Critical thinking has been identified as the foundation of the problem-solving thought processes that people use in everyday situations. The Carnegie Foundation's report, Educating Nurses: A Call for Radical Transformation (Benner, Sutphen, Leonard, & Day, 2010), called for a paradigm shift from the concept of critical thinking in nursing to one that expands thinking skills and habits for clinical judgment or reasoning. A shift to critical reflection was suggested, where students would pose questions about an event, a patient, or a clinical situation on which they can draw attention to deconstructing the situation to evaluate the thinking processes used. Critical reflection is a way of developing clinical reasoning and imagination to help students examine what happened and what to consider when confronted with another similar clinical situation. However, it remains unclear how nurse educators can incorporate critical reflection into clinical and classroom learning. If educators are to enhance this thoughtful process, they need tools to analyze and interpret students' thinking through reflection and provide feedback related to the effectiveness of this process. This article will discuss some of the basics of critical thinking and critical reflection and propose a method for educators using journaling to guide students in the critical reflection process.
Both the nursing and social science literature have attempted to define critical thinking. Nursing and other social science educators have developed methods for teaching and evaluating the critical thinking skills, when defined, of their students (Brookfield, 1987; Dewey, 1933; Ruthman et al., 2004; Scheffer & Rubenfeld, 2000). However, before teaching and evaluation tools can be developed, those definitions must be better understood. In reviewing the definitions provided in the literature, some common characteristics identified include that critical thinking is a process of reflection, analysis, decision making, and awareness, as well as the ability for the appraisal of assumptions, inquiry, interpretation, and consideration of contextual perspective (Riddell, 2007).
The concept of critical thinking has its origins in the social sciences. As early as the 1980s, the literature related to general education describes a recognition of critical thinking as the foundation of the educational process. In 1990, the American Philosophical Association conducted a Delphi study that was spearheaded by a psychologist and nurse team (Facione, 1990). That team focused on a cross-disciplinary definition of critical thinking. The resulting definition has been used as the basis for student evaluation by educators at all levels (Facione, 1990).
As early as 1932, the National League for Nursing recognized critical thinking as being an important concept for nursing education (Urch, 1932). Over time, several nurse educators attempted to define critical thinking for nursing; however, there was no consensus on how it was applied to nursing. Therefore, in 2000, two nurse educators, Rubenfeld and Scheffer (2010), conducted a second Delphi study built on the work of Facione (1990). That study was designed to formalize their original definition of critical thinking, making it specific to nursing. The results included the following consensus statement:
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, seeking information, logical reasoning, predicting, and transforming knowledge. (Scheffer & Rubenfeld, 2000, p. 357)
From this definition, Rubenfeld and Scheffer (2010) developed educational and evaluation tools for implementation in nursing education. That work is based on their earlier consensus statement and supported the themes identified as they related to the habits of the mind and cognitive skills. Those educators highlighted the value of a purposeful reflective process to evaluate critical thinking in clinical situations (Scheffer & Rubenfeld, 2000). Using their earlier consensus statement, they suggested that reflection may be the one tool that is best suited for student learning and assessment (Rubenfeld & Scheffer, 2010).
Reflection in Nursing Education
Reflection is defined as “contemplation upon a subject, especially one's assumptions and thinking, for the purposes of deeper understanding and self-evaluation” (Scheffer & Rubenfeld, 2000, p. 358). Mezirow (1991) indicated that becoming aware of the assumptions one makes in thinking and action involves recognizing the influence of culture and life experiences, as well as learning how to compensate for one's limitations. Mezirow suggested that reflection becomes an important element in the development of critical thinking. Foundational to those assumptions is the work of Dewey (1933), who defined reflection, or reflective thought, as a process that is active, persistent, and requires careful consideration of any belief or supposed form of knowledge to support and develop further conclusions about it. Dewey further suggested that the process is sequential and begins with questioning knowledge in a deliberate format.
The use of reflection to foster critical thinking is not a new concept. In 1987, Brookfield wrote about developing critical thinking in adults in all disciplines and professions. In those writings, Brookfield (1987) suggested that critical thinking is a process of identifying assumptions, challenging those assumptions, and finding alternatives, while understanding the importance of the context within which the assumptions or alternatives are made. Brookfield suggested that to be a critical thinking adult, one must ask questions about one's normal ways of thinking by probing, questioning, and reflection. He called the process reflective skepticism and suggested that ideas must be subjected to testing against experiences through a process of reflection.
Schön published works on the development of character and professional knowledge as early as 1983. His focus was on reflective practicum, in which he suggested that practical knowledge related to the actions of the professional was essential to knowledge development. Schön spoke about both knowing in and on actions but defined each as unique and specific. He used the term reflective practicum to support knowledge acquisition from practical experience, (Schön, 1987). Using concepts from these and other educators, nurse educators have suggested that critical reflection and analysis in relation to practice is essential to critical thinking skill development (Benner et al., 2010).
The Reflective Process
Throughout nursing education, reflection has been used to enhance knowledge and refine action to improve care delivery. However, questions remain about the methods used for reflection in nursing education, whether undergraduate or graduate. In the report by Benner et al. (2010), several suggestions were made regarding improvements to nursing education. Point 17 suggests that educators foster student learning opportunities for practice reflection (Benner et al., 2010). Benner et al. described student-generated accounts of their experiences with patients and families as a method of identifying students' strengths and weaknesses related to the patient care in which they had been engaged during the student experience. This can occur as classroom discussions, small-group case conferences, or journaling.
In a study by Ruthman et al. (2004), clinical journaling was described as a teaching tool to help undergraduate students develop their critical thinking skills. The focus, as defined by those authors, was to allow students to begin to express in written form their attitudes, feelings, and cognitive learning experiences from the clinical settings. It allows the student to link prior knowledge, observation, description, critical thinking, and clinical decision making to the clinical experiences so they can connect theory and practice and then reflect on the process. Ruthman et al. suggested a format for the journaling to help define and enhance the reflection so that a consistent framework supports learning, evaluation, and feedback.
In their book, Critical Thinking Tactics for Nurses: Achieving the IOM Competencies, Rubenfeld and Scheffer (2010) discussed the role of reflective thinking as a method for educators to assist students in reviewing clinical situations and drawing from what they learned. They proposed a process of reflective thinking through structured journaling as one method to help students focus on thinking, related to the actions of the clinical situation. On the basis of the consensus statement of critical thinking developed from their Delphi study, Rubenfeld and Scheffer formulated a series of questions that students should ask themselves as they reflect. The questions are based on the critical thinking habits of the mind and skills, as outlined in their consensus statement, which then guides the student to identify the knowledge used for learning.
The Application Process
Rubenfeld and Scheffer (2010) suggested that for this reflective journaling to be useful, students need feedback to close the loop in the reflective process and support the assumptions. They described a process whereby students would journal about various clinical experiences, using a three-step, structured format that encourages students to reflect in a more formal way. The format calls for the students to frame the vignette or clinical scenario as a description of one element of the critical thinking definition from their consensus statement (habit or skill). The first step simply describes how the vignette represents the selected element. The second step offers the students the opportunity to support the actions of the vignette as a demonstration (or, in some cases, not a demonstration) of the element. The third step provides a format for the students to decide on how they would act in another similar situation to demonstrate the critical thinking skill or habit. Each step is only one paragraph, and the entire journal entry is only one page, forcing the students to identify the key elements of the situation or vignette and be succinct in their discussion.
The value of a structured journal activity is that the instructor now has a formal process from which to critique and provide guided feedback. Rubenfeld and Scheffer (2010) provided a rubric scoring system to evaluate students' journaling and provide opportunities for feedback on the reflection and use of the critical thinking element in the clinical setting. The expectation was that students would reflect on what they wrote and then learn from their own experience, as well as from feedback from faculty. The result would be recognition of their own critical thinking skills in that particular situation and the application of such skills in a future similar clinical situation.
The Outcomes of Reflection
The journaling activity was implemented as a part of the clinical experience in a master's nurse practitioner program. Using the definitions from the consensus statement of the critical thinking skills or habits of Scheffer's and Rubenfeld's work (2000), students were assigned a clinical scenario or vignette and were asked to reflect on how the described scenario did or did not effectively represent the skill or habit they had identified. Initially, students expressed some confusion with knowing exactly what the skill or habit represented. They also found the reflection to be more difficult than they had initially thought. However, as the students began to look at the scenario more carefully and reflect on what they were thinking and feeling during the experience, they were better able to relate the scenario or vignette to the skill or habit. Finally, with this increased reflection, the students were more likely to describe how they would continue to work toward utilization of the skill or habit in future similar situations. By the end of the two semesters in which they completed the journals, the students expressed a stronger understanding of critical thinking and how it enhanced their clinical decision-making abilities. In addition, the students commented that they felt better equipped to cope with a variety of clinical situations, knowing how to approach the situation through a more structured thinking process. It provided them with a new sense of confidence in their ability to function in the expanded role of the advanced practice RN.
Faculty working with the journaling activity found that the initial scoring rubric was too limited in scope to apply to the advanced practice RN student experience. However, by modifying the scoring system and providing a more detailed rubric, faculty found it easier to score the journal entry and offer constructive feedback. The result was a positive learning experience for the student engaged in reflective journaling and a positive teaching tool for faculty eager to assist their students in enhancing their critical thinking and improving their clinical decision making. Faculty found that it was easy and quick to read just one journal page per student, score the sections, and offer feedback so that students were able to receive the feedback in a timely manner. This helped close the loop on the reflective process. Table A (available in the online version of this article) provides an example of a student's journal entry and shows the rubric score sheet used to grade the student's reflection.
Sample Journaling With Rubric Scoring Sheet