Dr. Jenkins is Assistant Professor, Mennonite College of Nursing, Illinois State University, Normal, Illinois.
The author has no financial or proprietary interest in the materials presented herein.
Address correspondence to Sheryl Daun Jenkins, PhD, APN, ACNP, Assistant Professor, Mennonite College of Nursing, Illinois State University, 214 Edwards Hall, Campus Box 5810, Normal, IL 61761; e-mail: firstname.lastname@example.org.
Critical thinking has been identified as a crucial element of nursing practice (Daly, 1998; Del Bueno, 2005; Scheffer & Rubenfeld, 2000, 2006). Although researchers have attempted to show that schools of nursing are teaching this skill, the literature does not support this assumption. Furthermore, scholars have not successfully demonstrated that nursing students and graduates are using critical thinking skills (Chabeli, 2007; Del Bueno, 2005; Rogal & Young, 2008; Scheffer & Rubenfeld, 2000, 2006; Toofany, 2008; Walsh & Seldomridge, 2006). The explanation for this disconnect may lie within the discipline’s definitions of critical thinking, which vary greatly. The literature shows that nurse scholars define critical thinking differently than nonnurse scholars and that the definition also varies within nursing (Campesino, 2008; Chabeli, 2007; Daly, 1998, 2001; Paul, 1992; Rogal & Young, 2008; Scheffer & Rubenfeld, 2000, 2006; Toofany, 2008; Walsh & Seldomridge, 2006).
A cross-cultural nursing perspective adds another dimension to critical thinking. Nurses’ knowledge has rapidly expanded far beyond national boundaries. Nurses live and work in a cross-cultural world where insights into other cultural practices are essential and where simply reporting on the practices of other cultures is not adequate (Boyle, 2000; Leininger, 1996; Schim, Doorenbos, Benkert, & Miller, 2007). The findings of this study contribute to an increasing body of knowledge about critical thinking in a cross-cultural context.
Definitions of critical thinking abound within nursing (Brigham, 1993; Campesino, 2008; Chabeli, 2007; Daly, 1998, 2001; Rogal & Young, 2008; Scheffer & Rubenfeld, 2000, 2006; Toofany, 2008; Walsh & Seldomridge, 2006). In fact, Brigham (1993) asserted that “there are as many definitions as there are experts” (p. 49). If this is true within the United States, one can assume that the differences in critical thinking definitions must be even more pronounced across cultures. Some scholars have expressed concern that the profusion of definitions interferes with the clear communication of what critical thinking really is (Scheffer & Rubenfeld, 2000, 2006), whereas others embrace the ambiguity of the term (Daly, 1998, 2001; Paul, 1992). Despite the ambiguities and differences, scholars generally agree that critical thinking is characterized by dialogical thinking, a disinclination to embrace a single dominant perspective, and a willingness to explore differing points of view. Regarding situations from multiple perspectives is crucial to fully analyzing information (Button, Cassam, Johansson, & Baker, 2005; Chabeli, 2007; Paul, 1992; Sternberg, 1986). The antithesis to critical thinking is unilogical thinking, or the tendency to see things from only a single perspective. There is a paucity of research regarding the link between critical thinking and cross-cultural nursing.
Doutrich and Storey (2004) reported that nursing students’ critical thinking skills, specifically open-mindedness and inquisitiveness, improved after an intervention aimed at enhancing their cultural competence. Nurses’ thinking skills can be broadened by exploring the beliefs, attitudes, and thinking processes of people in other cultures. To create a deeper and broader knowledge base for nursing, such cross-cultural research must go beyond a simple report of practices to a richly descriptive analysis that includes ways of knowing (Boyle, 2000; Button et al., 2005; Leininger, 1996; Schim et al., 2007).
Most cross-cultural nursing research focuses on the health care practices of other countries rather than on nurses’ thinking skills. Furthermore, the cross-cultural studies that are available to English-speaking nurses are limited to those done in the United States, Great Britain, Canada, and Australia. This presents nurse educators with a limited, ethnocentric view of critical thinking. By focusing on Thailand, this study provides an examination of critical thinking from both Western and Asian view points and seeks to bridge the gap in the nursing literature about critical thinking from a non-Western perspective.
Thai nurse scholars have conducted research studies on critical thinking, but few of these studies are available in English translation (Kaveevivitchai, Piaseu, Luptrawan, Sirikoon, & Panijpan, 2007). Other studies cited here were translated from Thai to English by an English-speaking Thai scholar for inclusion in the literature review. Kerdkul, Kardu-dom, Trinnamaitip, and Pongsittithaworn (1999) used Watson and Glaser’s (1980) Critical Thinking Appraisal to test nursing instructors’ critical thinking. They found that more experienced teachers had more self-confidence and higher critical thinking abilities, and they concluded that less experienced nursing faculty should have extra support in teaching critical thinking. Lausuwanagoon (2000) and Tharamas (1999) found improved critical thinking skills in nursing students who completed courses that emphasized the development of critical thinking skills.
This cross-cultural study used qualitative methodology to explore how nurse scholars describe critical thinking in nursing. Nurse educators in Thailand and the United States were questioned concerning the following aspects of critical thinking: essential components; teaching and evaluation techniques; characteristics of critical thinkers; and the importance of a consensus definition for critical thinking in nursing.
Setting and Sample
This study was conducted at two state universities in the midwest United States, and a large university in central Thailand. Each university has several nursing departments and teaches students at both the baccalaureate and master’s level. The three institutional review boards granted permission to conduct the study, and participants gave informed consent and were assured of confidentiality. The interview forms were identified only by a subject code number.
A small, purposive sample of five nurse scholars from Thailand and five from the United States was used. To select participants with sufficient background in critical thinking who were fluent in English, the researcher (S.D.J.) requested the cooperation of two American scholars who had engaged in critical thinking research. They were selected because of their expertise in critical thinking, as well as their extensive contacts with nurse educators in the United States and Thailand who might be qualified to participate in the study.
Each participant was employed as a dean, department head, or director of a program that emphasized the development of critical thinking skills in students. Furthermore, each described their use of techniques in the classroom or clinical setting to enhance and evaluate critical thinking. Four had conducted research on critical thinking, five said they were responsible for instilling critical thinking into the curriculum, and one was known for incorporating critical thinking strategies into the classroom setting (Table).
Table: Participants’ Demographic Information
The interview questions were guided by Sternberg’s (1986) framework. The questions elicited a meta-analysis of critical thinking through the philosophical, psychological, and educational traditions. Asking participants to describe their ideal critical thinker allowed them to offer insights through a philosophical lens. Eliciting a discussion of critical thinking as it exists in the real world of nursing practice cast the issue in a psychological light. Exploring the participants’ thoughts on teaching critical thinking yielded an educational point of view.
Each interview was conducted face-to-face in the participant’s office and tape recorded by the researcher. Only the researcher (S.D.J.) and participant were present during interview sessions. In general, the Thai participants spoke more slowly as they attempted to communicate in English. The interviews conducted in Thailand took an average of 60 minutes, whereas those conducted in the United States took an average of 45 minutes.
Every effort was made to put participants at ease. Several remarked that they were not sure their thoughts on critical thinking would be very helpful, and some worried that the researcher would not be able to understand their English. The researcher attempted to reassure them that their thoughts were valuable and that their English was understandable. A few minutes spent in informal chatting about common nursing experiences before the tape recorder was turned on was effective in helping the participants relax. The interview questions were not presented in advance to evoke the most natural and honest responses from the participants. Open-ended interview questions, as well as follow-up questions, were used to obtain the most detailed descriptions of critical thinking in nursing.
Each tape was transcribed verbatim as soon as possible after the interview. This became especially important when transcribing the Thai transcripts, which were more difficult for the researcher to understand and more time consuming to transcribe because of the language barrier. Follow-up interviews were conducted with each of the 10 participants to address the appearance of unanticipated themes that emerged during the Thai interviews. Follow-up interviews averaged 20 to 25 minutes for both the Thai and American participants. Analysis of the data was conducted manually. Themes were not reviewed with participants after data analysis. The same researcher (S.D.J.) conducted and transcribed the interviews and analyzed the data.
Key elements of critical thinking were evident, but they were wrapped up in nursing content. It soon became apparent that, at least to the participants, critical thinking was a complex construct. The participants did not separate critical thinking and nursing knowledge. Rather, critical thinking was woven throughout every aspect of nursing knowledge and nursing practice. Themes emerged that pointed to trends in how nurse educators think about critical thinking. As the Thai transcripts were compared with the American transcripts, similarities and differences became apparent. The findings indicated that there are both common and specific cultural aspects of critical thinking in nursing (Figure).
Figure. Results of Interview Analysis.
American and Thai participants had much in common when asked about the essential components of critical thinking. They emphasized that students must be able to take in nursing knowledge from many sources and synthesize it, consider the big picture to avoid taking information out of context, and evaluate their thinking and actions to solve nursing problems. They wanted students to be able to link nursing theory to clinical practice. They also frequently mentioned analysis as an important component of critical thinking, but they did not usually elaborate on that skill or describe what it looks like in clinical practice.
Several participants mentioned that they did not want students to passively accept what they are told. Instead, they thought it was important for students to question and investigate until they had gathered all of the necessary information. An American participant also wanted students to question themselves. She described a critical thinker as:
Someone who asks themselves questions about what’s going on with the plan of care for that patient. And if they don’t know, they find out. They ask the right questions.
Only American participants mentioned decision making as an essential component of critical thinking, and only Thai participants stated that applying critical thinking to all aspects of life, not just one’s student role, was crucial. One participant from Thailand asserted that:
Students who think critically are able to take what they learn...and apply it to their lives beyond nursing. We should see evidence of critical thinking outside the school of nursing.
Thai participants also mentioned that happiness was essential to critical thinking. One stated: “They enjoy their work if they are critical thinkers. They know this is better for the patient.” Another explained that critical thinking makes students happy because:
In Thailand, students do not discuss things with parents. Parents tell them what to do and there is not discussion. Now, with critical thinking, they can discuss many things and they are happy.
When asked to describe the observable characteristics that demonstrate critical thinking ability, most of the participants expected to see a depth of understanding of all elements of nursing practice. They also anticipated that critical thinkers would exhibit both emotional maturity and a mature, disciplined approach to learning. Several participants discussed nursing expertise, in which students could interpret subtle cues, prioritize data, distinguish relevant from irrelevant facts, and act efficiently, and perhaps even intuitively, to help their patients.
Only American participants mentioned motivation as a characteristic of critical thinkers. One described students who “struggle with the material and look up the material. They come to class prepared.” Only Thai participants asserted that critical thinkers were likely to question their teachers’ statements. As one explained:
In Thailand, it is not like America. Students...do not question the teacher. In the nursing program, we are now teaching critical thinking, but still it is difficult for them to question the teacher.
Participants in the United States and Thailand had several techniques for teaching critical thinking in common. Case studies, class presentations, student–teacher interactions, and active learning strategies were discussed by most of the participants as helpful for enhancing critical thinking. Each of the study’s participants thought that cross-cultural nursing experiences could enhance students’ critical thinking skills. A Thai participant discussed her experience in a doctoral program in the United States:
When I was in the United States...my job was to enter data into the Access file. But once the file was full and I could not enter the data. My mentor said, “Think about this. What do you think you should do?” My idea was to separate the data into several smaller files and in this way we could enter all the data. But my mentor said, “No, we will buy a bigger computer with more memory.” So we both had the same goal, but our methods were very different.... American people and Thai people think differently.... It is very important to think about cross-cultural nursing.
Only Thai participants identified student-led clinical rounds, student-to-nurse shift reports, and the nursing process as tools for teaching critical thinking. The use of clinical simulation laboratories, decision trees, and reflective journals were mentioned only by United States participants.
Participants from both the United States and Thailand believed they could evaluate students’ thinking ability by their written examinations, the quality of their written work, and by student–teacher interactions. A Thai participant said that in evaluating students, she looked for emotional maturity in their interactions:
They try to understand things that are going on. They should be listeners. They should be calm [people] and think things through in an orderly way. They know how to study independently. They decide what to believe, and not depend on the teacher to tell them what to think. Not only in school, but in their whole life.
Only the American participants mentioned research and reflective journals as means to evaluate critical thinking. Only Thai participants said they could evaluate critical thinking by how happy the student was:
At first, when they hear about critical thinking in the classroom, they are not happy. They say, “Why do you want me to think about that?” Then we explain our goal for critical thinking. Finally, in the end, they are very happy. Because now they can think in different ways, not in just one way. At first it was, “I will just believe you, whatever you teach me.” But after they have learned to think critically, they say “Now I can think for myself.” .... That makes them happy. In Thai culture, in the past, we raised our children to just follow protocol in everything. But now they have lots of information outside the home. So they might think differently than parents.... They cannot discuss different ideas with parents.... So they can discuss many things with instructors, and this makes them happy. Now they can think for themselves and discuss their ideas. When they can do this, they are happier and we know they are better critical thinkers.
Impact of a Consensus Definition
Participants in both countries identified several potential benefits for developing a consensus definition of critical thinking for nursing. All but one said a consensus definition would promote unity in nursing, simplify evaluation of critical thinking, and facilitate nursing research, especially research on critical thinking. On the other hand, they were also concerned that finding one common definition of critical thinking would deprive nursing of the richness of multiple perspectives.
Although the participants of this study acknowledged the value of many points of view, all but one of the participants thought nurses should develop a common definition of critical thinking. For the most part, these participants were interested in identifying the core concepts that comprise critical thinking in nursing. An American participant did not think that developing a common definition would be good for nursing. She was concerned that a consensus definition of critical thinking would limit future growth and impede understanding of the concept. She asserted:
I think a consensus definition would be dangerous, actually. Because once we decide that this is what we are going to say critical thinking is, then we’re stuck with that. Like, when we talked about the nursing process and students’ ability to use that. At the time, the nursing process was the end all and be all of what nurses did. If we hadn’t moved on to discussing critical thinking, I think we wouldn’t have as much insight into how nurses think, and how to teach it, and how to work with students. I don’t think arriving at a common definition would be a good thing.
Many of the findings of this study could have been expected based on a review of the nursing literature; however, some unexpected findings emerged. Although the nursing literature does not link critical thinking with the ability to stay calm, participants of this study emphasized the importance of staying calm in emergencies. Several participants related specific situations in which their students remained calm in frightening situations, allowing them to think things through, reevaluate their plans of care, and help their patients.
Perhaps the most unexpected finding was that Thai participants saw happiness as an essential component of critical thinking, and they stated they could tell whether their students were critical thinkers by the degree of happiness they displayed for learning and patient care. While acknowledging the Thai philosophy of accepting what one is taught without question, the Thai participants asserted that thinking critically, thinking for oneself, and the freedom to discuss ideas with teachers made students happy. They also thought that because critical thinking improved the students’ ability to care for their patients, critical thinkers could be expected to be happier in their newfound ability to affect the quality of patient care. Neither the American participants nor the Western nursing literature have tied critical thinking to happiness.
Another unexpected finding was that, although the nursing literature is divided on the value of a consensus definition of critical thinking for nursing, the participants involved in this study were almost unanimous in their support of a consensus definition. Most said they valued multiple perspectives, and they acknowledged that a consensus definition might narrow our view of critical thinking for nursing. However, they thought the benefits, such as promotion of unity in nursing, simplification of evaluation methods, and facilitation of research, outweighed the potential risk.
This study found that there are many similarities and a few differences in how nurse educators in the United States and Thailand view critical thinking for nursing. The study revealed both common and specific cultural aspects of critical thinking. Limitations of this study are that it was a qualitative study using a small sample of participants and was limited to two countries. The results cannot be generalized to nurse educators worldwide or even to nurse educators in the two study countries. The study is also limited in that one researcher conducted and transcribed the interviews and analyzed the data. Because the researcher does not speak Thai, her ability to communicate effectively with Thai participants was limited by their fluency in English. A translator was not used in this study because four of the five Thai participants had completed doctoral education in the United States and the fifth had traveled extensively in the American midwest. All had been recommended for their fluency in English. In fact, their English was at least as good as that of the two translators the researcher had been considering. In addition, the Thai participants used nursing jargon familiar to the American researcher.
Conclusion and Implications
However, despite these limitations, the findings do expand the known range of variables that comprise critical thinking in the United States. The new variables used by Thai participants in their descriptions of critical thinking have not been emphasized in the nursing literature until now. The links between critical thinking and staying calm or being happy are important connections with rich potential for future research. Future studies should explore how staying calm affects nurses’ ability to think critically, and researchers should also ask whether staying calm is important to critical thinking as it exists in other disciplines. In an era of nursing shortages, researchers should ask what keeps nurses satisfied with the profession. If, as the participants of this study asserted, the ability to think critically makes nurses happy or helps them to enjoy their work, that connection warrants further exploration through larger studies in multiple settings. This study brought to the forefront the advisability of developing a consensus definition of critical thinking for nursing, an issue that will need to be explored further, using larger samples. This research indicates the need for future studies that identify the core components of critical thinking to develop flexible, usable structures that explain critical thinking without limiting nurses to narrow interpretations of the concept.
This pilot study demonstrates the crucial need for further research to explore the effect of cross-cultural nursing experiences on critical thinking skills. Such research has considerable implications for nursing education. Currently, cross-cultural experiences are largely used to enhance the cultural awareness of nursing students. If researchers find that these events also enhance critical thinking, nurse educators will have an additional tool to foster critical thinking in their students. A richer understanding of what critical thinking looks like in different cultures would enhance the students’ abilities to tolerate multiple perspectives while simultaneously strengthening their grasp on the meaning and importance of critical thinking. Nursing education lends itself particularly well to the development of different critical thinking skills; classroom settings foster reflective reasoning, whereas clinical experiences strengthen the ability to organize and prioritize rapidly changing patient data. Cross-cultural nursing has the potential to become an excellent way of teaching critical thinking.
- Boyle, J.S. (2000). Transcultural nursing: Where do we go from here?Journal of Transcultural Nursing, 11, 10–11. doi:10.1177/104365960001100103 [CrossRef]
- Brigham, C. (1993). Nursing education and critical thinking: Interplay of content and thinking. Holistic Nursing Practice, 7(3), 48–54.
- Button, L., Cassam, T., Johansson, I. & Baker, C. (2005). The impact of international placements on nurses’ personal and professional lives: Literature review. Journal of Advanced Nursing, 50, 315–324. doi:10.1111/j.1365-2648.2005.03395.x [CrossRef]
- Campesino, M. (2008). Beyond transculturalism: Critiques of cultural education in nursing. Journal of Nursing Education, 47, 298–304. doi:10.3928/01484834-20080701-02 [CrossRef]
- Chabeli, M.M. (2007). Facilitating critical thinking within the nursing process framework: A literature review. Health South Africa, 12(4), 69–89.
- Daly, W.M. (1998). Critical thinking as an outcome of nursing education. What is it? Why is it important to nursing practice?Journal of Advanced Nursing, 28, 323–331. doi:10.1046/j.1365-2648.1998.00783.x [CrossRef]
- Daly, W.M. (2001). The development of an alternative method in the assessment of critical thinking as an outcome of nursing education. Journal of Advanced Nursing, 36, 120–130. doi:10.1046/j.1365-2648.2001.01949.x [CrossRef]
- Del Bueno, D.J. (2005). A crisis in critical thinking. Nursing Education Perspectives, 26, 278–282.
- Doutrich, D. & Storey, M. (2004). Education and practice: Dynamic partners for improving cultural competence in public health. Family and Community Health, 27, 298–307.
- Kaveevivitchai, C., Piaseu, N., Luptrawan, S., Sirikoon, N. & Panijpan, B. (2007). Supportive-educational program: Using bioscientific multimedia to enhance clinical problem solving skill in general nurse practitioner students. Thai Journal of Nursing Research, 11, 295–307.
- Kerdkul, P., Kardu-dom, P., Trinnamaitip, J. & Pongsittithaworn, K. (1999). Critical thinking ability of nursing instructors. Bangkok, Thailand: Institute of Pra Boromratchanok.
- Lausuwanagoon, W. (2000). A development of enrichment curriculum to promote critical thinking skills in nursing process (Unpublished doctoral dissertation). Srinakharinwirot University, Bangkok, Thailand.
- Leininger, M. (1996). Major directions for transcultural nursing: A journey into the 21st century. Journal of Transcultural Nursing, 7, 28–31. doi:10.1177/104365969600700206 [CrossRef]
- Paul, R. (1992). Critical thinking: What every person needs to survive in a rapidly changing world. Santa Rosa, CA: Foundation for Critical Thinking.
- Rogal, S.M. & Young, J. (2008). Exploring critical thinking in critical care nursing education: A pilot study. Journal of Continuing Education in Nursing, 39, 28–33. doi:10.3928/00220124-20080101-08 [CrossRef]
- Scheffer, B.K. & Rubenfeld, M.G. (2000). A consensus statement on critical thinking in nursing. Journal of Nursing Education, 39, 352–359.
- Scheffer, B.K. & Rubenfeld, M.G. (2006). Critical thinking: A tool in search of a job. Journal of Nursing Education, 45, 195–196.
- Schim, S.M., Doorenbos, A., Benkert, R. & Miller, J. (2007). Culturally congruent care: Putting the puzzle together. Journal of Transcultural Nursing, 18, 103–110. doi:10.1177/1043659606298613 [CrossRef]
- Sternberg, R.J. (1986). Critical thinking: Its nature, measurement, and improvement (Report No. CS 209 962). Washington, DC: National Institute of Education.
- Tharamas, W. (1999). Relationship between learning experience and problem solving and critical thinking in nursing students (Unpublished doctoral dissertation). Srinakharinwirot University, Bangkok, Thailand.
- Toofany, S. (2008). Critical thinking among nurses. Nursing Management UK, 2(9), 28–31.
- Walsh, C.M. & Seldomridge, L.A. (2006). Critical thinking: Back to square two. Journal of Nursing Education, 45, 212–219.
- Watson, G. & Glaser, E. (1980). Critical thinking appraisal manual. New York, NY: Harcourt Brace.
Participants’ Demographic Information
|Participant||Years as a Nurse Educator||Current Position||Educational Preparation||Study Outside Country of Origin||Years Teaching Evaluating Critical Thinking||Additional Critical Thinking Expertise|
|U.S. scholar #1||25||Director, Graduate School of Nursing||BSN, MSN, PhD; Education Administration||U.S.||13||10 years conducting research on critical thinking|
|U.S. scholar #2||10||Director, Undergraduate Nursing||BS in Psychology, BSN, MSN, EdD||United States||10||6 years incorporating critical thinking into undergraduate program|
|U.S. scholar #3||26||Director of Graduate Nursing, Coordinator of Research||ADN, BSN, MSN, PhD in Nursing||United States||16||10 years conducting research on critical thinking|
|U.S. scholar #4||26||Head of Department of Medical Surgical Nursing||BSN, MSN, MS in Physiology, PhD in Physiology||United States||15||8 years incorporating critical thinking into department|
|U.S. scholar #5||21||Head of Department of Medical Surgical Nursing||BSN, MSN, PhD in Nursing||United States||21||20 years incorporating critical thinking into nursing curricula|
|Thai scholar #1||12||Head of Department of Nursing Administration||BSN, MSN, PhD in Curriculum Research and Development||Thailand||12||6 years conducting research on critical thinking|
|Thai scholar #2||27||Dean of College of Nursing||BSN, MSN, PhD in Education Administration||United States and Thailand||10||10 years incorporating critical thinking into nursing curricula|
|Thai scholar #3||19||Associate Dean for Research||BSN, MS in Nursing and Midwifery, PhD in Nursing||United States and Thailand||6||6 years conducting research on critical thinking|
|Thai scholar #4||10||Associate Dean of College of Nursing||BSN, MSN, PhD in Nursing||United States and Thailand||10||5 years incorporating critical thinking into nursing curricula|
|Thai scholar #5||9||Head of Department of Maternal Child Nursing||BSN, MSN, PhD in Nursing||United States and Thailand||5||Named by colleagues as expert at incorporating critical thinking in the classroom|