The impetus for this review was the writer's surprise and concern that nursing students in an exploratory study that she conducted seemed to make no significant gains in the development of critical thinking over an academic year. The heavy emphasis upon nursing process would lead to the expectation that involvement in nursing education would enhance one's critical thinking ability. Likewise, one would expect that strength in critical thinking would impact upon nursing performance, particularly in terms of clinical judgment.
* Does nursing education generally impact favorably upon the development of critical thinking?
* Does nursing education impact favorably upon the development of clinical judgment?
* What is the relationship between critical thinking and clinical judgment in nursing?
* What is the relationship between critical thinking and achievement in nursing education?
Further analysis of relevant studies in the nursing literature with these questions in mind revealed perplexing findings.
For purposes of this review, the generic nature of the term critical thinking and the discipline-specific nature of the term clinical judgment are conveyed in the following definitions. Critical thinking is "reasonable and reflective thinking that is focused upon deciding what to believe or do" (Norris and Evans as cited in Norris, 1989, p. 21). Clinical judgment is:
... a series of decisions made by the nurse, in interaction with the client regarding (a) the type of observations to be made in the client situation, (b) the evaluation of the data observed and derivation of meaning (diagnosis), and (c) nursing actions that should be taken with or on behalf of the client (management) (adapted from Kelly's work by Tanner, 1987, p. 154).
Nursing Education and Critical Thinking
Five studies presenting longitudinal data provide mixed results regarding the impact of nursing education on critical thinking. Three (Bauwens & Gerhardt, 1987; KintgenAndrews, 1988; and Sullivan, 1987) found no significant gains in critical thinking over the periods of their studies. Bauwens and Gerhardt administered the Critical Thinking Appraisal developed by Watson and Glaser (1980) to baccalaureate students as they entered and exited upper division study. For the 53 students who took the test on both occasions, no significant differences were found between entry and exit. At the beginning and end of an academic year, Kintgen-Andrews administered the Watson-Glaser Critical Thinking Appraisal (WGCTA) to 55 practical nursing students, 38 university prehealth science freshmen, 55 two-year associate degree nursing students, and 29 university generic nursing program sophomores. None of the groups made a significant gain over the academic year. Sullivan administered the WGCTA to registered nurse students as they entered and exited baccalaureate study. For the 46 students who took the test on both occasions, again, no significant differences were found between entry and exit. On the other hand, Berger ( 1984) administered the WGCTA to 137 baccalaureate students as sophomores and again as seniors and reported significant gains. Gross, Takazawa, and Rose (1987) administered the WGCTA to students entering and exiting the 2-year associate degree program and students entering and exiting the baccalaureate upper division. For both the 37 associate degree students and the 34 baccalaureate students who took the test on entry and exit, there were significant gains.
Three of five studies presenting cross-sectional data seem to support the impact of nursing education upon critical thinking. Frederickson and Mayer (1977) administered a standard critical thinking test to 27 second-year associate degree students and 28 baccalaureate senior students. The baccalaureate seniors scored significantly higher than the second-year associate degree students. Scoloveno (1981) administered the WGCTA to 93 secondyear associate degree students, 97 third-year hospital diploma students, and 90 senior baccalaureate students. The baccalaureate seniors scored significantly higher than the associate degree or hospital diploma students. Pardue (1987) studied 121 registered nurses prepared in associate degree, hospital diploma, baccalaureate, and master's programs. Nurses with master's and baccalaureate degrees had the highest WGCTA scores. (While these three studies seem to support the impact of nursing education upon critical thinking, a major question that must be raised is whether the higher critical thinking scores might have been related to the progressive selectivity of students. For example, one might ask whether associate degree students who complete baccalaureate programs actually improve their critical thinking scores with baccalaureate education or is the difference between associate degree and baccalaureate scores attributable to the fact that very low-scoring associate degree students are not the type of students who are likely to complete a baccalaureate program?)
The other two studies identified presenting crosssectional data fail to give support to the impact of nursing education upon critical thinking. Matthews and Gaul (1979) found no significant difference between the WGCTA scores of 26 graduate students and 22 undergraduate students. Dungan (1986) found no significant difference between the Cornell Critical Thinking Test (CCTT) scores of 23 entering freshmen, 31 second-year associate degree students, and 43 senior baccalaureate students.
Nursing Education and Clinical Judgment
Relevant to the present exploration are a group of studies that deal with the relationship between level of education and clinical judgment. The majority of these studies are identified by Tanner (1987) in her review on the teaching of clinical judgment. Seven of the nine studies reported below would support the impact of nursing education on clinical judgment. (The caution expressed above about cross-sectional data in this area of endeavor seems applicable to these studies.)
Verhonick, Nichols, Glor, and McCarthy (1968) produced five filmed clinical situations and studied the abilities of 1,576 registered nurses viewing the films to make observations, describe the actions they would take, and explain the rationale. Descriptive analyses indicated that relevant observations and the ability to relate actions to these observations were positively related to academic degree held.
Davis (1972, 1974), using Verhonick's materials, first studied 20 clinical nurse specialists and 20 baccalaureate graduates and then 40 clinical nurse specialists, 20 baccalaureate graduates, and 27 hospital diploma graduates. Clinical nurse specialists scored higher than baccalaureate nurses and baccalaureate nurses scored higher than diploma nurses.
Aspinall (1976), using a single case study to evaluate clinical judgment, asked 187 nurses to identify possible causes for the patient's condition. Nurses with baccalaureate degrees scored higher than associate degree and hospital diploma nurses.
Del Bueno (1983) studied 85 nurses with associate degree, diploma, and baccalaureate preparation. Using 12 newly developed patient situations, she asked the subjects to perform the same tasks as those performed in the Verhonick study. Academic preparation and experience were related to clinical judgment ability. Experienced baccalaureate graduates performed best.
Other studies supporting the impact of nursing education upon clinical judgment were cited earlier: Matthews and Gaul (1979) found that the graduate students outperformed the undergraduate students in ability to derive nursing diagnoses from a case study. Scoloveno (1981) reported that baccalaureate students scored significantly higher than associate degree and hospital diploma students on the Revised Nursing Process Utilization Inventory (RNPUI). Dungan (1986) found significant differences related to educational level in performance on the Nursing Process Utilization Inventory (NPUI) among entering freshmen, second-year associate degree students, and senior baccalaureate students.
The two studies that fail to provide support for the impact of nursing education on clinical judgment also were cited earlier: Frederickson and Mayer (1977), using Verhonick's materials, found no significant differences in the process of clinical problem-solving between the associate degree and baccalaureate students they studied. Pardue ( 1987) found no significant differences with regard to self-reported frequency of decisions made, self-perceived difficulty in making decisions, and self-reported factors that influence decisions among associate degree, diploma, baccalaureate, and master's prepared nurses.
Critical Thinking and Clinical Judgment
Of the studies cited previously that measured both critical thinking and clinical judgment, only Scoloveno (1981) indicated an impact of nursing education on both measures. In Frederickson and Mayer (1977), and Pardue (1987), higher educational level is related to higher critical thinking ability but not to better performance in clinical judgment. In Matthews and Gaul (1979), and Dungan (1986), higher educational level is related to better performance in clinical judgment but not higher critical thinking ability.
Likewise, four other studies report no relationship between critical thinking ability and clinical judgment. Tanner (1977), in her study of 54 senior baccalaureate nursing students, found no relationship between WGCTA scores and any of the seven measures related to clinical judgment. Gordon (1980) studied the influence of inferential ability as measured by the Miller Analogy Test or the Verbal Aptitude Subtest of the Graduate Record Examination on hypothesis-scanning strategy, diagnostic accuracy, and confidence in diagnosis. Level of inferential ability did not significantly influence any of these measures. Gunning (1981), studying 66 baccalaureate seniors, found no significant relationship between critical thinking ability and clinical problem-solving ability. Holzerner and McLaughlin (1988) carried out a study of the validity of 52 types of clinical simulation tests using 34 nurse-practitioners. There were no significant correlations between the simulation scores and the WGCTA scores.
Critical Thinking and Achievement in Nursing Education
Several of the studies referred to previously present correlations between measures of critical thinking and measures of nursing achievement. Again, the findings are mixed. Berger (1984), studying baccalaureate students, reported no significant relationships between WGCTA scores and cumulative nursing grade point average (GPA). Sullivan (1987), studying registered nurse baccalaureate students, reported no significant relationship between exiting "clinical skill" as measured by the Stewart Evaluation of Nursing Scale and either entering or exiting WGCTA scores. On the other hand, Baumens and Gerhardt (1987), studying baccalaureate students, report a .31 correlation (p = .002) between entry WGCTA scores and National Council Licensing Examination (NCLEX) scores. For the respective groups of nursing students studied (practical nursing, associate degree, and baccalaureate), Kintgen-Andrews (1988) found correlations between WGCTA and nursing GPA to range from .24 to .65, and between WGCTA and NCLEX scores to range from .34 to .56. Correlations were highest for the practical nursing students.
Summary of Findings of Nursing Studies
An in-depth analysis of the studies reported with regard to sample size, design, and adequacy of measuring instruments is not the intent of this paper. The rather perplexing findings, however, can be summarized in general terms:
* Studies presenting longitudinal and cross-sectional data relevant to the impact of nursing education on generic critical thinking have produced mixed results. Strong support for the impact of nursing education is lacking.
* The cross-sectional data presented by studies of clinical judgment, for the most part, support the impact of nursing education.
* The studies that tested both critical thinking and clinical judgment provide practically no evidence of congruence between the two.
* The relatively few studies that present correlations between critical thinking ability and measures of achievement in nursing education produced mixed findings. Strong support for the relationship between critical thinking and success in nursing education is lacking.
Insights from the Field of Education
For some insights into the perplexities described, the writer looked into research within the discipline of education. The synthesis by Norris (1985) and the review by McMillan (1987) were key resources. The results of studies in the education literature, it seems, are no more conclusive than those in the nursing literature. Largely in response to this situation, the two authors offer some very interesting insights.
First, critical thinking is more complex than the construct which is commonly measured. Several diverse dimensions are proposed:
* Metacognition is an important element of critical thinking. Norris (1985) defines cognitive skills as those directly applied in carrying out some task and metacognitive skills as relating to the planning, monitoring, and revising of the progress of the cognitive skills. He refers to Brown's 1978 study indicating that metacognitive skills mark a difference between better and worse readers. McMillan (1987) points out the similarity between the dispositions necessary for critical thinking described by Ennis and the concept of metacognition.
* Productivity, "in the sense of conceiving alternate courses of action and candidates for belief, before critically appraising which alternative to choose," (Norris, 1985, p. 40) is an important component of critical thinking. This position calls to mind the conceptual frameworks of some authors in the nursing literature. Murphy (1985) addresses the integration of the creative and the logical when she uses the term "scientific creativity." Berger (1984) describes creative thinking as incorporating both reasoning and imagination.
* The critical spirit is essential to critical thinking (Norris, 1985). Paul takes the position that not only must one employ critical thinking skills but one must also think critically about one's thinking and have the disposition to act in accord with the dictates of critical thought (cited in Norris, 1985).
* Ability in dialectical, dialogical reasoning or using the perspectives of others to develop a holistic sense of rationality must support the "micro-logical, analytical critical skills" according to Paul (cited in McMillan, 1987). Paul (1985) states:
Most everyday thinking about pressing real-life problems crosses disciplinary categories and domains and involves opposing points of view and contradictory lines of reasoning . . . We need to ensure, therefore, that students receive a substantial amount of practice in reasoning dialogically and dialectically, so that they become comfortable with and skilled in weighing, reconciling, and assessing contradictory points of view through rational dialogue, discussion and debate (p. 46).
McMillan (1987) suggests the similarity between Paul's thinking and the developmental scheme proposed by Perry (1970), which begins with dualistic absolution and progresses to mature levels based on an acceptance of generalized relativism. Pascarella (1985) addresses the related concept of "intellectual flexibility.* He refers to the description of this concept by Winters, McClelland, and Stewart as the ability to reason effectively and abstractly within relative value systems invoking the ability "to keep cool and see the elements of truth in all sides of a heated controversy, to analyze argument and construct coherent ways of evaluating them" (1981, p. 32).
A second important notion that emerges from the education literature is the need for greater understanding of how critical thinking occurs. Norris (1985) points out that it is essential to know what conclusions are reached through critical thinking processes but also essential to understand the processes themselves. To assess an individual's critical thinking it is crucial to know whether an error is due to violation of principles of critical thinking or to particular background beliefs or assumptions. Norris suggests encouraging individuals to think aloud as they progress through critical thinking processes. He supports exploration of the reasoning processes of experts. The work of nurse researchers interested in thinking processes such as Tanner (1977, 1981) and Corcoran (1986) is relevant here.
A third notion that comes from the education literature relates to the time frame necessary for change in critical thinking ability. McMillan (1987) points out that broad measures like the WGCTA are influenced over a long period of time by many factors; yet, the majority of studies look for changes over a relatively brief period.
A fourth notion derived from the education literature is the importance of the subject matter about which one is called on to think critically. It appears that interest in, and familiarity with, the subject matter about which one is attempting to think critically influences one's critical thinking performance. McMillan (1987) refers to Glaser's review of research on cognition and problem-solving in knowledge-rich domains. Glaser concludes that knowledge of content is a significant factor in problem-solving and cites research on expert problem-solving to show that process is, to some extent, dependent upon the degree of knowledge. Norris (1985) cites the work of Evans in deductive logical reasoning. Even though deductive reasoning emphasizes form over content, people reason better deductively when dealing with thematic contexts that relate to their personal experience. It is interesting to note that a nurse researcher, Dungan (1986), stating that she is using Emus' framework, refers to the logical dimension of critical thinking as measured by the CCTT and the pragmatic dimension represented by nursing knowledge acquired.
A fifth notion derived from the education literature is somewhat related to the fourth: Different disciplines require different kinds of reasoning skills. Powers and Enright (1987) studied the responses about reasoning skills that came from 255 faculty members representing six fields of graduate study (chemistry, computer science, education, engineering, English, and psychology) and 64 graduate institutions across the country. The detailed analysis that resulted indicates that some general skills were thought to be critical in all of the academic areas but, more typically, the disciplines differed markedly with respect to the importance attached to different kinds of reasoning skills. It is interesting to note here that, in one of the nursing studies referred to above, sophomore baccalaureate nursing students did make a significant gain over the academic year in the WGCTA Inference subtest, although, like the other groups of nursing students in the study, they made no gain in overall scores (Kintgen-Andrews, 1988). McMillan (1987), addressing the outcomes of no significant differences in studies in which specific variables were expected to affect critical thinking, makes the following comments:
The Watson-Glaser CTA was developed to provide a sample of the ability to think critically about statements encoun- " tered in daily work, magazines, and newspapers. Consequently, it is not surprising that it would be difficult to show how a specific curriculum, course, or teaching strategy affects such general critical abilities in a different context than what was studied in class (p. 10) . . . what is needed, perhaps, is greater specification of what thinking skills are being developed, with specific measurement of those skills (p. 14) ... To improve research in this area, it may be necessary that measurement of critical thinking coincide closely with what the intervention seeks to change (p. 15).
Implications for Nursing Education
Certainly the writer's limited study of research related to critical thinking in the field of education does not begin to address all the perplexities presented by the nursing research referred to earlier in this paper. Still, without losing sight of possible problems in the nursing studies (such as sample size, design, and instruments used to measure clinical judgment), one finds some of the questions raised by the results of the nursing studies are indeed addressed in the education literature. We don't really know how nursing students would perform on a critical thinking test incorporating the elements suggested as constituting a more complex construct of critical thinking - metacognitive skills, productivity of alternate courses of action and candidates for belief, the "critical spirit" ability in dialectical, dialogical reasoning.
Relevant here is the interest of nursing scholars in the importance of intuition. In this regard, Miller and Rew (1989) cite the work of Agan, Benner, and Pyles, and Stearn. Perhaps the use of intuition is also part of an expanded construct of critical thinking. In addition, we do not know how nursing students would perform on a test that would incorporate the process of critical thinking in order to differentiate between errors due to violation of critical thinking principles and errors due to particular background beliefs or assumptions. Nor do we know how nursing students would fare in critical thinking studies over extended timeframes. Finally, the absence of strong support for the impact of nursing education on generic critical thinking and the seeming weakness of the relationship between the constructs of critical thinking and clinical judgment in nursing should not be surprising when one considers the evidence that familiarity with subject matter affects the process of critical thinking and that different disciplines emphasize different kinds of reasoning skills.
Then is there a message for nursing educators? Some might be inclined to suggest that teaching and research efforts be directed solely toward the development of clinical judgment since clinical judgment skills are clearly central to nursing and since the strongest support for the impact of nursing education seems to be in this area. A more reflective analysis, however, reminds one that the research results regarding critical thinking, clinical judgment, and the interrelationship between the two constructs are, by no means, conclusive, and the logic of generic critical thinking as a basis for clinical judgment is strong. Furthermore, Norris (1989), citing Siegel's basis for promoting critical thinking, says:
Critical thinking, conceived as the appropriate use of reasons, enables an understanding of the various disciplines, because to understand the disciplines one must understand the role of reasons in them and how those reasons are assessed . . . Critical thinking enables people to partake rationally in the decision-making of a democratic society, thus helping to sustain a democratic way of life (p. 22).
Surely Siegel addresses the values most nursing educators have for nurses as practitioners, scholars, professionals, and citizens. The writer believes that the following kinds of involvement would be appropriate for nursing educators:
* Continue to participate in teaching and research related to the development of clinical judgment.
* Contribute to a clear explication of the construct of clinical judgment and the development of instruments to measure the construct.
* Use opportunities in the nursing curriculum to promote generic critical thinking on the basis of monitoring research related to the development of critical thinking, explication of a more inclusive definition of the construct, and the development and refinement of measuring instruments.
* Participate in teaching and research related to understanding the relationships of generic critical thinking with nursing performance and clinical judgment as well as the exploitation of such relationships.
Holbert and Abraham (1988) report an experience in teaching generic thinking skills to nursing students. They indicate the need for research to test the transfer of this learning to nursing and other areas of study but are optimistic about the evaluation they have done to date. On the other side of the coin, McMillan (1987) observes that "general skills" may develop as an outgrowth of skills developed to an advanced state in several different areas.
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