The ability to think critically and reason logically is important in clinical nursing practice. Increased patient acuity and the movement of patient care from acute care facilities to community settings have increased the demand for nurses who can critically evaluate and quickly choose patient care strategies. Both the American Association of Colleges of Nursing (AACN) (1986) and the National League for Nursing (NLN) (1991) have identified the development of critical thinking as an essential component of baccalaureate nursing education.
Although much research has been conducted on critical thinking, the concept itself remains poorly understood. Most of the research to date has focused on critical thinking in the classroom and general program setting rather than in the clinical or field setting (Gross, Takazawa, & Rose, 1987; Ircink Waite, 1989/1990; Miller, 1992; Shor, 1993; Stoiber, 1991). Many studies of critical thinking have used the Watson-Glaser Critical Thinking Appraisal (WGCTA) (1980), a quantitative instrument that examines reasoning ability to measure critical thinking. The WGCTA is not specific to nursing, and a number of studies have shown no significant changes in students' critical thinking when the WGCTA was used as a measure (Bauwens & Gerhard, 1987; Kintgen-Andrews, 1988; Sullivan, 1987). This may reflect the fact that critical thinking is discipline specific with the core ingrethent being the foundation knowledge of the discipline (Brookfield, 1987; Meyers, 1986; Paul, 1993). More recently, Dr. Noreen Facione is conducting a national critical thinking meta-study to aggregate student assessment data on a variety of variables and measures including the use of the California Critical Thinking Skills Test (Pacione, 1990) and the California Critical Thinking Dispositions Inventory (Facione & Facione, 1992) as a measure of clinical judgment (Facione, Facione, & Sanchez, 1994).
Clinical nursing is a highly valuable but time-consuming component of the nursing curriculum (Infante, 1985); therefore, developing insight into the critical thinking abilities of nursing students needs to start in the clinical setting. However, little research has focused on students' in-depth perspectives on their initial clinical experiences and the development of critical thinking abilities, and ability to use logical reasoning. More research is needed to help draw conclusions about the instructional methods, curriculum materials, and courses that would facilitate critical thinking (McMillan, 1987).
Critical thinking has been defined in numerous and varied ways in the literature, reflecting the complexity of the concept. Critical thinking has been viewed as a pursuit of assumptions (Brookfield, 1987; Meyers, 1986; Scriven, 1976), as an attitude of inquiry (Meyers, 1986; Paul, 1993; Watson & Glaser, 1980), and as a reflective thinking process (Dewey, 1910; Ennis, 1985; Mezirow, 1991).
Mezirow and Associates (1991) described critical thinking as being informed by reflection or as reflective learning. According to Dewey (1910), reflection guides critical thinking through assessment and scrutiny of one's beliefs and knowledge. Reflective professional practice has been characterized by Schon (1983, 1987) as reflection-in-action and reflection-on-action. The reflective practitioner thinks while acting and responds to uncertainty and conflict situations; this is "thinking on one's feet." Following an action, reflection takes place as one reconsiders what has been done. Educators can facilitate critical thinking by providing opportunities for reflection (Brookfield, 1987). One instructional strategy identified as useful in facilitating students' cognitive processes is reflective journal writing (Hahnemann, 1986; Holly, 1989; Hoover, 1994; Pultorak, 1993; Saylor, 1990; Sedlak, 1992).
The purpose of this study was to describe beginning baccalaureate nursing students' reflections and critical thinking processes during the first clinical nursing course. The theoretical framework for the study was derived from Paul's (1993) critical thinking dimensions that include: 1) elements of reasoning (e.g., questions/problems, assumptions, inferences, implications and consequences, points of view); 2) abilities of reasoning (e.g., questioning, clarifying issues, generating solutions, assessing solutions, comparing analogous situations, evaluating actions); and 3) traits of reasoning (e.g., affective attitudes such as humility» courage, confidence, curiosity, fair-mindedness, thoughts underlying feelings).
Critical thinking was defined in the study as a reasoning process in which the nursing student reflects on the ideas, actions, and decisions of oneself and others related to clinical experiences (Sedlak, 1995). Reflection was defined as recall of clinical experiences that seemed to lead toward critical thinking to gain insight into one's learning, decisions, critical thinking abilities, and professional development (Sedlak, 1995). The overall research questions guiding the study were: 1) What do beginning baccalaureate nursing students reflect about during their first clinical nursing course? and 2) What do beginning baccalaureate nursing students think critically about during their first clinical nursing course?
Qualitative methodology using the case study approach of Merriam (1988) and Yin (1989) was used to describe and analyze students' critical thinking. Seven female, sophomore full-time baccalaureate nursing students, ages 20 to 33, were selected from a pool of 26 students. Phone interviews with all students assisted in the selection of participants. Student selection was based primarily on the desire to have a mix of students of various ages. Three of the seven students had entered nursing school directly from high school, and four students had entered nursing school after being out of high school for several years. The sample size was determined from a pilot study of four participants in which adequate saturation of data was obtained. Informed consent was acquired from each participant. Participants completing the study were compensated with a one-year subscription to a nursing journal. Participants' instructors were not informed of the identities of the research participants.
Student participants were enrolled in the first clinical course of a baccalaureate nursing program. The context of the study was beginning students' weekly clinical experiences in the acute care hospital setting on adult medicalsurgical divisions. Clinical experience was one day a week for 6 hours from 8 AM to 2 PM. Patient care responsibilities included conducting head-to-toe physical assessments, assisting patients with morning care (e.g., bath, mouth care), administering medications, conducting treatments (e.g., dressing changes), and charting. One clinical instructor supervised a maximum of 10 students. Students were graded on a satisfactory/unsatisfactory basis for their clinical performance. In addition to the clinical hospital experience, students participated in a weekly 2-hour lab at the School of Nursing where they were presented with a variety of topics such as administration of injections and dressing changes. In lab, students had the opportunity to practice skills and participate in group discussions.
Sources of Data
Sources of data to describe students' critical thinking and perspectives included: 1) weekly reflective journal writing (over 12 weeks), 2) participation in three structured interviews, and 3) the researcher's nonparticipatory lab observations. The reflective nature of the journal accounts and interviews served as a vehicle for soliciting in-depth data on participants' critical thinking and reflections about their clinical decision-making as they interacted with patients, families, and health care personnel.
Journals. Participants were asked to keep a weekly written account of their reflections about their clinical experiences. Guidelines for journal writing were given to participants both verbally and in writing at the beginning of the study. Participants were asked to write about clinical experiences that they perceived as important and that required making some type of decision. They were asked to describe the situation(s) involving decision-making and to address how they went about making the decision and their thoughts before, during or after making the decisione); feelings generated; questions raised; alternatives considered; resources needed; and evaluation of outcomes. Students were also asked to write three learning goals for the following week's clinical experience. There was no limit on the length of the weekly entry but students were asked to write at least one page. The researcher gave nonjudgmental written feedback acknowledging the entries and often asking students to further reflect on specific points in the journal entry.
Interviews. Three 30-minute tape-recorded structured interviews were conducted at the beginning, middle, and end of the semester to substantiate journal data. Each interview provided an opportunity to ask questions that probed and expanded on issues and clarified journal entries. Questions were open-ended to encourage participants to freely describe clinical experiences from thenperspectives (e.g., "Tell me about the decisions you have made in clinical since the beginning of the semester." "What helps you make clinical decisions?" "What hinders your decision-making?" "Have you changed in the way you go about making decisions?"). The first interview was conducted two weeks after the journal writing began. The second interview was conducted near the middle of the semester, and the final (exit) interview was held one week prior to the last week of the course.
Nonparticipatory Observation. Because direct observation of participants in the clinical setting was not feasible, the researcher conducted nonparticipatory observation of participants in the fundamentals lab in the School of Nursing. The intent was to gather data to describe students' activities and their interactions with classmates and the instructor in a simulated clinical setting. Participants were informed that the researcher would observe them during three labs and they would not be judged or evaluated. Lab instructors were not informed of the identities of the research participants. Although the lab instructors were also the clinical instructors for several participants, the researcher did conceal the identities of participants during the observation. This was possible because the lab consisted of about 40 students in an environment where multiple student learning activities occurred simultaneously.
Reflection Domains and Categories
Content topics for the labs observed included sterile technique/dressing changes, injections, and catheterization. During the two-hour lab, the researcher took detailed notes documenting the interactions between participants and their classmates, between the lab instructor and participants, and participants' learning styles. Lab activities included students' skills practice, student discussions, and questions raised by the students.
Data analysis involved: 1) processing the qualitative data, 2) analyzing the data to identify major themes, 3) comparing data, and 4) integrating the data into a case study report. Data analysis was based on the qualitative techniques of Miles and Huberman (1994) and Spradley (1979), and the case study method of Merriam (1988) and Yin (1989). Journal entries and interviews were transcribed verbatim into a researcher-developed computer software program using the "Paradox 4.1" database to manage the data. Over 2,000 pages of printed data were generated. The printed data were reviewed and coded into a framework of reflection domains and categories (Table 1) and critical thinking dimensions (Table 2).
Guidelines used to code categories followed those suggested by Lincoln and Guba (1985), Miles and Huberman (1994), and Spradley (1979). Students' reflections were first placed in one of three domains: affective, cognitive, or psychomotor (Bloom, 1956) to organize the reflections. Use of these general domains to describe students' reflections stemmed from the pilot study's initial data analysis in which the topics of students' reflections addressed affective, cognitive, and psychomotor domains. The reflections were then placed in a reflection category within a particular domain. Reflection categories in the affective domain included feelings, role, self-care, ethical dilemmas, and values. Reflection categories in the cognitive domain included assessment, communication, learning, organization, safety, and teaching. Reflection categories in the psychomotor domain included hygiene skills (e.g., bathing patients) and "other" skills (e.g., injections, dressings).
Students' reflections were further coded according to Paul's (1993) critical thinking dimensions, incorporating elements of reasoning, abilities of reasoning, and traits of reasoning. Elements of reasoning included development of perspectives, and exploration of the implications and consequences of actions. Abilities of reasoning included abilities to generate/assess solutions, analyze actions, compare analogous situations, and raise questions. Traits of reasoning included independent thinking, intellectual humility, fair-mindedness, exploration of thoughts and feelings, and intellectual courage. Because of the comprehensive nature of Paul's (1993) critical thinking dimensions, the data fit quite well into the dimensions.
Critical Thinking Dimensions
Coding categories for reflections and critical thinking dimensions were verified by a second experienced coder. The reflection categories and critical thinking dimensions identified were then used to develop themes describing students' reflections and critical thinking. Like ideas and patterns were clustered and examined for themes. At the completion of the data analysis, portraits were developed of each student as a means of further analysis and reporting of the data. The portrait is a depiction in words that serves to develop the likeness of a person and takes the reader into the life of another to gain understanding and insight (Holly, 1989). The written portrait consisting of a 10-page narrative account for each student began with a profile of the participant that introduced the participant to the reader and included information such as age, work experiences, family background, major life experiences, and reasons for pursuing nursing as a career. An in-depth description of the participant's clinical reflections and a description of the participant's critical thinking was included in the portrait. The portrait was shared with the participant at the end of the data collection to gain participant reactions and suggestions regarding possible inaccuracies.
The organizing theme for the findings was perspective development. The perspectives of beginning nursing students developed through their critical thinking about clinical decisions. Four major themes were revealed: 1) Development of the Professional Self-Perspective With Orchestration of the Emotional Self, 2) Development of a Perfectionist Perspective, 3) Development of a Caring Perspective, and 4) Development of a Self-Directed Learning Perspective.
1. Professional Self-Perspective With Orchestration of the Emotional Self. In developing as professionals, students described a variety of emotions about themselves and their patients. Students' emotions ranged from feeling vulnerable, embarrassed, overwhelmed, and insecure to feeling confident, comfortable, and enthusiastic. Emotions of students served as beacons in pointing them toward what was key to understanding themselves.
Students discussed the process of identifying and disidentifying with their emotions in given circumstances of patient care. They described the challenge of identifying with their own emotions while being sensitive to the emotions of their patients and trying to understand them in an empathetic, humane manner. They also spoke of needing to learn to disidentify or disengage from their emotions so they would not become overwhelmed, emotionally drained, and unable to function. Students often reflected on thoughts and feelings about their first experiences of observing painful procedures and disfigured body parts, and carrying out unpleasant tasks. When observing their first surgery, many students spoke of being overcome with emotion in seeing the patient's incision and perceiving the patient's pain. One student wrote:
After I started watching I actually felt like I was going to get sick. The orange juice that I just drank was not settling well, but I told myself to hang in there and be strong. I was not even that close to the table. The thing that amazed me was that the lady was awake and her eyes completely open while the doctor was lifting off the skin on the side of her nose. Wow!"
Another student stated:
...while I was rinsing his dentures I thought of what I was actually doing and then I started thinking it was actually pretty gross. There I am rinsing food particles off someone else's teeth and gums. But then I want to become a nurse so bad and if this is what I have to do to become one then I'll do it.
Students reported the need to disidentify from their emotions in an effort to pull themselves together to continue on, rather than running away in hysteria, overcome with emotion.
2. Perfectionist Perspective. As students worked to balance their personal and professional development, their thinking conveyed the need to be "perfect." This was especially evident in younger students as they focused on deficits in their organization, communication, and assessment skills. Being a "good nurse" involved being perfect in giving patient care (especially when conducting first time procedures) and feeling responsible for "fixing" all problems of patients. The perceived need to be perfect created great pressure and generated feelings of inadequacy, vulnerability, and lack of confidence.
During the first few weeks of clinical, students voiced fear ofudoing something wrong" as well as "having something happen and having to fix it" by themselves. During one student's first week of clinical, this fear came true. When accompanying a patient to x-ray, the patient's TV site started to bleed. The student, having no experience with IVs, did however recognize that contact with the blood was an issue and told the patient to apply pressure with the sheets while she hurried to look for gloves and find help. Later, as the student elaborated on her decisionmaking process, she explained, "Now I always have gloves in my pocket."
Students identified needing more time for thinking about what they were doing as the fast-paced nature of clinical often required quick thinking and on-the-spot decisions. As the semester progressed, students reported discovering that solutions to patient care problems were not always "black and white" but, rather, involved many shades of gray. As students gained more experience in interacting with patients they spoke of having improved communication skills and moved from viewing communication as a dichotomy between "good and bad" techniques to seeing communication as a complex interpersonal process. For example, one student wrote about an interaction regarding death and dying:
...the recent death of her husband kept coming up... she talked about her past with her husband... I found myself becoming uncomfortable and felt so bad for her, it was making me depressed. Luckily the instructor came in and....spoke to the patient.. .After.. .the instructor asked to talk to me in the hall. I started to tell her how I was feeling about this talk about death, and I began to cry... What made me uncomfortable was I did not know what to say to the patient. I did not know how to make her feel better. The instructor... made me realize... that I don't have to say anything to make someone feel better, to just listen.
Students found it especially difficult to deal with situations involving ethical dilemmas regarding nursing care. They expressed disappointment and disillusionment at nurses who were "supposedly" more experienced. For example, one student's ethical dilemma involved observing a nurse placing a patient in jeopardy for infection during a bladder catheterization. She explained:
I didn't agree with her technique... I just hoped that the lady did not get an.. .infection... I was caught between a rock and a hard place because any question I would ask her she would say that "this is the way they teach you, but my own personal preference in what you are supposed to do is..." [The student explained] I did not learn anything... except bad technique.
Students' perspective on nurses as authority figures prevented them from speaking up, especially since they perceived themselves as being just "student nurses" who were guests in the hospital.
3. Caring Perspective. Students frequently discussed an attitude of caring, for both their patients and themselves. Caring about patients' feelings was demonstrated through students' concern to not cause patients pain, especially when conducting first-time skills such as giving injections. A reverence and respect for life were evident in students' perspectives as they often commented on the value of life, particularly when caring for extremely ill patients. A caring perspective was displayed when students identified unsafe situations that could cause injury to patients. Caring was also evident as students offered help to staff and peers who were busy with heavier patient loads.
Students' self-care was especially evident when they reported the need to alleviate their stress and anxiety. Younger students reported feeling very anxious the night before clinical and anxious during clinical. They said: "I feel anxious and don't have confidence," "I have no idea how to get psyched up and feel confident" and "I feel so insecure because I don't know enough." Older students tended to analyze their anxiety in more depth. They indicated ability to identify the sources of their anxiety and the ability to generate solutions to reduce stress. The older, more experienced students reported taking time to observe and listen to themselves to find solutions to their stresses. For example, one student who had difficulty getting to sleep the night before clinical decided to use some relaxation techniques as a regular routine before going to bed to help reduce her anxiety. Other students identified exercise as a means to decrease stress. A student who was a single parent raising two young children identified tremendous stress in preparing for clinical. She had to wake up at 4:30 AM the day of clinical to get her two young children ready to take to the babysitter. She found herself drinking several thermoses of coffee to stay awake. By the second week of clinical she identified the need to go to bed earlier, reduce her caffeine intake, and eat more nutritiously. Throughout the semester she consistently implemented these health promotion strategies.
Older students tended to rely on themselves for positive feedback through self-evaluation of their successes and used their own seff-affirmation as a source of internal motivation. Perhaps they were more introspective because they perceived themselves rather than others as the key in taking charge and dealing with their stressors. Younger students identified feedback from patients as a source of external motivation and affirmation for increasing their confidence. Examples of students' reflections included: "The patient made me feel good like I made a difference," "The patient warmed up to me quickly, she wanted me there," "The patient made me feel comfortable."
4. Self-Directed Learning Perspective. Students seemed to view themselves as self-directed learners. All students used common sense in deciding when to seek out staff or the instructor for help, and when to try to figure out things independently. However, lack of confidence and lack of life experiences, especially among younger students, constrained their potential to independently figure out things. As students developed more knowledge, they worked on being more self-directed in their problem-solving, trying to generate solutions more independently. For example, a student recognized the serious effect of the patient's emphysema on her ability to tolerate activity. The student found that the patient (who had a medical order for bedrest) had gotten out of bed by herself and insisted on sitting up in a chair. The student immediately used assessment data to communicate that the patient's extreme shortness of breath and flushed face were indications of the strain placed on the heart and lungs. Upon receiving this information, the patient realized the need to get back into bed to rest.
Students demonstrated intellectual humility by acknowledging their mistakes and recognizing the value of learning from mistakes. As the semester progressed, students realized that they were not perfect and that although mistakes should be avoided, mistakes indeed occur. Students usually turned their mistakes into a positive experience and discussed learning from the mistake rather than becoming engulfed in the mistake as a humiliating ordeal. For example, one student identified that she had made her patient's bed while the patient used the bedside commode located next to the bed. She explained:
As I wrote this journal I realized I should have left for a few minutes after I put her on the toilet... I need to remember to respect people's privacy...
A week later, the student followed through by providing privacy for a patient using the bedpan. This same student, reflecting on her journal writing experiences stated:
...the journal writing has helped me to improve my thinking in clinical. By writing down how the day went, I found mistakes on things I would like to do better the next week. To reflect on the day through writing really gave me a chance to analyze my actions. By doing this, I was able to remember the next week what I wanted to change, or mistakes to look out for.
As adult learners, students took responsibility for their learning and recognized that learning is ongoing.
The study findings indicate that beginning students do indeed think critically. Through journal writing and interviews, students shared their perspectives on clinical experiences. Reflection prompted students to think critically about their experiences and facilitated self-directed learning as students developed skills as professionals. The implications for nursing education are discussed below.
Students' perspectives on their clinical experiences provided in-depth examples of how beginning students come to terms with their emotions and their intellects, in orchestrating their development both as caring individuals and as self-directed professionals. With emotions identified as being central to critical thinking (Brookfield, 1987); and with critical thinking often necessitating one to monitor feelings and reason oneself into the feelings and emotions appropriate for the situation (Paul, 1993), it is vital that faculty and students acknowledge the role of emotions in implementing nursing care.
Currently the nursing education literature is limited in acknowledging the crucial role of nursing students' emotions for learning and for implementing humane care. The results of this study suggest that beginning students' critical thinking tends to focus on the affective and cognitive aspects of nursing rather than on psychomotor skills as one might assume. The affective and interpersonal aspects of technical skills need to be emphasized more overtly throughout the curriculum when teaching beginning students skills in the lab.
Students' reported stress was especially high as they struggled to transfer basic skills learned in lab to the clinical setting with live, sick individuals who were strangers, in a new environment away from the security of the lab setting. The fast paced nature of the clinical setting contributed to students' need to be perfect, especially as they realized their responsibilities in caring for human fives. More time needs to be built into the curriculum for learning by trial and error, and for facilitating students to openly acknowledge their mistakes, especially during first time experiences.
Students' need to be "perfect" may have been promoted by too few opportunities to practice newly learned skills. Students need to be encouraged to use their time to practice lab skills at their own pace since not all students learn in the same manner. More research needs to be conducted on how students transfer learning from the lab setting to "real patients." Research is also needed on students' perspectives of learning from mistakes made during first time clinical experiences.
Educators play a crucial role in assisting students to develop adult perspectives in which they are less impatient with themselves, feel more secure, and recognize the perspective that life is complicated. Beginning students' first time clinical experiences need to be acknowledged as having a major impact on students' sense of self and their role as nurse.
A caring environment is especially important because beginning students' egos are so vulnerable as they focus on their limitations. Diekelmann (1990) notes the irony of nurses trying so hard to create a caring environment for patients but not for themselves. These study findings indicate students' sources of affirmation to include patients and themselves. However, faculty are in a key role for helping to build a sense of caring among students. Collegiality could be further developed among students as they take the time to give one another support and listen to one another. For example, engaging in dialogue and sharing clinical experiences as exemplars at the freshman, sophomore, junior, and senior levels could facilitate students' critical thinking and also decrease stress. Creative use of Benner's (1984) framework of novice to expert nurse and addressing Benner's domains of nursing practice could be a vehicle for promoting student dialogue in a planned brown bag lunch colloquium for enhancing personal and professional growth as reflective practitioners. Description of Benner's domains of nursing practice through clinical exemplars has helped to promote a better understanding of nurses' roles (Harvey, 1994). Students sharing their clinical exemplars through storytelling would serve as a creative vehicle to celebrate nursing practice. Details on how to develop "Exemplar Celebrations" is further discussed in depth by Harvey (1994).
Stress reduction strategies for self-care should be addressed more overtly throughout the curriculum. Much time is spent on teaching students how to care for clients but very little time is spent on addressing the stresses of being a nursing student and coping with being a student and a nurse.
Students seemed to view themselves as self-directed learners as they used common sense in deciding when to seek help from staff and instructor. Self-directed learning does not necessarily mean that students learn by themselves. The self-directed learner seeks out others to share ideas, reinforce directions, or confirm conclusions (Cooper, 1983). A major aspect of students' self-directed learning was identification of the value of observing others, especially health professionals and peers. Although observation of others may be viewed by faculty as a passive activity, it helps students actively think about their nursing practice and analyze areas for improvement. This active thinking is essential as students move from the banking concept of being repositories of educators' knowledge to adult learners having control over their learning. Teaching strategies that help students reflect and critically think about their own learning and identify their learning needs may be helpful for developing self-directed adult learners.
Faculty need to examine students' use of critical thinking and reflection during the early clinical courses where critical thinking skills are developing. Tanner (1990, 1992) suggests the need for educators to explore assumptions regarding curriculum and traditional teaching methods. For example, reliance on written care plans using the nursing process may focus too closely on objective and evaluative criteria. Broader methods that promote dialogue and tap into the rich subjective experiences of students are needed to understand beginning students' critical thinking and help students reflect on the process of making decisions.
Because nursing emphasizes the human element, students need to be educated rather than trained to deal with people's illnesses, suffering, and life and death situations. More research using qualitative methods is needed to describe students' interpreted experiences as they develop and grow. Research is essential for identifying methods to improve critical thinking in the clinical setting. Because critical thinking is an ongoing process, longitudinal studies may be more helpful than quantitative instruments, such as the WGCTA Currently, the author is replicating this research with the same students during their senior year to describe their critical thinking and to examine changes in critical thinking over time.
In conclusion, the descriptive aspects of this study indicate that students do indeed think critically during their first clinical nursing course. Students' critical thinking throughout the semester indicates an ability to describe and analyze how their perspectives on learning from clinical develop and change. Students conveyed the need to share their perspectives regarding their clinical experiences and the need to be listened to. A supportive, caring, and nonjudgmental environment promotes students' critical thinking as reflective practitioners and facilitates students' development as individuals and as professionals.
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Reflection Domains and Categories
Critical Thinking Dimensions