Nurses in today's challenging health care settings need to be skilled critical thinkers. The rapid advances in science and technology, the growing body of nursing knowledge, as well as the economic impetus changing health care delivery, require a practitioner who can think critically. The nurse must be able to use a broad knowledge base to mobilize resources, coordinate actions and evaluate outcomes in complex new situations where there are no precedents. Well-developed skills in critical thinking enhance the nurse's ability to provide care in a time of shrinking resources and growing responsibilities.
Nursing endorses the development of strategies for increasing both student and faculty understanding of critical thinking. Nurse educators are beginning to define critical thinking and to evaluate students' ability to think critically. To this end a committee was formed in the school of nursing of a midwestern university to assess a baccalaureate program for critical thinking outcomes. The charge to the committee was to define critical thinking, to determine the presence of baccalaureate students' critical thinking and to develop evaluation methods. The process employed follows.
EXAMINING VIEWS OF CRITICAL THINKING
Some authors imply that critical tninking is synonymous with logical thinking. Others define critical thinking as problem-solving (Beyer, 1985), or scientific inquiry (Bandman & Bandman, 1995), but most agree that critical thinking is a dynamic process. The process of critical thinking is not linear but reflective and imaginative (Passmore, 1967). The thinker examines many different perspectives (Paul, 1992) and in some instances, applies imagination to reason (Passmore, 1967).
When students are encouraged to learn to think critically, the teacher, as well as the student, is challenged to explore unfamiliar areas (Paul, 1992). This openness to thinking requires a mutually trusting environment that encourages continuous self-evaluation by both student and teacher (Rogers, 1969). In this context learner/teacher roles may interchange as new areas are explored. Many points of view must be analyzed when engaging in critical thinking. With thoughtful discussion, differing alternatives may be generated. Sometimes even contradictory alternatives may emerge (Bowers & McCarthy, 1993; Kintgen-Andrews, 1991; Paul, 1992).
Critical Thinking Empirical Indicators
DEVELOPING A DEFINITION OF CRITICAL THINKING
Recognizing that nursing demands critical thinking, what then is critical thinking? The task of developing a definition of critical thinking in nursing was at times frustrating, painful, and required perseverance. Discussions by nursing faculty on the ad hoc critical thinking committee revealed different assumptions about critical thinking. Initially committee members viewed critical thinking as a globed process that would normally be fostered in interactions with students. In moving from understanding critical thinking as a global thought process to a specific definition, articles and references were reviewed, shared and discussed. Terms such as comparison, simplification, synthesis, analysis, deliberation, decision-making, examination, and repetition were considered. After extensive reading and numerous faculty discussions, the following definition was written: "Critical thinking is the repeated examination of problems, questions, issues, and situations by comparing, simplifying, synthesizing information in an analytical, deliberative, evaluative, decisive way" (Bandman & Bandman, 1995; Dewey, 1933).
Student input into defining critical thinking was also a part of the ongoing iterative process. The students were presented with the definition of critical thinking and then asked to recall a situation in nursing where they thought they had used critical thinking. Four faculty members independently reviewed situations described by students and rated whether critical thinking was present in each identified situation. The overall interrater agreement for identifying evidence of critical thinking was .92 and was judged acceptable (number of agreements divided by the number of agreements and disagreements) (Polit & Hungler, 1991; Topf, 1986).
Students were able to recall and write situations that were relevant to their particular setting for practice and consistent with the provided operational definition of critical thinking. However, the situations did not describe specific information about or the context in which the critical thinking had occurred. The committee realized that they had spent many months developing the definition of critical thinking, yet were expecting students to be able to understand the terms used in the definition without guidance. The student's responses prompted the committee to clarify the attributes of critical thinking.
Through dialogue and continued literature review the committee determined critical thinking to include the following processes: analysis as the taking apart of information/data to find clues or patterns; evaluation as weighing the merit of the data/information; decision-making as acting on the data/information or preparing for action; and synthesis of information as a momentary end product or byproduct of the preceding cognitive activities. The definition of critical thinking that was operationalized follows:
In nursing, critical thinking is the repeated synthesis of relevant information, examination of assumptions, identification of patterns, prediction of outcomes, generation of options and choice of actions with increasing independence.
Following adoption of the operational definition, a list of indicators (Table) was generated (Bandman & Bandman, 1995; Bevis, 1993; Beyer, 1985; Dewey, 1933; Oermann, 1994; Paul, 1992; Pond, Bradshaw, & Turner, 1991; White, Beardslee, Peters, & Supples, 1990; Wilkinson, 1992). The indicators are useful to recognize elements that may indicate critical tninking. The list of indicators is not complete nor are the terms mutually exclusive.
Additional Student Participation
Students initially identified critical thinking in actual clinical scenarios, but the students' responses were related to their individual experience and therefore not conducive to comparison, even among students in the same semester of nursing courses. The next approach asked students to react to a nursing situation. A case study was given to all students in each semester of the nursing program. The responses were reviewed to identify evidence of critical thinking indicators, not to identify whether students used the nursing process, logic, or decision-making.
Different sets of directions were used to determine if different numbers of empirical indicators of critical thinking would be elicited when applied to the same nursing situation. Three different sets of directions were given to the students as follows to determine the effect of instructions on responses.
A) list and prioritize the actions they would take in a given situation,
B) describe what they would do in a given situation, or
C) describe their thinking as they would intervene in a given situation.
Students were randomly assigned one of the sets of directions and given 20 minutes to respond to the case study.
The set of directions that elicited the largest number of empirical indicators of critical thinking was C): "Describe your thinking as you would intervene in this situation." These directions generated 280 critical thinking behaviors (iV=130). The sets of directions of "listing and prioritizing actions" (alternative A above) and "describing actions" (alternative B above) did not elicit the breadth of critical thinking reflected in the use of the "thinking" directions. Alternatives A and B elicited 207 and 192 responses, respectively, signifying critical thinking as determined by faculty raters. One explanation of the difference is that neither alternative A nor B encouraged students to state the thinking processes that would indicate what they would have done in the situation.
The students' responses to the nursing situation were analyzed to determine the evidence of critical thinking. The indicators in the Table were used to determine if critical thinking was present or not. Some indicators such as "identifies missing data" and "determines a choice of action" seemed to be elicited more often than others. Indicators that were seldom present included "transfers thought and concepts to multiple settings" or "develops alternate courses of action, and detects bias." However this may have been due to the nature of the case study.
The students were able to give examples of critical thinking when responding to a given situation. These responses were useful in refining the critical thinking indicators and establishing a set of directions for eliciting critical thinking behavior. Further study is needed to develop reliability in using a nursing situation (case study) approach to evaluation of critical thinking.
Critical Thinking Indicators in Other Formats
In addition to the use of a case study, the committee explored the possibility of examples of critical thinking being found in forms already available in the nursing curriculum. Nursing care plans were examined for evidence of critical thinking. The care plan was viewed as a useful means of identifying critical thinking when evaluated by the student's clinical instructor. However, others, not familiar with the client situation, frequently had difficulty identifying critical thinking in a nursing care plan. Course papers were also examined and were found to have similar obstacles for outside observers. The committee found that written work more readily showed evidence of critical thinking if the course instructor's comments identified the presence or absence of thinking skills. Clinical evaluation forms were useful for measuring critical thinking when the critical thinking indicators were included in the evaluation of practice performance.
Defining and evaluating critical thinking is a continuing process that becomes increasingly complex the more one learns. Faculty may feel that the process is too timeconsuming and too abstract to produce measurable outcomes. However, the effort is necessary to determine if critical thinking skills are learned. Inherent in evaluating critical thinking is the acknowledgment that one's ideas, definitions, and measures of critical thinking will change as further research is done. The definition and indicators, when applied to a nursing situation, were meaningful and usable for faculty and students.
The faculty have initiated the process of analyzing the curriculum for evidence of progression of critical thinking skills across the semesters. Faculty are asking, "Are the measures of critical thinking that we are using valid?" Discussion continues to explicate what experiences in various courses help students develop skill in using the empirical indicators of critical thinking.
Faculty can teach in such a manner that they are role modeling critical thinking in both lecture and clinical courses. These courses can be closely analyzed for teaching methods that facilitate critical thinking. Difficult questions for faculty to ask themselves are "Do I know what critical thinking is?" and "Am I asking students to think critically?" "How can I teach the thinking process instead of teaching only information?"
Students and faculty who have been accustomed to the "pour it in" style of teaching may find the purposeful inclusion of critical thinking activities requires increased student and faculty preparation. Students can determine what they really know and what they need to know in order to provide quality care. Students need to be actively thinking at all times, not just passively accepting information. Exciting, challenging opportunities exist for both faculty and students to grow as they think critically.
Determining whether students' ability to think critically increases during the nursing program could be addressed by administering the case study at the end of the first semester and at the end of the fourth semester. Individual and group comparisons could be made regarding responses to the case study. Such studies will further assist faculty to refine the measurement of critical thinking.
In summary, an initial definition has been developed, empirical indicators which may manifest critical thinking have been formulated, and the use of a case study in measuring critical thinking continues to be evaluated. Thinking critically about facilitating the process of critical thinking in nursing education has been and continues to be an arduous but exciting process. Extensive reading has served to answer some questions and generate many others. It has been necessary to continually refer to the mission of the committee which is to define critical thinking, find a way to measure it, and develop teaching strategies to foster critical thinking. Readers' reactions to the process used by the faculty in developing a definition of critical thinking and an initial list of indicators are welcomed. Through consideration of shared ideas and reactions, the critical thinking skills of faculty and student will be promoted.
- Bandman, E.L. & Bandman, B. (1995). Critical thinking in nursing. Norwalk, CT: Appleton & Lange.
- BeviB, E.O. (1993). All in all, it was a pretty good funeral. Journal of Nursing Education, 32(3), 101-105.
- Beyer B.K (1985). Critical thinking: What is it? Journal of Social Education, 270-276.
- Bowers, B. & McCarthy, D. (1993). Developing analytic thinking skills in early undergraduate education. Journal of Nursing Education, 32(3), 107-114.
- Dewey, J. (1933). How we think, a restatement of the relation of reflective thinking to the educative process. Boston, MA: Heath &Co.
- Kintgen-Andrews, J. (1991). Critical thinking and nursing education: Perplexities and insight. Journal of Nursing Education, 30(4), 152-157.
- Oermann, M.H. (1994). Professional nursing education in the future: Changes and challenges. Journal of ObstetricalGynecological-Neonatal Nursing, 23(2), 153-159.
- Passmore, J. (1967). On teaching to be critical. In R. Peters (Ed.), The concept of education. New York, NY: Routledge and Kegan Paul.
- Paul, R. W. (1992). Critical thinking. Sonoma, CA: Foundation for Critical Thinking.
- Polit, D.F. & Hungler, B.P. (1991). Nursing research (2nd ed.). Philadelphia, PA J.B. Lippincott Co.
- Pond, E.G., Bradshaw, M.J. & Turner, S.L. (1991). Teaching strategies for critical thinking. Nurse Educator, 16(6), 18-22.
- Rogers, C. (1969). Freedom to learn: A view of what education might become. Columbus, OH: CE. Merrill.
- Topf, M. (1986). Three estimates of interrater reliability for nominal data. Nursing Research, 35(4), 264-266.
- White, N.E., Beardslee, N.Q., Peters, D. & Supples, J.M. (1990). Promoting critical thinking skills. Nurse Educator, 15(5), 16-19.
- Wilkinson J.M. (1992). Nursing process in action: A critical thinking approach. Redwood City, CA: The Benjamin/Cummings Publishing Co.
Critical Thinking Empirical Indicators