize task completion over reflective decision-making [12]. More experienced nurses relied on intuition and past encounters, whereas newer nurses benefited from mentorship and structured guidelines [22]. These insights highlight the necessity of fostering an organizational culture that provides nurses with the time and resources essential for effective reasoning.

The adoption of technology, including machine learning systems and electronic health records, was also noted to improve clinical reasoning. Such tools assisted in the early detection of sepsis indicators and offered decision-making support, allowing nurses to execute timely and precise interventions. For example, automated monitoring systems accurately identified over 90% of early sepsis cases, demonstrating the role of technology in improving decision-making [19, 28]. Furthermore, accurate and prompt nursing documentation played a crucial role in clinical reasoning. Research by de Mendonça Henrique et al. stressed that meticulous record-keeping and adherence to established protocols like the Surviving Sepsis Campaign bundle enabled early interventions and lowered mortality rates [29].

Discussion

The systematic review provides a comprehensive understanding of the intricate relationship between nurses’ knowledge, confidence, and clinical reasoning skills in sepsis management, revealing essential insights for both nursing practice and education. A deeper examination of the evidence across these studies highlights critical areas for improvement, ongoing challenges, and the significant role of targeted interventions in enhancing sepsis management outcomes. The discussion below delves into these factors in more depth, synthesizing the evidence to extract actionable insights and identifying gaps that remain in current practices.

Knowledge of sepsis management: the foundation of clinical competency

The ability of nurses to recognize and manage sepsis hinges on a solid foundation of knowledge, which serves as the bedrock for clinical competency in critical care. Across the 14 studies reviewed, several key determinants of knowledge emerged, with formal education, specific sepsis training, and clinical experience standing out as pivotal. While structured education improves knowledge acquisition, it does not necessarily translate into improved clinical performance. A key challenge is the retention and practical application of knowledge in real-world, high-pressure environments.

Studies have shown that knowledge decay occurs over time, particularly in nurse who do not regularly encounter sepsis cases [1]. This highlights the need for ongoing, embedded education programs rather than one-time training sessions. Institutions should shift toward competency-based education models, incorporating periodic skill improvement, bedside teaching, and case-based discussions. The evidence indicates that didactic knowledge alone may be insufficient. This suggests that while theoretical understanding is necessary, its practical application in high-pressure environments is where knowledge gaps become most apparent. Therefore, educational interventions must focus on experiential learning, simulations, and real-time decision-making scenarios that mirror the complexity and urgency of sepsis care in clinical settings. Institutions should develop ongoing, structured education programs that ensure nurses remain up-to-date on the latest guidelines, such as the Surviving Sepsis Campaign, and new diagnostic tools like qSOFA and Sepsis-3 criteria [2]. This continuous learning environment ensures that nurses can transition from basic understanding to mastery of sepsis management.

Another critical finding is the role of clinical experience, particularly in acute care settings such as ICUs and emergency departments. The findings that nurses with more clinical exposure, especially to sepsis cases, have higher knowledge levels are consistent with previous studies. According to a previous review [30], experience must be coupled with reflective practice and supported by clinical mentorship programs where senior, experienced nurses guide less experienced staff in interpreting complex clinical signs. This mentorship model could help bridge the gap between theoretical knowledge and practical application, especially in fast-paced and high-stakes environments.

Confidence in sepsis management: beyond knowledge to action

The discussion around nurses’ confidence in sepsis management reveals a more complex interplay between knowledge, experience, and environmental factors. Confidence is not simply a byproduct of knowledge [1, 9], but is deeply affected by institutional support, the work environment, and the presence of structured, ongoing training programs.

One of the most salient findings across the studies is that formal sepsis training significantly boosts confidence [8, 10]. These findings align with a previous review that suggests the inclusion of high-fidelity simulations in training programs [9], is particularly effective in building confidence, allowing nurses to practice sepsis management in a controlled, low-risk environment. However, the broader institutional context plays a crucial role in shaping and sustaining that confidence once nurses are back in the clinical environment. Confidence tends to erode when nurses face overwhelming workloads, insufficient staffing, and a lack of clear guidelines—factors that were identified as significant barriers [30]. This suggests that confidence is as much a function of environmental support as it is of individual competence.

Thus, while education and simulation are necessary, they must be supplemented by organizational changes that promote a supportive work environment [31]. Institutional policies should aim to reduce nurse-to-patient ratios, ensure adequate staffing in critical care areas, and provide clear, evidence-based sepsis protocols [32]. This creates an ecosystem where confidence can flourish, as nurses are empowered not only with knowledge but with the resources and support necessary to apply that knowledge effectively [33]. Additionally, ongoing feedback mechanisms, such as regular debriefings after critical incidents or sepsis cases, can reinforce confidence by allowing nurses to reflect on their performance, identify areas for improvement, and validate their clinical decisions [33].

Clinical reasoning in sepsis management: integrating knowledge, confidence, and decision-making

Perhaps the most complex element of sepsis management is the development of strong clinical reasoning skills, which allow nurses to synthesize knowledge, interpret clinical cues, and make timely decisions. The evidence reveals that clinical reasoning is a dynamic process influenced by multiple factors, including organizational pressures, experience, and the availability of decision-support tools [34].

One of the key findings is that organizational factors, such as patient flow and time constraints, can significantly impede nurses’ ability to engage in thorough clinical reasoning, leading to task-oriented rather than reflective approaches to care [35]. This review highlights that in emergency settings, where sepsis care is often delivered, nurses may feel pressured to act quickly, sometimes at the expense of deep clinical reasoning. Institutions must balance efficiency with quality care [12]. Optimizing workflows can ensure nurses have the time and resources for clinical reasoning by adjusting patient allocation, reducing non-care tasks in sepsis-prone areas, and integrating rapid response teams [36].

Technological tools also emerge as a critical factor in supporting clinical reasoning. The review findings [23, 28] that demonstrate the potential of machine learning models and artificial intelligence (AI) to enhance clinical decision-making align with previous findings. Robot Laura^® can predict clinical deterioration providing nurses with real-time alerts that enable quicker, more informed decisions [37]. This suggests a future direction for improving sepsis care—embedding AI-driven decision-support tools within electronic health record systems to guide nurses through complex diagnostic and treatment pathways. However, for these tools to be effective, nurses must receive adequate training in their use, and institutions must ensure that technology complements rather than overwhelms clinical reasoning processes.

This review emphasizes the importance of accurate nursing documentation in supporting clinical reasoning. This finding is supported by which emphasizes that detailed and timely documentation allows for better tracking of early warning signs of sepsis, which can be crucial for early intervention [37]. Institutions should prioritize training nurses in effective documentation practices, ensuring that electronic systems are designed to capture relevant clinical information without adding unnecessary complexity to nurses’ workflows.

Implications for practice and future directions

The synthesis of evidence from this systematic review underscores the multifaceted nature of sepsis management in critical care settings. Improving nurses’ knowledge, confidence, and clinical reasoning skills requires a comprehensive approach that integrates education, institutional support, and technology.

First, education must move beyond one-off training sessions and focus on continuous professional development, using simulations, hands-on experiences, and mentorship to bridge the gap between knowledge and practice. Institutions should prioritize regular, mandatory sepsis training programs, including both theoretical and practical components, to ensure that nurses are equipped to handle sepsis cases competently.

Second, building and maintaining nurses’ confidence in sepsis management requires a supportive work environment. Institutions should address organizational barriers, such as inadequate staffing and workload pressures, that undermine confidence. Implementing evidence-based sepsis protocols and ensuring access to decision-support tools can provide nurses with the resources they need to feel confident in their clinical decisions.

Finally, fostering clinical reasoning skills in sepsis management requires a combination of education, experience, and technological support. AI-driven tools, real-time alerts, and structured clinical pathways can aid nurses in making timely, accurate decisions. However, these tools must be integrated into a supportive clinical environment where nurses are given the time and space to engage in reflective practice.

In conclusion, the findings from this review highlight the importance of a holistic, multi-level approach to improving sepsis management among critical care nurses. By addressing the interconnected aspects of knowledge, confidence, and clinical reasoning, healthcare institutions can better equip their nursing staff to deliver high-quality care, ultimately improving patient outcomes in the management of sepsis.

Recommendations for future research

Based on the findings of this systematic review, it is strongly recommended that healthcare institutions implement a comprehensive, multi-faceted approach to improve sepsis management among critical care nurses. First, continuous professional development programs should be established, focusing not only on theoretical knowledge but also on practical, simulation-based training that mirrors the high-pressure environments in which sepsis cases are managed. Regular, mandatory refresher courses on the latest sepsis guidelines, such as Sepsis-3 criteria, should be integrated into nursing practice, ensuring that knowledge remains current. Additionally, mentorship programs pairing experienced nurses with junior staff can bridge the gap between theoretical knowledge and clinical application, fostering more effective clinical reasoning. Institutions should also address systemic issues like understaffing and overwhelming workloads, which negatively affect confidence and decision-making, by improving nurse-to-patient ratios and ensuring sufficient support is available in critical care settings. Furthermore, incorporating AI-driven decision-support tools and real-time alert systems, such as those used in machine learning models, into electronic health records can enhance timely sepsis recognition and treatment. To maximize the effectiveness of these tools, nurses should be trained extensively in their use, ensuring seamless integration into everyday practice. Lastly, clear, evidence-based sepsis protocols should be standardized across departments to guide clinical decisions, particularly in high-stakes scenarios, promoting consistent, high-quality care and improving patient outcomes.

Strengths and limitations

The strengths of this systematic review include its comprehensive analysis of studies from diverse geographical regions, which provides a global perspective on sepsis management among critical care nurses. The inclusion of a wide range of research designs, from cross-sectional to quasi-experimental studies, enhances the robustness of the findings. However, limitations exist, such as the variability in the tools used for measuring knowledge, confidence, and clinical reasoning across studies, which may affect comparability. Additionally, the reliance on self-reported measures in some studies may introduce bias, and the relatively small sample sizes in certain studies limit the generalizability of the results. Furthermore, this review included only articles written in English which may introduce a selection bias.

Conclusion

In conclusion, this systematic review highlights the critical role of nurses’ knowledge, confidence, and clinical reasoning in sepsis management, emphasizing the need for ongoing education, training, and institutional support to enhance these competencies. Across diverse healthcare settings, factors such as formal education, clinical experience, specific sepsis training, and supportive work environments consistently emerged as key determinants of effective sepsis recognition and management. The integration of technology, structured protocols, and continuous professional development were shown to significantly improve clinical outcomes by enabling timely interventions. However, notable gaps remain in sepsis knowledge and confidence, particularly in under-resourced settings, underscoring the necessity for targeted interventions to close these gaps and improve patient care. Future efforts should prioritize comprehensive educational programs, tailored to the specific needs of critical care environments, to optimize sepsis care globally.