Critical thinking (CT) has been a much-debated subject over the last decade. The U.S. Department of Education, the National League for Nursing (NLN), and the American Association of Colleges of Nursing (AACN) have formally acknowledged the importance of CT in undergraduate education (Department of Education National Educational Goals 2000 Panel, 1992; National League for Nursing, 1992; American Association of Colleges of Nursing, 1998). Yet, there is little consensus on the meaning and application of CT in nursing. The purpose of this study was to achieve consensus on critical thinking in nursing from an international panel of nursing experts in education, practice, and research.
Some believe that CT is a universal phenomenon common across all disciplines; others believe that some aspects of CT must be discipline-specific (McKeachie, Pintrich, Lin, Smith & Sharma, 1990). According to Beyer (1987), "The term critical thinking is one of the most abused terms in our thinking skills vocabulary. Generally it means whatever its users stipulate it to mean" (p. 32). A decade later, Valiga and Bruderle (1994) continued to address concerns about multiple interpretations of CT among nursing faculty and the difficulties this caused as they communicated with students. "In essence faculty may use similar words but mean different things" (p. 118). Multiple definitions of CT have resulted in confusion and misinterpretations among clinicians, educators, and researchers.
Miller and Malcolm (1990), after their literature review, posed several important questions about the clarity of the CT construct. Specifically, they asked how CT relates to clinical judgment and how one evaluates CT. Jones and Brown (1991) noted that CT is misunderstood in the nursing community, being viewed as synonymous with the scientific method or as simple, linear problemsolving. Kintgen- Andrews (1991) concluded that CT in nursing was more complex than what was usually measured; it needed to be better defined and accurate measuring instruments were needed.
As long as there is no specific definition accepted as a "best fit" with nursing, the potential for ongoing confusion remains. In an attempt to formulate a definition of CT in nursing from the ground up, we conducted a Delphi Study. The specific purpose of this study was to arrive at a consensus statement on CT in nursing from nursing experts in practice, education, and research.
REVIEW OF LITERATURE
The term "critical thinking" has been prominent in the general educational literature since the early 1980s. More recent literature, however, acknowledged the relevance of CT in higher education. Ennis (1985) described CT as "reflective reasonable thinking . . ." (p. 45). Paul, the founder of the Foundation for Critical Thinking, offered everal definitions including, "Critical thinking is the art of thinking about your thinking while you are thinking in order to make your thinking better . . ." (1992, p. 643). Paul (1993) also identified three essential components of CT. elements of thought, intellectual standards, and affective traits.
The most comprehensive attempt to define CT was sponsored by the American Philosophical Association (APA) under the direction of Facione (1990). Using the Delphi method, Facione surveyed 53 experts from the arts and sciences and arrived at the following consensus statement:
We understand critical thinking to be purposeful, self-regulatory judgment which results in interpretation, analysis, evaluation, and inference as well as explanation of the evidential, conceptual, methodological, criteriological, or contextual considerations upon which judgment is based (p. 2).
While the process of CT in nursing has not always been labeled as such, it has long been a part of nursing's repertoire of skills. Yura and Walsh (1973) emphasized "intellectual skills" as an essential component of the nursing process. Matthews and Gaul (1979) defined CT as, "an attitude of inquiry which involves the use of facts, principles, theories, abstractions, deductions, interpretations and evaluation of arguments" (p. 19). In 1988, Bandman and Bandman defined CT in nursing as, "the rational explanation of ideas, inferences, assumptions, principles, arguments, conclusions, issues, statements, beliefs, and actions" (p. 5).
The early nursing-specific definitions were largely focused on the intellectual or cognitive skills of thinking. Recently, the affective component of CT has received more attention. Tanner (1997), asked, "If affective components are not being included [in critical thinking], what in the world is happening to the relational dimensions of nursing practice, to caring and caring practices that draw, at least to some extent, on emotional involvement?" (p. 3).
Investigation of critical thinking in nursing continued through the decade of the 1990s. Videbeck (1997) surveyed NLN accredited baccalaureate nursing programs to determine how they were addressing NLN's Accreditation Criterion 20: Critical Thinking. She found that 28 programs selected definitions of CT from the nursing literature while 22 selected definitions of CT from non-nursing literature. She also found that 43 programs selected definitions that included both cognitive and affective components of CT, whereas 12 programs focused primarily on the cognitive components.
Models of CT in nursing have also emerged. Rubenfeld and Scheffer (1995) conceptualized the T.H.I.N.K. model of CT, emphasizing five modes of thinking and the need for synergy among the modes. Gendrop and Eisenhauer (1996) developed the Transactional Model of Critical Thinking to address the complexity of CT in nursing. While the T.H.I.N.K model has proved to be a useful teaching/learning tool for beginning nursing students, and the Gendrop and Eisenhauer model provides guidance for practicing nurses, both of the of these are theoretical formulations as yet without empirical support.
Nursing as a profession presently lacks an inductively derived statement about the unique aspects of CT in nursing. This study was conceived as a means toward achieving a more comprehensive understanding of CT in nursing and a definition reflecting the views of a diverse group of nurse experts.
To obtain diverse input from nurses, we selected the Delphi technique. This method generates discussion and judgments on a topic, using experts who do not directly interact (Goodman, 1987). It is particularly useful when seeking agreement on a complex phenomenon from a geographically dispersed, heterogeneous group.
Waltz, Strickland, and Lentz (1991) and Talbot (1995) provided specific guidelines for using the Delphi method. They described the use of several rounds of input from a heterogeneous panel of experts in response to a sequence of questions. Each round of responses is analyzed by the researchers to determine patterns and outliners, which are summarized and returned to the panel with an additional set of questions for the next round. The number of rounds depends on how quickly consensus is reached; studies range from three to nine rounds. Five rounds were needed for this study.
Identifying the panel of nurse experts (research participants) was an evolutionary process. The aim was to find nurses employed in education, practice, and research who were diverse in gender, geography, culture, and practice specialties. A list of international nurses was obtained from the Division of Research, National League for Nursing. Nurses who had contacted us at conferences and through our professional practices were added. A literature review on "critical thinking in nursing" was conducted and authors were added to the participant list. Twelve names from the Nursing Diagnosis Journal Advisory Board were added. The first participant group consisted of 50 nurses from a wide variety of cultural, geographic, and practice areas.
Invitation letters were sent to potential participants asking if they agreed with the basic assumptions of the study (CT in nursing can and should be defined and CT can be taught, learned, and evaluated) and, if so, were they willing to participate? They were given a brief explanation of the Delphi technique, told the study would take about 2 years, and they were asked to suggest names of one or two nurses who demonstrated CT abilities and who would likely agree with the assumptions of the study. Recommended nurses were sent invitation letters. By March 1995, 135 potential participants had been invited to contribute. Of these, 86 agreed to participate. This research was carried out by two nurse educator/researchers. A graduate student provided assistance during the initial phase of identifying the panel of experts.
Overview of Process of Rounds
Five rounds were conducted, the last ending in August 1998. The number of participants in each round varied. We sent Round II materials to the 72 participants who responded to Round I and, from that point on, to all who had responded to at least one of the previous 2 rounds. In Round rV, participants were asked to sign permissions for use of their names in a list attached to publications of this study. Respondents who had participated in most previous rounds, but who did not respond to Round IV, were asked for their permissions in Round V. The final number of nurses in the expert panel was 55 (see Appendix).
To maintain anonymity each participant was given a code number in Round I. AU response forms were coded. A list of names and codes was kept in a log for the purpose of sending reminder letters as needed.
Because the Delphi technique is an emergent research method, we wanted participants to be fully aware of the data analysis procedure. We attempted to avoid overstructuring by recording the process of analysis and sharing the explanation of the process with participants in each new round. These explanations helped maintain an audit trail from the raw data through the various "crunching" procedures for each round. It also allowed participants to see how the analysis was grounded in their raw data each time.
Each round, except for the first, contained a packet of materials consisting of a cover letter, an explanation of the analysis of the previous round, directions and objectives for the current round, coded answer/score sheets, and an envelope for return mailing. Postage was included for participants within the U.S. Participants outside the U.S. were asked, and graciously agreed, to provide their postage. Table 1, "Overview of the Procedure," outlines the evolution of the study.
Round I Initial Question
Round I consisted of asking participants to respond to the question, "What skills and habits of mind are at the core of critical thinking for nurses in any setting: practice, education, and research?" The words "Habits of Mind" and "Skills" were chosen to capture the affective and cognitive aspects of CT. The wording of this question was developed in consultation with Peter Facione, who conducted the APA study of CT. This question format was thought to promote a broad consideration of the concept and its components and avoided premature closure of ideas.
The 72 respondents to Round I (6 men and 66 women) represented 10 countries (Brazil, Canada, England, Iceland, Japan, Korea, Mexico, Netherlands, Thailand, and 25 states in the US). These participants had expertise in various clinical specialties and many years in practice, teaching, and research.
Round I Analysis
The raw data in Round I were the most daunting because of the broad responses to the open-ended question. The data came back in a variety of forms, from lists of habits of mind and skills, to hand- written paragraphs, to several typed pages with documentation. Some participants divided concepts into habits and skills; some did not. Maintaining the richness of the data but also organizing it into a manageable form for Round II was a lengthy challenge. First, all responses were photocopied so that both of us had a copy of all responses. We transcribed each comment on 4 ? 6 cards, grouping duplicate and very similar comments on the same cards. Being concerned that we might influence each other if we analyzed the data together, we randomly selected sets of responses to transcribe independently. After transcribing 40 responses independently, we compared our work to be sure we were transcribing accurately and combining comments in a similar manner. When consistency was determined, together we analyzed the remaining sets together. More than a thousand cards were used to complete this portion of the analysis.
After having the comments on each card typed (for easier processing), we clustered the comments into temporary categories. When comments were very similar, we selected a temporary label for that category (e.g., "pattern recognition"). When there were single comments with none similar, but broad enough to be considered a category, the verbatim comment was recorded as a category of its own (i.e., analysis).
There also were specific comments not broad enough to be considered a category and not seeming to fit with any temporary category (e.g., "time factors"). These we included as a "miscellaneous" category rather than "forcing" a fit with other comments. At the end of Round I "crunching" we had 40 temporary categories, including the miscellaneous one. Each of the 40 clusters contained 5 to 20 of the participants' verbatim comments from Round I. Our temporary labels were removed when the clustered comments were sent to participants for Round II. Directions for Round II asked participants to provide an appropriate label for the 40 unlabeled clusters.
Round II Analysis
The focus of Round II was to continue to consolidate data. See Round II objectives in Table 1. When Round II was returned, we recorded the cluster labels provided by the participants and the frequency with which each label was suggested. There were definite patterns of response. Although participants were asked to provide possible definitions for the labels they selected, many did not provide definitions, often citing that they did not have time to do that. Others gave extensive definitions. We realized that asking for definitions at that point in the process was premature.
Overview of the Procedure to Achieve a Consensus Statement on Critical Thinking in Nursing
We tallied the number of yes/no responses to the question, "Do all comments fit in the cluster?" Some clusters had more "yes" answers, showing that the cluster was "cleaner." However, ultimately, that tally was not very helpful. Participants' comments indicating where certain items should fit and which clusters should be combined were more helpful. Those comments were used to help us crunch some clusters together and shift items to other clusters.
Because there were many diverse comments on some items and clusters, we established criteria to make the analysis feasible. The first criterion was: If at least 3 participants had the same comment (e.g., move an item to the "predicting" cluster or combine 2 clusters) that item or cluster would be moved accordingly. At first we attempted to do this rearranging on the computer, but found that cutting and pasting worked better. After rearranging the clusters and items, we found some clusters were very small. Keeping in mind the pitfall of over-structuring, but also paying attention to participants' encouragement to simplify the complex process, we ultimately had to do some moving with less rigid criteria. At the end of Round II analysis, we had 22 refined clusters.
We also analyzed the feedback on the miscellaneous comments. Participants had ranked those comments in order of importance from 0 to 5, with 5 being the most important. To get a total score for each comment, we multiplied each number by the number of responses and added them. Those scores ranged from 21 (relatively unimportant) to 114 (quite important). We recorded the 9 comments that had a score of 75 or more for participant input during Round III.
Round IU Analysis
The focus for Round III was to continue to refine the data. See Round III objectives in Table 1. First, we tallied yes/no responses to the question corresponding to objective a, "Are the items in each of the 22 clusters related?" We then read all explanations for "no" answers. Except for 5 of the 22 clusters, there were many more "yes" responses than "no" responses. We looked very closely at the 5 because they had 8 or more "no" responses (representing more than 15% of the responses). Those data revealed that some clusters needed to be split while others belonged in different clusters. After combining and separating, we had a set of 24 clusters with adequate data to represent consensus.
We counted votes for each cluster label. For most clusters, one label had a large majority of agreement and those were the words we used during our deliberations. We then examined how the participants had separated labels into "skills" and "habits of the mind." According to the majority of votes, 10 labels were habits and 13 were skills. One cluster did not have a clear designation as a habit or skill. However, many participants had used descriptions that implied affective more than cognitive qualities. That cluster was therefore added to the habit list. A total of 11 habits of the mind and 13 skills were established from the analysis of Round III.
Consensus on Cluster Labels for Habits of the Mind and Skills of Critical Thinking in Nursing
As to the completeness of the set of clusters/labels, while most thought the list looked complete, there were several comments that merited another vote in the next round. A few people suggested additions that we did not want to ignore. The vote on the miscellaneous comments was overwhelmingly consistent. For example, participants wrote that while the miscellaneous comments were important for introductory or explanatory merit, there was no further action needed on them in future Rounds.
For the next round we needed to offer definitions of the "habits" and "skills." This task proved to be a difficult one. First, we looked back at the definitions from Round II and then looked up the label words in a dictionary. Definitions for habit labels were fairly apparent. However, it became clear that the labels for skills varied in level of specificity. Some skills seemed to be subskills of other skills. To maintain the focus on cognitive skills was important. Many tasks implied cognitive function, but were not explicit thinking skills. For example, "data collection" seemed to be a "doing" task more than a cognitive skill. As these realizations emerged during our attempts to define labels, we reorganized the list into skills and subskills, changing the Round Ill count of skills from 13 to 7. with subskills being offered for consideration.
Participants were given detailed explanations of our process for determining the Round III definitions for the skills. A preliminary attempt to identil subskffls for each of the 7 major skills was also identified by the researchers and presented to the participants for input during Round IV. The researcher-proposed subskills are listed in parentheses after each of the 7 major skills: information-seeking (probing, receiving); discriminating (classif~'ing, choosing relevance/irrelevance, recognizing gaps/inconsistencies, prioritizing); analyzing (comparing, contrasting, contemplating); transforming knowledge (recognizing theory from practice, testing theory in practice and synthesis); predicting (anticipating, hypothesizing, planning); applying standards (evaluating, critiquing, idealizing); and logical reasoning (inducing, deducting, decisionmaking, argumentation, validation).
Round W Analysis
The focus for Round IV was to move toward closure (see objectives for Round IV, Table 1). There were 45 participants who responded to Round IV, but 2 of those responses came after the analysis was completed. The feedback on those 2, while consistent with the tallied results, was not included in the tallies.
The first objective, to arrive at consensus on label names for the "habits of the mind" and "skills" of CT in nursing, was accomplished (see Table 2). There was strong agreement on all labels.
The second objective was to arrive at consensus on the completeness of the lists of "habits of the mind" and "skills" of CT in nursing. There were only 3 specific suggestions for additional habits or skills, with each addition being suggested by only one participant. Because there were few suggestions and the agreement on the lists was so strong, we concluded there was consensus on the completeness of the lists.
The third objective, move toward consensus on definitions of habits of the minds and skills of CT in nursing, was met `with strong agreement (see Thble 3 for final definitions derived in Round V). Those who disagreed offered suggestions for changes in the definitions and here is where we had to make another difficult decision. Because there was such high agreement, should we consider changing the definitions? However, many suggestions made good sense-better sentence structure, more concise, clearer, and so forth. Because most changes were editorial, we decided to make changes and ask for agreement again in the last round.
The four-th objective, moving toward consensus on the subskffls, was a more difficult task. First, in the raw vote, there was very high agreement on the 23 subskills. For example 14 of the subskills received almost 100% agreement.
While there was high agreement on the subskills, some respondents' comments created a dilemma. "The subskills create an untidiness that I just didn't like"; "I'm bothered by these subskills." Other comments related to specific subskills. We pondered what to do. The original intent of this study was to arrive at consensus on CT in nursing by identifying skills and habits of the mind. Technically, we had arrived at consensus on those concepts. We had offered the subskills in Round III so participants could see that, during the data crunching, we envisioned certain skills as subcomponents of broader skill categories. With respect to the validity of the study, we believed the subskills had not been adequately studied, especially as to their completeness. Therefore, our recommendation was that the subskills should be addressed only as aspects of skills that needed further study. To arrive at a full consensus on the subskills would require either several more rounds of this study or a second study. We asked the participants in Round V how to deal with the subskills.
The fifth objective asked for suggestions on the format for the consensus statement on CT in nursing. The draft of a consensus statement that had been sent in this round was met with almost complete agreement, with minor editorial suggestions. The draft statement was developed by using an introductory sentence acknowledging the role of CT in professional accountability and quality care. It concluded with a simple listing of the 10 habits of the mind and 7 cognitive skills agreed upon by the participants.
Round V Analysis
In the final round, we returned to the participants the Round IV analysis that included tables reflecting the actual numbers of agreement on each of the tasks. The focus of this round was to achieve closure unless the participants choose to continue to study the subskills.
We made one final decision about the arrangement of both lists (skills and habits of the mind). Considering the implications of "order" we decided on the neutrality of alphabetical listing. Ordering or ranking would require more consensus-building than was planned or requested for this research project.
There were 51 people who responded to Round V. A vote on the following consensus statement was 45 (88.2%) agreeing, 4 (7.8%) disagreeing, and 2 (3.9%) no answers:
Critical thinking in nursing is an essential component of professional accountability and quality nursing care. Critical thinkers in nursing exhibit these habits of the mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection. Critical thinkers in nursing practice the cognitive skills of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting and transforming knowledge.
The final agreement on the definitions of the habits of the mind and the skills was equally positive. Table 3 lists the definitions and the votes of agreement on the habits of the mind and skills of CT in nursing.
The final question for Round V asked participants to indicate their agreement with our conclusion that subskills needed further study beyond this project's aims. The vote on this was 47 agreeing, 1 disagreeing, and 3 no answers, providing consensus on relegating the subskills to a later study.
This study provided a strong consensus statement from a diverse group of nurse experts as to the nature of CT in nursing. It provided descriptions of both the affective and cognitive components of CT in nursing through its defined habits of the mind and skills of critical thinkers in nursing. The findings affirmed the importance of including the affective domain (habits of the mind) when examining CT in nursing. And, when comparing this study's findings to the APA findings (Facione, 1992), it is apparent that nursing experts believe that CT in nursing includes two more affective components, "creativity" and "intuition."
The consensus achieved from this study has many implications for nurses in practice, education, and research. Nurses in practice may use the results of this study to examine their own CT by asking how they demonstrate these habits of the mind and skills. With this common language, administrators, practicing nurses, and staff development personnel have clearer ways of describing CT to peers. Performance objectives and performance appraisal tools could be developed using this consensus language of CT. Equally important, nurses could observe how patients demonstrate CT characteristics and consider how patients and their families may be assisted in their CT to enhance their participation in their care.
In education, nursing faculty and students now have a common language for CT. Faculty can use this language when designing learning activities and assessing students' CT outcomes. This language can be helpful when addressing professional accreditation criteria. Faculty and students can use this consensus language to collaborate with nurses in practice to promote patient care, staff development, and research. Students can also use this consensus language for self-evaluation of their CT abilities, setting up a valuable habit that can be retained beyond the novice period.
Nursing researchers now have consensus language regarding CT in nursing. This provides the foundation for further testing and validation. Standardized language for CT in nursing also provides opportunities for computer programming and the development of research instruments. Ultimately, nurse researchers could develop instruments to more effectively assess the complexity of CT in nursing.
Limitations of this study must also be considered with any attempt to apply this new knowledge. The lengthy time periods between each round (a function of the volumes of data) most likely influenced the momentum and continued participation of some respondents. With only two researchers analyzing the data, the process was slow. While the number of participants, ranging from 42 to 72 in various rounds, is acceptable considering the type of data, it is certainly reasonable to assume that a larger group of nurses might arrive at an even broader scope of understanding. Although we attempted to counteract the pitfall of over-structuring by providing detailed information on our analysis with each round, there is still a possibility that our preconceptions of CT in nursing influenced the results. The international perspective could be strengthened by increasing the number of participants from each country and adding other countries.
Consensus on Definitions of Habits of the Mind and Skills of Critical Thinking in Nursing
Achieving consensus on the habits of the mind and skills of CT in nursing from an international panel of 55 nurses is, however, a significant step toward a better understanding of the essence of CT in nursing. It is clear that the nursing experts in this study place great value on CT in nursing. Without the participants' extraordinary contributions of time, energy, and expertise, this study could not have been completed.
Yet, this study's results are still a beginning step. From this consensus on language, several questions emerge for further study. How do the subskills of CT relate to the primary skills of CT in nursing? What are the relationships among CT, diagnostic reasoning, clinical judgment, problem solving, and the nursing process? What are the most effective ways of nurturing the CT of nursing students? What could nursing faculty do to nurture their CT abilities? How do practicing nurses maximize their CT abilities and assist patients to use their CT? How do nursing administrators practice CT and nurture it with their staff? What instruments will most effectively measure CT in nursing? Studies that address these questions will be most valuable if they are also done through the collaborative efforts of practitioners, educators, and researchers. We invite nurses to evaluate critically the results of this study and continue the knowledge building for a growing understanding of the meaning of critical thinking in nursing.
The authors acknowledge the Research in Teaching and Learning Fellowship Program, Eastern Michigan University; Faculty Research Release Time, Eastern Michigan University; Sigma Thêta Tau, International, Eta Rho Chapter Research Award; Lynn LeBeck, RN, MS, graduate assistant; and Peter Facione, PhD, Dean, Santa Clara University.
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Overview of the Procedure to Achieve a Consensus Statement on Critical Thinking in Nursing
Consensus on Cluster Labels for Habits of the Mind and Skills of Critical Thinking in Nursing
Consensus on Definitions of Habits of the Mind and Skills of Critical Thinking in Nursing