17 Dimensions Of Critical Thinking In Nursing

INTRODUCTION

Critical thinking has been identified as a vital element to evidence-based practice (EBP; Profetto-McGrath, 2015; Morténius, Hildingh, & Fridlund, 2016) despite being a complex construct that is difficult to define both from the conceptual and the empirical point of view. The development of critical thinking prepares nurses in achieving the new EBP competencies for practicing nurses (Melnyk, Gallagher-Ford, Long, & Fineout-Overholt, 2014). It is an essential component in nursing practice for providing safe, competent care (Romeo, 2013; Paul, 2014; Edwards, Hawker, Carrier, & Rees, 2015) and is of particular relevance in the current healthcare context, which is both ever-changing and increasingly complex. Furthermore, the need to implement EBP that will serve to help in the design of patient-centered care plans is a factor contributing to increased attention on critical thinking as an educational and professional subject that is indispensable in current nursing (Chang, Chang, Kuo, Yang, & Chou, 2011; Shoulders, Follett, & Eason, 2014). From this, the ability of the nursing professional to improve the quality of care depends in large measure on developing critical thinking skills, especially to improve diagnostic accuracy and to be able to contribute in a favorable manner to more positive results in the health of the patient (Lunney, 2010).

The measurement of the level of critical thinking has been the focus of various studies over the past three decades. A review of several definitions of critical thinking that emerge from these studies is an indication of the conceptual diversity resulting from the disciplinary framework from which they derive (Ennis, 1993; Paul & Elder, 2014). The American Philosophical Association (APA), in its Delphi Report (Facione, 1990), agreed upon a definition of critical thinking as an intellectual process which, in a decided, deliberate, and self-regulated manner, seeks to arrive at a reasonable decision. The report also concluded that components of critical thinking include cognitive abilities and attitudinal disposition.

A definition of critical thinking has emerged from nursing authors. Critical thinking is a cognitive process that represents the capacity to reflect upon reasoning with the aim of minimizing the errors in decision-making(Chao, Liu, Wu, Clark, & Tan, 2013; Shinnick & Woo, 2013; Alfaro-LeFevre, 2016).

Quite a few instruments have been reported in the literature for measuring critical thinking. Some have been used in studies that have yielded data on reliability and validity, although others are less well known, with limited applications and without informed metric properties (Pitt, Powis, Levett-Jones, & Hunter, 2015). The most widely used standardized instruments are those derived from the definition of the APA as a theoretical base. The California Critical Thinking Disposition Inventory (CCTDI; Facione, Facione, & Giancarlo, 1992) was designed to measure the attitudes of critical thinkers in the general adult population. It is complemented by the Critical Thinking Skills Test (CCTST; Facione & Facione, 1992) used to measure critical thinking ability in university students. The Health Science Reasoning Test (HSRT; Facione & Facione, 2006) is an adaptation of the CCTST for students and professionals in the healthcare field. From a review of the literature (Carter, Creedy, & Sidebotham, 2015), it is clear that the reliability of the instruments used to measure critical thinking among nurses has not been systematically examined (Atay & Karabacak, 2012; Naber, Hall, & Schadler, 2014), and they yield results that are inconsistent from one study to another (Zori, Kohn, Gallo, & Friedman, 2013; Gorton & Hayes, 2014; Hunter, Pitt, Croce, & Roche, 2014). The majority of the instruments measure critical thinking ability in the training of nursing professionals but not in their clinical practice, which is a relevant area if we consider that it is an essential competence for the providing of quality care in the setting of today's health care.

Theoretical Framework

Alfaro-LeFevre (2016) put forward the idea of 4-Circle Critical Thinking (CT), a theoretical model that offers a definition of critical thinking applied in the context of clinical practice. The 4-Circle CT Model describes the construct of critical thinking as the integration of four components: (a) personal characteristics (PC), (b) intellectual and cognitive abilities (ICA), (c) interpersonal abilities and self-management (IA), and (d) technical abilities (TA). The first of these, the PCs, are a pattern of intellectual behavior (attitudes, beliefs, and values) that function as an activating element in thinking ability. The second, the ICAs, are knowledge of actions and understanding linked to the nursing process and decision-making. The third, the IAs, are the abilities that allow for therapeutic communication and for obtaining information that is relevant to the patient. And finally, the fourth component, the TAs, is the knowledge and expertise in procedures that are part of the discipline of nursing. Alfaro-LeFevre proposes a series of indicators of critical thinking, the so-called critical thinking indicators (CTIs), for each component. The CTIs are descriptions of behavior that encourage critical thinking in clinical practice. Competence in critical thinking is, then, the result of the combination of attributes in relation to these four dimensions.

The work of Alfaro-LeFevre in this area has had a tremendous conceptual impact on nursing; it is widely referenced by many authors in the field. But no study was found that made the conceptual and structural posits of the model fully operative.

The purpose of the study was to develop and validate an instrument to assess critical thinking ability in nurses working in health care based on the 4-Circle CT Model of Alfaro-LeFevre, which we have called the Nursing Critical Thinking in Clinical Practice Questionnaire (N-CT-4 Practice).

METHODS

Cross-Sectional Study Conducted in Two Phases

Phase 1: Generation of the items and content validity of the instrument

The items were generated from the 79 CTIs in the 4-Circle CT Model of Alfaro-LeFevre and from an exhaustive review of the literature on critical thinking (Zuriguel Pérez et al., 2014), on the aspect of competence, and on ethical considerations in the nursing profession (International Council of Nurses, 2012). The items were drawn up following the criteria for uniformity of expression recommended by experts (Streiner, Norman, & Cairney, 2014). The instrument was called the Nursing Critical Thinking in Clinical Practice Questionnaire (N-CT-4 Practice), it was first drawn up in Spanish (“Cuestionario del pensamiento crítico enfermero en la práctica clínica”) and was initially made up of 112 items distributed among the four dimensions that make up the theoretical model of reference. With the aim of validating the content, it was referred to a committee of six expert professionals in clinical practice and education who had worked in the area of critical thinking. They were chosen following the selection criteria laid out by Leape, Park, Kahan, and Brook (1992) regarding suitability, heterogeneity, expert knowledge of the subject, and availability.

The determination of content validity was made using the methodology proposed by Lynn (1986) and Polit, Beck, and Owen (2007) on the basis of two calculations: The Item Level Content Validity Index (I-CVI) and the Scale Level Content Validity Index (S-CVI). The experts were enjoined to evaluate the relevance and pertinence of each item on a four-point ordinal scale, from not relevant/not pertinent (1) to very relevant/very pertinent (4). The experts were also asked to make suggestions about how the items might be improved. Acceptable scores for the items were I-CVI ≥ .78, and S-CVI > .80 was considered a high score for validity of content (Lynn, 1986; Polit et al., 2007).

The results of the I-CVI showed that 83% (n = 93) of the items were scored as acceptable. As to the S-CVI, the score was .85, it is evidence accrued in estimating content validity. Items that did not score as acceptable were reviewed, as were the suggestions by the experts for their improvement. Following this review, the I-CVI of 13 items of the 112 items did not meet the cutoff of .78. These 13 items were eliminated from the instrument and 12 items were revised to improve clarity in response to comments from the experts, yielding a final total of 109 items.

Pilot testing and structure of the questionnaire

A pilot test was carried out with a sample group of 18 nurses, whose characteristics were similar to those of the study group, in order to evaluate the comprehensibility and feasibility of the N-CT-4 Practice. The time required to complete the questionnaire was 20–25 minutes. After debriefing of the volunteers, it was decided that no further changes in design or content were in order. The final version of the questionnaire was made up, then, of 109 items covering the four dimensions that make up the 4-Circle CT Model, as follows: personal (39 items); intellectual and cognitive (44 items); interpersonal and self-management (20 items); and technical (6 items). A Likert-like response format was devised with 4 points, running from never or almost never (1) to always or almost always (4), to indicate the frequency with which the professional presented a particular ability in critical thinking in the clinical setting.

Phase 2: Psychometric properties

Psychometric evaluation was then conducted with a sample of 339 nurses.

Sample

The participants were nursing professionals selected by convenience criteria from the in-patient medical, surgical, and intensive care units of a 1,100-bed tertiary carehospital in Barcelona, Spain. The study excluded emergency units, operating theatre, and central services or other in which patient are not hospitalized. A list of eligible nurses was obtained (n = 800). The required sample size was estimated to be n = 350, with an α risk of .05 for 5% precision, as recommended by Kline (2016). In order to select the professionals, stratified sampling was carried out with proportions set for the units as follows: medical (44%, n = 154), surgical (41%, n = 143), and critical care (15%, n = 53). All nurses working in these units were invited to participate in the study. Nurses who leave at the time when the study data were being compiled were not included.

In order to evaluate the test–retest reliability, units were also randomly selected and from those, a total of 20 nurses were selected as a follows: medical (44%, n = 9), surgical (41%, n = 8), and critical care (15%, n = 3).

Sociodemographic, professional, and academic information regarding the sample was collected by means of a form made up of 11 questions.

Ethical Considerations

The project was approved by the Clinical Research Ethics Committee of the Vall d'Hebron Hospital (Barcelona). Participants were informed about the authorship and purpose of the research, and were told that all data would remain anonymous and confidential.

Data Collection

Administration of the N-CT-4 Practice and of the form, carried out jointly, took place in March and April 2015. Study instruments were anonymously distributed in unsealed envelopes to enable the nurses to return the completed questionnaires in sealed envelopes. Only the nurses of the randomly selected units were asked to use a 6-digit code where to link to the test–retest instruments, to guarantee the questionnaires (performed with a 14-day gap) belonged to the same person.

Data Analysis

Descriptive statistics were used to summarize the data collected. Analysis of the items included calculation of the average, standard deviation, and corrected item-total correlation.

Internal consistency was calculated using the Cronbach's α coefficient, establishing as acceptable the value of α ≥ .70 (Nunnally & Bernstein, 1994). Test–retest reliability was examined with a subsample of n = 20 selected from the total sample studied. The questionnaire was readministered 2 weeks following the first administration, using the intraclass correlation coefficient (ICC), and considering values ≥.75 as demonstrating excellent reliability (Fleiss, 2011).

Construct validity was assessed by confirmatory factor analysis (CFA) based upon the four dimensions in the theoretical model put forward by Alfaro-LeFevre (2016). The CFA was carried out with structural equation modeling and the estimation of parameters was made using the maximum likelihood model. Model fit was determined with several methods because diverse authors have suggested using a number of indicators to determine the fit of models (Hu & Bentler, 1999; Schreiber, Nora, Stage, Barlow, & King, 2006). The goodness-of-fit of the model was evaluated using the indices and criteria suggested as being acceptable by (Hu & Bentler, 1999): chi-square test (χ2; nonsignificant), the ratio between chi-square and the degree of freedom (χ2/df; <2),the root mean square error of approximation (RMSEA; <.06), the comparative fit index (CFI; >.95), the Tucker–Lewis index (TLI; >.95), and the standardized root mean square residual (SRMR; <.08).

All analysis was carried out using the statistical package R, version 3.3.0.

RESULTS

Sample

The questionnaire was completed by n = 339 nurses. Response rate was 96.8%. The majority of the sample were women (87.0%, n = 294) and the average age was 44 years old (SD 11.1, range 22–52 years). Most were working full time (64.6%, n = 219). The nurses with more than 21 years’ experience (45.1%, n = 153) were working in surgery units (43.1%, n = 146). Half had undergone postgraduate education (51.0%, n = 173), although less than half had received training in specific nursing methodologies (33.0%, n = 111).

Reliability

The total Cronbach's α value for the N-CT-4 Practice was .96, which qualifies as excellent according to (Waltz, Strickland, & Lenz, 2010). It ranged from .78 for the technical dimension to .94 for the intellectual. Most of the items had corrected item-total correlations >.20. Only three items had corrected item-total correlations <.20 (items 3, 5, and 70), but if the items were deleted, it did not increase the total α value. The items in question were “I show my feelings,” “I know how others feel,” and “I treat interventions and actions to prevent or control problems,” respectively (Tables S1–S4, available with the online version of this article). In the analysis of the interitem correlations, no value below .20 or above .80 was identified. These results suggest that none of the 109 items should be eliminated (Kline, 2016).

The ICC for the whole instrument was .77, and for the dimensions ranged from .70 to .84, and were all statistically significant at least at p < .05 level, indicating good stability over a 2-week period.

Construct Validity

The result of the chi-square test was significant (χ2 = 11279.527; p < .0001), indicating that the hypothesis of a perfect model needed to be rejected. However, in light of these values and bearing in mind the problems associated with the use of this test alone, it was felt that other statistical tests were needed to evaluate the theoretical model in question. The adjusted indices based on covariance reported optimal values: RMSEA = .055, SRMR = .65, as did the χ2/df ratio = 1.95, although the incremental measurement indices yielded values below the level of acceptability: CFI = .629, TLI = .621.

All of the values for estimated parameters for the model were significant, in line with what was expected, with p < .05 in all cases except for item number 5, “I know how others feel” (p = .124). None of the variances or correlations yielded values deemed to be inappropriate to the extent that the proposal would be invalidated. Figure 1 offers a graphic representation of the results of the model. The values that appear with the arrows between the circles (latent variables) and the squares (variables) indicate the factor load; the correlations between the circles are represented by means of bidirectional arrows. At the top of the squares are the residual variance values. The first variable associated with each latent variable has a regression value of 1.0 and is represented by a broken arrow.

DISCUSSION

The need to develop an instrument to assess critical thinking in clinical nurses arose from the observation, in the context of a review of the scientific literature, that most instruments were not specific to the nursing profession or else had been designed to measure critical thinking in student samples for the evaluation of specific educational endeavors.

Critical thinking as an essential skill to support EBP and can contribute positively to patient outcomes. Furthermore, it was felt to be essential to be able to measure critical thinking based on a theoretical model that was complex enough to engage the construct in an effective manner, a relevant consideration, given the complexity of the model.

Along this line, an instrument was developed and validated to assess critical thinking in working nurses, based on the 4-Circle CT Model of Alfaro-LeFevre (2016), which is distinguished by its conceptual clarity. Nevertheless, making the Alfaro-LeFevre model operative is no easy matter, given that the concepts that make up the construct of critical thinking are by nature quite complex. The multidimensional concept of critical thinking has been upheld by most theoreticians in the field (Facione, 1990) who argue that critical thinking is comprised of a series of abilities that must be understood to be interrelated. However, to date, validated instruments that clearly and adequately addressed this multidimensional perspective have not been available, which is why the N-CT-4 Practice represents an important new development.

The results obtained in the present study demonstrate that the N-CT-4 Practice is endowed with good psychometric properties. And the questionnaire was shown to be extremely viable, given that all but two participants filled it out in its entirety.

Regarding the assessment of the internal consistency of the questionnaire, the Cronbach's α coefficient obtained (α = .96) places it in the same line of values as reported for other instruments such as the Critical Thinking Diagnostic (α = .93; Berkow, Virkstis, Stewart, Aronson, & Donohue, 2011) and the CCTDI (α = .90; Facione & Facione, 1992). The ICC would seem to indicate that the questionnaire possesses good stability over time.

From the CFA one may deduce that the initial four-dimensional hypothetical model offers a good fit to the data, although there is room for improvement. It should be borne in mind that the indicators of the fit decrease with the increase in the number of parameters to be considered (Hu & Bentler, 1999), a new, smaller version would therefore improve the results. Nonetheless, given that the goodness-of-fit values were close to those considered appropriate, and that the correlations of both the items and of the dimensions were favorable, the structure of the proposed questionnaire is acceptable. Subsequent studies with broader samples would serve to verify the results obtained in the present study with increased robustness. As to the homogeneity of the items, of the 109 analyzed, all but one, number 5, “I know how others feel,” functioned correctly. This item would also need to be revised in a future version of the N-CT-4 Practice with the aim of bringing it into line with the rest of the questionnaire.

In summary, the N-CT-4 Practice is a research tool that can be used for assessing the levels of critical thinking in nursing practice. Futures studies are needed to investigate the tool's value to measure in the quality of care and patient outcomes.

This study is not without limitations. First, the characteristics of our sample proscribe generalization of the results to other populations of interest. Second, the limitations of a self-administered questionnaire need to be taken into account when interpreting these results. The participants answered freely in accordance with their opinions, but this information was not verified by other means such external observation. Third, the use of CFA fit indices is one of many possible equivalent models, also the design of a specific measuring instrument is new, represent a limitation when analyzing criteria validity. Lastly, the sample analyzed has a small percentage of males is a limitation if one wishes to generalize to other groups with parity between men and women.

CONCLUSIONS

The empirical structure of the N-CT-4 Practice is consistent with its theoretical underpinnings; there is evidence that the proposed dimensions behave appropriately for the analysis of critical thinking. Therefore, one may conclude from the results of the study that the N-CT-4 Practice allows for the evaluation of critical thinking on the basis of four interrelated dimensions: The personal dimension, which explores individual patterns of intellectual behavior; the intellectual and cognitive dimension, which examines intellectual abilities related with the discipline of nursing; the interpersonal and self-management dimension, which analyzes interpersonal abilities that allow for the establishing of effective links with the patient, the clinical environment, and other members of the professional team; and finally, the technical dimension, which is concerned with knowledge of the procedures that are part of the nursing profession.

The empirical evidence appears to justify use of the instrument to explore the critical thinking of nurses in the clinical setting. Future research should be designed to increase the metric robustness of the questionnaire by focusing more deeply on those areas pinpointed in the limitations noted above.

Building instruments for psychological evaluation is a complex process. The N-CT-4 Practice offers an initial foray into investigation and assessment of the critical thinking of nurses in the business of providing care to patients. In like manner, the validation of conceptual models is also a painstaking task that calls for empirical studies to provide clinical scientific evidence. The N-CT-4 Practice is a bridge that provides scientific evidence concerning the model of critical thinking advanced by Alfaro-LeFevre.

Future studies should examine the metric properties of the N-CT-4 Practice in relation to other variables and in other samples of interest. Along these lines, it would also be of interest to determine the predictive capacity (sensitivity and specificity) of the N-CT-4 Practice in longitudinal studies. Finally, the present study leaves open the possibility of future studies examining other types of validity (discriminant and convergent). 

LINKING EVIDENCE TO ACTION

  • Critical thinking is vital in developing EBP.
  • The N-CT-4 Practice is valid and reliable and it can be used to measure the critical thinking in the nursing practice.
  • This study makes substantive and methodological contributions that support researchers’ efforts to assess critical thinking in nursing.
  • This instrument can be used to measure nurse's critical thinking competence and consequently design strategies to improve nurse's competence.
  • Further research using this instrument must be conducted in relation to other variables and in other samples of interest.

Introduction

The importance of critical thinking in nursing is so evident that educational programs are evaluated according to the development of skills related to this sort of thinking. Numerous authors have underscored the need for nurses to be able to think critically in order to use the appropriate knowledge and skilled judgments in delivering patient care (Brooks & Shepherd, 1990; del Bueno, 1992; Ford & Profetto-McGrath, 1994; Krammer, 1993; Miller & Malcolm, 1990; Paul & Heaslip, 1995; Tschikato, 1993). They agree that critical thinking and decision-making skills are essential to the future of professional nursing.

In this regard, several definitions have been postulated to describe various and profound aspects of critical thinking in general and within the profession of nursing in particular. Critical thinking is a composite of attitudes, knowledge, and skills which includes: (1) attitudes of inquiry that involve an ability to recognize the existence of problems and an acceptance of the general need for evidence in support of what is asserted to be true; (2) knowledge of the nature of valid inferences, abstractions, and generalizations in which the weight or accuracy of different kinds of evidence are logically determined; and (3) skills in applying and applying the above attitudes and knowledge (Watson & Glaser, 1980 ).

Scheffer and Rubenfeld (2000) believed that the habits of the mind of critical thinking in nursing include confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection. Skills of critical thinking in nursing consist of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting and transforming knowledge (p. 352). Ennis (1985) described critical thinking as “reflective reasonable thinking...” (p.45). Varied perspectives of critical thinking exist in nursing. Kataoka-Yahiro and Saylor (1994) defined critical thinking as reflective and reasoned thinking about nursing problems without one solution, focused on decisions about what to believe and do. Another view is that critical thinking is the thought process that underlies effective clinical problem solving and decision-making (Oermann, 1997; Oermann and Gaberson, 1998).

Critical thinking is defined as purposeful, self-regulatory judgment; an interactive, reflective, reasoning process of making a judgment about what to believe or do (Facione & Facione, 1996). Critical thinking is the cognitive engine that drives the processes of knowledge development and critical judgment in nursing. The skills and dispositional attributes of critical thinking are central to nursing and that they embody a search for best knowledge in a given context. They demand an openness to new evidence and a willingness to reconsider judgments. They value a focused and diligent approach to clinical reasoning and they require a tolerance of multiple perspectives when those perspectives can be supported by reason and evidence (Facione & Facione, 1994). Critical thinking opens doors to new perspectives about the world, fosters self-confidence, and encourages life-long learning (Chafee, 1994).

The ideal critical thinker is habitually inquisitive, well informed, trustful of reason, open-minded, flexible, fair-minded in evaluation, honest in facing personal biases, prudent in making judgments, willing to reconsider, clear about issues, orderly in complex matters, diligent in seeking relevant information, reasonable in the selection of criteria, focused in inquiry, and persistent in seeking results which are as precise as the subject and the circumstances of inquiry permit (Facione, Facione, & Giancarlo, 1994).

Scholars believe that critical thinking cannot be developed by itself. Some of them contend that critical-thinking mastery is improved if developed and assessed within the context of a discipline (Blatz, 1989; McPeck, 1981, 1990a). McPeck asserted that critical thinkers evaluate information in light of background knowledge, context, and reflective skepticism (McPeck, 1981, 1990a) and postulated that it is impossible and incoherent to attempt to teach critical thinking in isolation from the skills being taught to students (McPeck, 1981). Further, Mc Peck noted that “truly suggestive, and therefore useful, thinking skills tend to be limited to specific domains or narrower areas of application” (McPeck, 1990a, p.12) and that “critical thinking is not a content-free general ability, nor is it a set of specific skills” (McPeck, 1990b, p.27).

Some nurse authors and educators (Alfaro-LeFevre, 1995; Brigham, 1993; Cascio, Campbell, Sandor, Rains, and Clark, 1995; Doona, 1995; Miller and Babcock, 1996; Miller and Malcolm, 1990) have described the context of critical thinking within the discipline of nursing. Alfaro-LeFevre (1995) asserted that “a key point to realize is that critical thinking is contextual... these skills require job-specific knowledge, and must be mastered within the context” (p. 35) Bandman and Bandman (1995) described the universality of critical thinking and their view of critical thinking as both subject-specific and general. Young (1998) stated, “in our hearts, we know what critical thinking is ... an individual who is able to respond to problems by using the nursing process effectively is a critical thinker” (p. 153).

Many nurse educators have written about teaching methods that reinforce critical thinking. Intensive strategies and suggestions for promoting critical-thinking skills in nursing students have been developed and described by several nurse writers. Case (1994) suggested that to promote critical- thinking skills in learners, active dialogue between the instructor and the student was vital. Doona (1995) suggested that nursing education could expand the critical-thinking abilities of students by encouraging reflective thinking through such activities as writing of journals and using group discussion to explore alternatives and arrive at conclusions. Free (1997) used a critical-thinking game called to encourage students to formulate alternatives to clinical or ethical decisions. Reynolds (1994) described a teaching tool called a “patho-flow diagram” (p. 333), designed to assist nursing students in connecting clinical events or decisions with information obtained in the classroom.

Nursing curricula (especially at the graduate level) should serve to free nursing students' minds and help them use their knowledge of higher-quality patient care and positive societal effects. Critical thinking can assist with insight into the societal conditions generating a patient's illness (Youngblood & Beitz, 2001). Teaching is really the development of cognition and metacognition and the belief that critical thinking be nurtured with active learning (Flavell & Wellman, 1987). Active learning techniques are suggested to improve critical thinking development. Critical thinking is promoted by active learning strategies because of their cognitive triggering processes. In fact, active learning processes and critical thinking development are intimately related (Youngblood & Beitz, 2001).

To refine critical thinking in classroom and clinical settings, many techniques may be used including teacher and learner-group debates over clinical and ethical scenarios; cooperative learning techniques about clinical conundrums that encourage questions, analysis, and reflection; and using clinical reports to increase students' metacognition in hypothesis generation for common clinical experiences (Alexander & Giguere, 1996; Abegglen & Conger 1997; Bethune & Jackling, 1997; Castillo, 1999; Facione & Facione, 1996; Chenoweth, 1998; Fonteyn & Cahill, 1998; Kramer, 1993; Oermann, 1997; Wissman, 1996). Cooperative learning occurs when small groups of trainees work together to maximize their own and each other's learning (Gibson & Campbell, 2000). As a matter of fact, interpersonal relations are at the heart of the interface between individuals and groups (Marotta, Peters, & Paliokas, 2000).

Nursing faculties generally agree that students who know how to think make better clinical judgments than those who have merely memorized facts. Theoretically, the acquisition of both critical thinking and clinical judgment begins with the education process (Brigham, 1993; Brooks & Shepherd, 1990). Benner, Tanner and Chelsa (1996) have conducted extensive nursing research that has evaluated critical thinking and clinical judgment skills. These authors use the term “clinical judgment” when referring to clinical decision-making. Miller and Malcolm (1990) actually defined critical thinking as clinical judgment. These authors believed clinical judgment was the outcome of thinking critically. More specifically, the subscales of inference and inductive reasoning had a positive correlation to clinical judgment (Bowles, 2000).

There is considerable agreement among nursing researchers that critical thinking is a vital component of successful nursing practice (Birx, 1993; Brigham, 1993; Jones and Brown, 1993; Pond, Bradshaw, and Turner, 1991; Miller and Malcolm, 1990; Pardue, 1987; Rubenfield and Scheffer, 1995; Tiessen, 1987; Woods, 1993). However, nurse researchers (Saarman, Freitas, Rapps, and Reigel, 1992; Hickman, 1993) have noted with concern the lack of discipline-specific assessment mechanisms to evaluate critical-thinking competency in nursing students. Hickman (1993) stated that: There is not a strong research base supporting a relationship between nursing curricula and critical thinking. It may be that this is due to the lack of an appropriate instrument to measure critical thinking in nursing (p. 46).

In fact, the evaluation of critical thinking has consistently received considerable attention in nursing education because of the requirement to produce outcome assessments of students' growth in these skills for accreditation purposes (Magnussen, Ishida, Itanu, 2000). Videbeck (1997) reports that the Watson Glaser Critical Thinking Appraisal (WGCTA) is the most widely used standardized test to measure critical-thinking skills of nursing students. Miller and Malcolm (1990) believed that the WGCTA appeared to be the most useful test for nursing because its emphasis on skills matches the need for practice ability in nursing. In addition, it has undergone 25 years of use, with resulting revisions and refinement. The WGCTA has been adopted and because of its established reliability, it can be easily administered and scored, and it has established norms and comparative data in the literature (Magnussen, Ishida, Itanu, 2000).

There have been disagreements in the literature about its efficacy, however. McMillan (1987), after analyzing research reporting the use of WGCTA with nursing students, found that the studies had mixed results. One apparent drawback was it was difficult to separate the effects of maturation from the program effects. She suggests that the WGCTA is not sensitive enough to be used in this way and posits that it is not suitable to measure growth of critical thinking in professional settings because the test is based on daily life. In their study of the impact of nursing education on students' critical thinking ability, Gross, Takazawa, and Rose (1987) found that both associate degree and baccalaureate degree students showed improvement in critical thinking (as measured by the WGCTA) after completing their nursing education.

More recently, however, Vaughn-Wroebel, O'Sullivan, and Smith (1997) found no significant differences in the WGCTA scores between entry and end of the program. They speculated that five factors could explain the negative findings: 1) the test, itself, may not be the best measure; 2) the expectation of gains during the upper division courses might be erroneous (citing studies that report gains in critical thinking occur more frequently in freshman year than later); 3) the curriculum may not be designed to enhance critical thinking; 4) traditional teaching strategies may not encourage critical thinking and may not be inclined to complete to complete the test carefully when they are almost through with their studies. Other studies (Bauwens & Gerhard, 1987; Kintgen-Andrews, 1988; Adams, Stover, & Whitlow, 1999; Frye, Alfred, & Campbell, 1999) have also found no significant increase in WGCTA scores between entry and end of the program.

The possibility that the WGCTA is not a valid measure of nursing student ability was suggested in Adams' (1999) review of research on critical thinking. She concluded, “perhaps WGCTA is appropriate to measure general critical thinking ability and appropriate for generalized education such as liberal arts curriculum. However, nursing is a science and as such may be more accurately tested with a tool developed with that discipline in mind (Adams, 1999 p.117). Evaluation of critical thinking is best conducted by asking nurses to analyze a situation, identify alternatives, choose among them, and provide a sound rationale for these decisions. According to Morrison et al. (1996), a critical thinking test can ask about a type of thinking that requires knowledge of more than one fact to logically and systematically apply concepts to a clinical problem (p. 28).

It is important that introductory material be geared to the levels of expertise and experiences of the nurse being evaluated. Using context-dependent items appropriate for novices with expert nurse may cause them to become bored and lose interest. On the other hand, using items appropriate for the competency testing of experienced nurses with novices may be overwhelming and frustrating for them (Oermann, Truesdell, & Ziolkowski, 2000). Different types of critical thinking exercises are available to be integrated in orientation and other educational programs: problem-solving strategies, case studies, discussions with Socratic questioning, debates, and media clips (Goodman, 1997). Test items may be of any format, but it should be noted that open-ended questions provide the most effective method of assessing the underlying thought processes involved. In writing the open-ended questions, the goal should be to assess nurses' underlying thought processes in arriving at the answers, not the answers alone. Reliance on true-false, short-answer, matching, and multiple-choice items may not capture nurses' abilities to engage in critical thinking about clinical situations they may face in their practice (Nitko, 1996).

Context-dependent test items can be developed to evaluate nurses' abilities to analyze simulated data, identify additional data needed, decide on all possible problems in the scenario, identify nursing interventions, and provide a rationale for their responses. One advantage of this type of testing is the opportunity to assess not only the decisions made but also the thought processes used to arrive at those decisions. The next step is to integrate these context-dependent items into, for example, educational program (Oermann, 1998). The types of scenarios developed as context-dependent items may be a typical patient, family, and other clinical situations nurses may face in practice; situations involving interactions with physicians, other health providers, and families; ethical issues; delegation and staffing problems; governance issues; and problems accessing resources and working within the health system. Context-dependent items may be developed for each content area in the educational program and may be used for formative evaluation and for testing (Oermann, 1997).

Along with exercises to promote critical thinking, context-dependent items may be integrated in tests developed for orientation and as part of competency testing. In a context-dependent test item, nurses are presented with introductory material to analyze and determine a course of action. The introductory material may be a description of a clinical situation, an issue they might face in their practice, or patient data (Nitko, 1996). Graphs, flow sheets, EKG strips, or photographs might be part of this introductory material. The introductory material needs to provide sufficient information for analysis without directing the thinking process in a particular direction or being too long. Questions are then asked about this material (Oermann & Gaberson, 1998).

Purpose

This quasi-experimental study was conducted to determine the effects of group-dynamic sessions on critical thinking skills of baccalaureate nursing students. The purpose of the research was to identify whether students could develop their critical thinking abilities after participating in these sessions as a teaching strategy.

Methods

All 60 senior nursing students in Shaheed Beheshti Faculty of Nursing and Midwifery were selected and randomly divided into two equal control and experimental groups. These students passed their clinical training in health clinics affiliated to the university. The subjects voluntarily participating in the study were between 22 and 24, with similar educational record. They were matched according to age, sex, term of study and passed units. No student was excluded during the research.

Research hypothesis was: “the critical thinking skills of nursing students passing their community health training by participating in group-dynamic sessions would increase compared with those of the control group”.

A questionnaire consisted of 12 questions and four clinical report forms to evaluate critical thinking skills were used for data collection. The forms were designed according to nursing process steps (Assessment, Diagnosis, Planning, and Evaluation) with a space provided to write clinical reasoning in each stage. Validity of the questionnaire was determined by content validity and internal reliability was measured by internal consistency (internal consistency: 99.95). To identify reliability in rating, an inter-rater reliability was measured (interrater reliability: 0.88).

It was supposed that by applying nursing process to analyze data, find different problems of clients, and provide the reasons behind any comment, suggestion or solution, students could reach to high levels of cognition according to Bloom's taxonomy and such activities could improve critical thinking abilities. According to Morrison and Walsh Free (2001), questions that require calculation or ask what is the , and so forth, require a high level of discrimination to answer, and therefore promote critical thinking. Such multilogical test items require the ability to relate and apply concepts to clinically-oriented situations and measure the students' ability to think critically within the discipline of nursing.

Each group was further divided into four subgroups with seven or eight members. For the experimental subgroups (two seven-member and two eight-member subgroups), eight to ten group-dynamic sessions, each lasted 1 to 1.5 hours, were held two days a week with at least a two-day interval. The topics of the sessions were chosen from the concepts of family health to be discussed over one or two sessions. A leader in the group involved the members by asking their views about the selected topic and discussing about it from different perspectives. The roles of community health nurse were discussed by each member to identify different aspects and probable problems, and appropriate ways or solutions were identified by providing reasons or arguments. At the end of each session, the topics of the next session as well as the leader of the group were announced by researchers.

For each subgroup, 8-10 sessions were held over 25 days and the whole intervention was completed during 5 months. Having clinical conferences and home visits, the control group passed their routine training. The researchers visited students in the experimental group once a week in the clinics to deliver new forms and solve any possible trouble regarding the completion of forms. These students completed their clinical forms in accordance with the sessions and assessment of families during their visits (one form in each week). On the other hand, students in the control group delivered their forms at the end of their course and assessment of families. They were guided to contact with the researchers as necessary to solve any problem or clarify any misunderstanding in the completion of forms. The groups did not have any communication or relation with each other.

About two weeks after the last session, all of the forms from both groups were collected and scored in single-blind format by using a devised scale. To score critical thinking abilities in the students of both groups, mean scores of responses to questions in each area including seeking information (1 point), diagnosis (2 points), clinical reasoning (9 points), clinical judgment (6 points), prediction (1 point), and creativity (1 point) were calculated as the score of each ability. The range of scores was between 0 and 20.

Results

Findings revealed that the majority of students in both groups were female and unmarried, with no occupation or experience at group work. They mostly lived with their parents. Chi-square and Mann-Whitney tests showed no significant difference between the two groups in the above variables as well as age, average score of the previous term and units passed (P>0.05).

Table 1 shows the mean scores of clinical report forms in both groups. Paired t-test showed a significant difference between the scores of the control and experimental groups (P = 0.0001). In table 2, the mean scores of each critical thinking skill in both groups are presented. Mann-Whitney test and t-test showed a significant difference between the scores of the two groups, except for seeking information (P = 0.0001). Table 3 provides the total scores of critical thinking abilities in both groups. These scores showed a significant difference between the control and experimental groups, verified by paired t-test (P = 0.0001). Additionally, diagram 1 shows the difference between critical thinking abilities in both groups.

Figure 1
Table 1: Mean scores of clinical report forms in the control and experimental groups
Figure 2
Table 2: Mean scores of critical thinking subscales in the control and experimental groups
Figure 3
Table 3: Mean total scores of critical thinking in the control and experimental groups
Figure 4
Diagram 1: Mean scores of critical thinking subscales in both groups

Discussion

Studies have shown that a positive correlation exists between age, academic educational background as well as clinical experience and scores of critical thinking abilities (Scheffer & Rubenfeld, 2000). Since demographic variables have been shown to be effective on critical thinking, the groups were matched in our study to avoid unwanted effects of intervening variables.

Bowles (2000) found a positive relationship between critical thinking and clinical-judgment abilities in baccalaureate nursing students. According to Loving (1993), the concept of critical thinking encompasses problem-solving, decision-making, clinical judgment, and creativity. All of these abilities were assessed and measured by the clinical report forms devised in this study and the researchers believe that they have been able to appraise critical thinking skills. Thus, the hypothesis of the study was supported with respect to the significant difference between the total scores of critical thinking abilities of the two groups.

Magnussen, Ishida, and Itano (2000) have showed that inquiry-based learning as a teaching methodology can develop critical thinking abilities. In addition, it has been indicated that these abilities are not developed during routine educational programs of nursing, which reveals the ineffectiveness of traditional teaching models in this regard. This is similar to our study in terms of assessing the impact of a cooperative learning method (group dynamics) on improving these abilities and changing the routine lecture-based educational programs. In fact, it appears that the effect of cooperation on the process of learning is so evident that such significant improvements can be observed in our study.

Many scholars believe that general tools for assessing critical thinking in students are not appropriate since it is a discipline-specific phenomenon and should be evaluated within the construct of its related discipline (Scheffer & Rubenfeld, 2000; Morrison & Walsh Free, 2001). Hence, this study presents a newly devised tool to assess critical thinking development in nursing as a specific discipline. The nursing process embedded in the questions of the tool can be considered as a framework for critical thinking with such skills as analyzing, applying standards, discriminating, logical reasoning, predicting, and transforming knowledge. The open-ended questions based on the concepts of family in community health nursing provided a challenge according to the students to use these skills and to improve their critical thinking abilities.

The scores of “seeking information” in both groups had no significant difference while, in all other abilities, a significant difference was found. This may be due to allocation of low score (1 point) to assessment, which has statistically brought about no significant difference. In fact, further studies in other courses of nursing with greater number of samples and specifically designed tools are needed to have more definite and conclusive findings regarding critical thinking.

It is evident that new learning methods should be applied to nursing education to generate nurses with powerful judgment and, therefore, skillful practice. Thinking and practicing are not dividable and the latter follows the former. Thinking allows nurses to find out what types of care should be provided and what activities should be performed with respect to clients' condition. All thinking abilities should be used in planning, diagnosing, and providing nursing care (Rubenfeld & Scheffer, 1995) and critical thinking is important in different aspects of nursing such as knowing, diagnosing, and bridging the gap between theory and practice (Clark & Hott, 2001).

It can be concluded that the more educators provide scenes for better and deeper thinking, the better learners can understand and analyze phenomena in the surrounding world to be better thinkers for better life.

Acknowledgements

We would like to thank the administrative staff of Tarbiat Modarres University and Shaheed Beheshti Faculty of Nursing and Midwifery for their assistance and cooperation. We would also like to express our gratitude to Ms. Kamelia Rouhani, community health nursing instructor in Shaheed Beheshti Faculty of Nursing and Midwifery, for her sincere cooperation during the implementation of the study. Finally, we are indebted to all students who participated in the study with full cooperation.

Correspondence to

Dr. H. Manoochehri, Dr.HoumanManoochehri@gmail.com

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