Journal of Nursing Education

Major Article 

Operationalizing the Concept of Critical Thinking for Student Learning Outcome Development

Lori Cooke, MEd, RN-BC; Carrie Stroup, MSN, RN, CNE; Christine Harrington, MSN, MBA, RN

Abstract

Background:

Creating a curriculum that can effectively develop critical thinking skills is an elusive outcome for undergraduate nursing programs. Despite the best efforts of faculty, employers continue to note an inability of new graduates to apply critical thinking concepts that improve patient outcomes. The lack of an operational definition of critical thinking appears to be a key contributor to this issue.

Method:

A concept analysis was developed to identify a definition of critical thinking that allows for clear, measurable learning outcomes.

Results:

Despite extensive discussion within the literature, a consistent definition of critical thinking is lacking; instead, a rather extensive list exists of the attributes and antecedents consistently found in individuals who think critically.

Conclusion:

Curricular student learning outcomes framed around operational attributes can promote the development of critical thinking skills and improve patient outcomes. [J Nurs Educ. 2019;58(4):214–220.]

Abstract

Background:

Creating a curriculum that can effectively develop critical thinking skills is an elusive outcome for undergraduate nursing programs. Despite the best efforts of faculty, employers continue to note an inability of new graduates to apply critical thinking concepts that improve patient outcomes. The lack of an operational definition of critical thinking appears to be a key contributor to this issue.

Method:

A concept analysis was developed to identify a definition of critical thinking that allows for clear, measurable learning outcomes.

Results:

Despite extensive discussion within the literature, a consistent definition of critical thinking is lacking; instead, a rather extensive list exists of the attributes and antecedents consistently found in individuals who think critically.

Conclusion:

Curricular student learning outcomes framed around operational attributes can promote the development of critical thinking skills and improve patient outcomes. [J Nurs Educ. 2019;58(4):214–220.]

The critical thinking ability of the nurse is essential for improving patient outcomes in an increasingly fast and complex environment. This has led to a growing expectation for nursing programs to produce new graduates who demonstrate competence in critical thinking (Chenot & Daniel, 2010; Fesler-Birch, 2005). To structure and evaluate competence, programs often thread critical thinking skills within their student learning outcomes (SLOs). Yet, even with increased attention to critical thinking processes, these skills remain underachieved (Paul, 2014). By clarifying the key components of critical thinking, nursing programs will be better able to operationalize attributes associated with this type of clinical decision making throughout course, level, and program completion SLOs.

Background

Nursing faculty and leadership at a private midwestern U.S. university identified the lack of conceptual clarity and an operational definition as causative factors in trends of deficiency related to critical thinking noted among students. A subcommittee was formed to examine the application and evaluation of critical thinking throughout the curriculum, as well as to review the curricular SLOs. It became obvious that the lack of an accepted, operational definition had a direct impact on the quality of the SLOs, which were based primarily on the nursing process and had vague references to critical thinking skills. The subcommittee sought to find a consistently accepted definition to provide universal language and to develop clear, measurable outcomes related to the critical thinking skills. A concept analysis was determined to be the best method by which to achieve these outcomes.

It must be noted that other terms are frequently used in nursing that are similar, but not synonymous, to critical thinking. These include clinical reasoning, clinical judgment, and decision making. It was determined that critical thinking was the broadest of these phrases and represents the initial cognitive analysis that is used in clinical reasoning and clinical judgment to make practice-based decisions and select appropriate interventions (Victor-Chmil, 2013). The decision to use the broader term of critical thinking for this concept analysis also allowed for the inclusion of an interdisciplinary voice in this work.

Method

The concept analysis followed the method developed by Walker and Avant (2011) of selecting a concept, stating a purpose, identifying uses of the concept in literature, determining defining attributes, constructing cases, identifying antecedents, consequences, and empirical referents. The literature review used peer-reviewed articles, as recommended by Risjord (2009), to determine the scientific, rather than casual, usage of the concept. To integrate the current interdisciplinary understanding of critical thinking, the following databases were searched: ATLA Religion Database®, Business Source Complete, ERIC, CINAHL®, MEDLINE®, PsycINFO®, and SocINDEX. The electronic search criteria applied the usage of the phrase critical thinking in the title of articles published in peer-reviewed journals between 2007 and 2018. This search resulted in 96 articles that met search criteria. The titles were reviewed to remove duplicates, resulting in 71 remaining articles that progressed to the abstract review. Inclusion criteria comprised the following: articles that identified critical thinking as a primary focus and supplied quality definitions and/ or attributes of critical thinking. This resulted in 28 articles that were initially included in the analysis. Additional sources were added throughout the analysis process to aid in making connections between critical thinking and SLO development.

Uses of the Concept in Literature

The study of critical thinking has resulted in key definitions that have become widely accepted and applied. These definitions have been cited directly or adapted to fit a specific, disciplinary context. Facione (1990) described critical thinking as “a 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 that judgment is based” (p. 2). Those who think critically are described by Paul and Elder (as cited in Foundation for Critical Thinking, n.d.), as demonstrating “self-directed, self-disciplined, self-monitored, and self-corrective thinking” (para. 12). Even when adapted, key themes remain identifiable and are frequently noted throughout the literature.

Interdisciplinary perspectives on critical thinking reveal consistent definition themes. In works on education, there is a distinct focus on the development of thinking skills, which encompasses a shift in teaching from memorization to practical application (Flores, Matkin, Burbach, Quinn, & Harding, 2012). Weissberg (2013), however, argued against the value of teaching critical thinking. As a university professor, he said that critical thinking ability is linked to a student's cognitive ability or IQ. There is ambiguity in theological circles regarding the value of critical thinking, with some questioning the reliability of its philosophical roots (Florence, 2014). Critical thinking in fine arts specialties focuses on the attributes of creativity, exploration, application, and reflection (Kokkidou, 2013).

Along with the previous definitions, critical thinking is often described by its attributes. These attributes seemingly describe everything from personality traits to processing skills and are organized in a variety of ways. The most common method describes two codependent skill sets: affective skills and cognitive skills. The habits of the mind—or affective components—include creativity, self-confidence, commitment, integrity, and self-reflection (Chan, 2013; Paul, 2014). These habits must be combined with cognitive or processing skills for critical thinking to be effective. Paul (2014) offered a concise list of these skills, and identifies “analysis, interpretation, self-regulation, inference, explanation, and evaluation” (p. 1357) as being pertinent to the critical thinking process.

In health care, critical thinking is often applied through the process of clinical reasoning. Alfaro-LeFevre (2017) described critical thinking as “purposeful, informed outcome-focused thinking” (p. 6). This thinking is the underpinning for both clinical reasoning and clinical judgment. Krupat et al. (2011) described the medical perspective on critical thinking as having both cognitive ability and affective components, which results in practitioners who will investigate, question, and thoughtfully make decisions. Because of the importance of critical thinking ability among practice disciplines, these skills must be intentionally integrated into the curriculum (Cassum, Gul, & Partillo-McGrath, 2015).

There is agreement in institutions of higher learning that critical thinking is a desired outcome. However, some argue that the lack of a clear definition hinders the pedagogy of critical thinking (Florence, 2014). Rowles, Morgan, and Burns (2013) proposed that the definition frames how the concept will be taught. Yet, as cited in Moore (2013), others have resisted the idea of a single unitary definition because critical thinking, by its nature, encompasses a variety of cognitive modes. Throughout this initial literature review, considerable areas of agreement were found. Definitions, although unique, had consistent themes and terms. Affective and cognitive components were combined to result in critical thinking. There was a consistent judgment, outcome, or result that occurred from the thought. These findings are integrated to identify the attributes, antecedents, and consequences consistently required for critical thinking to occur.

Defining Attributes

Critical thinking has historically been measured as a cognitive skill. However, a review of the literature revealed the complexity of this concept. Rather than concise definitions, lengthy discussions were related to patterns of thinking and extensive lists of diverse attributes. According to Walker and Avant (2011), identification of the defining attributes of a concept allows the researcher to determine criteria that differentiate this concept from another. It became evident from the literature that the various processing skills, which allow the thinker to mobilize thought into action, were the defining attributes of this concept. The framework for categorizing these attributes was modified from Chan's (2013) work and includes three categories: gathering and investigating, analyzing and evaluating, and applying and problem solving.

Gathering and Investigating

Gathering and investigating is the initial step the critical thinker takes to obtain relevant data from a variety of sources. This evidence becomes the foundation for the subsequent steps in the process (Banning, 2006; Chan, 2013; Kokkidou, 2013; Weimer, 2011). According to the literature, critical thinkers have the courage to pose relevant questions, search a variety of sources, and evaluate the truth and validity of the findings (Banning, 2006; Facione, 1990; Gupta & Upshur, 2012; Kokkidou, 2013; Papathanasiou, Kleisiaris, Fradelos, Kakou, & Kourkouta, 2014; Paul, 2014). This in-depth investigation is consistently attributed to attitudes of inquisitiveness or curiosity (Alfaro-LeFevre, 2017; Banning, 2006; Facione, 1990; Kerby, 2008; Kokkidou, 2013; Paul, 2014). Thinkers are not passive in this inquiry; rather, they strive to identify relevant data based on the context (Alfaro-LeFevre, 2017). This type of investigation results in the identification of all relevant data that can be used for the subsequent steps.

Analyzing and Evaluating

Analysis and evaluation in critical thinking involves taking the data gathered and processing it in such a way that allows for determination of value and significance in its relation to the particular situation (Banning, 2006). During this process, the nurse examines the data that have been obtained, evaluates the data for accuracy and relevance, and reflects on whether their own personal bias is influencing the situation (Banning, 2006; Flores et al., 2012). It is also during this phase that the nurse begins to justify why certain data hold more meaning or weight than other data, and why they believe their decision will produce the best outcome (Kaddoura, 2013; Miller, Tice, & Harnek Hall, 2011). Ultimately, the goal of analysis and evaluation is that the nurse is able to choose the best course of action and achieve the best outcomes for the patient (Kaddoura, 2013).

Applying and Problem Solving

Problem solving is an integral part of the critical thinking process that requires a response (Banning, 2006). This response requires some risk taking on the part of the nurse, as the need to make a decision may be immediate and require rapid processing of information (Kaddoura, 2013). Therefore, the nurse must manifest some degree of confidence, so that the problem-solving phase does not further jeopardize the patient. This can occur if the patient's condition continues to decline while the nurse is struggling to make a decision. If the nurse is able to act proactively, rather than reactively, the patient not only avoids potential complications, but the nurse is better able to problem solve under less stressful conditions (Kaddoura, 2013).

Critical Thinking Cases

Following is a situation with three cases which apply the defining attributes of critical thinking in varying ways. The model case provides a complete picture of the application of the concept, whereas the borderline case contains some, but not all, of the defining attributes. The contrary case excludes all the attributes, thereby providing a clear picture of what the concept is not (Walker & Avant, 2011).

Background/Situation

Mrs. Gonzales is a 76-year-old woman admitted to the general medical floor status after ischemic stroke, which has left her both aphasic and dysphasic. She has a past medical history of diabetes and hypertension and is obese. She is currently ordered to have nothing by mouth (NPO) and is receiving 5% dextrose in 0.45% normal saline, with 20 mEq of potassium chloride per liter of fluid at 75 mL/hr through a triple lumen peripherally inserted central catheter (PICC). She has a naso-gastric tube (NGT) that is currently set to low intermittent suction. She is receiving telemetry, which reveals a normal sinus rhythm. Mrs. Gonzales has been ordered morning blood work, which the night shift nurse draws from the PICC line, and the results include a potassium level of 5.8 mEq/L; all other laboratory results are within normal limits, including her blood urea nitrogen and creatinine. The night shift nurse reports the level to the resident on call, who orders 15 g of sodium polystyrene sulfonate via the NGT every 4 hours for a total of four doses, with a repeat potassium level following the fourth dose. The night shift nurse administers the first dose of sodium polystyrene sulfonate prior to giving morning report.

Model Case

Ms. Jones, the day shift nurse, receives report on Mrs. Gonzales regarding the elevated potassium level and subsequent treatment. During the report, Ms. Jones also notes the patient's NPO status, identifies that the patient had a potassium level within normal limits the previous 3 days, no signs of renal impairment, and no additional potassium supplementation other than the 20 mEq/L of fluid running at 75 mL/hr. Not finding any pathophysiological reason for the elevated potassium, Ms. Jones questions the technique used in obtaining the specimen for the bloodwork from the PICC line. Ms. Jones contacts the resident and notifies him of her concerns and receives an order to redraw the potassium level. Per the hospital protocol for obtaining the sample, Ms. Jones turns off the maintenance fluid, flushes the line, and draws the waste and sample from an unused port. The repeat potassium level is 3.5 mEq/L, and the resident discontinues the remaining doses of sodium polystyrene sulfonate. Nurse Jones reports the situation to the charge nurse and nurse educator, so that a review of the appropriate technique for obtaining a blood sample from a central line can be integrated into the next unit meeting.

Borderline Case

Ms. Jones, the day shift nurse, receives morning report regarding the elevated potassium level and subsequent treatment. During report, Ms. Jones notes that the patient is NPO, and that the potassium level is only mildly elevated at 5.8 mEq/L. She becomes concerned that administering the four doses of sodium polystyrene sulfonate is excessive in this situation and could potentially drop the potassium level below normal. Ms. Jones contacts and collaborates with the attending physician, who orders a potassium level after the second dose of sodium polystyrene sulfonate, and instructs Ms. Jones to discontinue the remaining doses if the potassium level is < 4.0 mEq/L. The repeat potassium level after the second dose was reported as 3.4 mEq/L by the laboratory, and the remaining doses of sodium polystyrene sulfonate are discontinued per the physician's order.

Contrary Case

Ms. Jones, the day shift nurse, receives morning report regarding the elevated potassium level and subsequent treatment. Given that sodium polystyrene sulfonate is the common antidote for elevated potassium level, and Ms. Jones views it as the responsibility of the resident to review all of Mrs. Gonzales' history and prior laboratory results, she does not question the order further and delivers the remaining doses of sodium polystyrene sulfonate throughout her 12-hour shift. Mrs. Gonzales is incontinent of loose stool several times throughout the shift, which Ms. Jones recognizes as being a normal adverse effect of the medication. She also notes some slight irregularities in Mrs. Gonzales' telemetry strip but attributes these irregularities as being an artifact caused by turning. After delivering the fourth dose, Ms. Jones redraws the potassium level, which is reported by the laboratory as a critical value of 2.4 mEq/L. The charge nurse also notes that Mrs. Gonzales is now in atrial fibrillation per the telemetry monitor, which is confirmed by a 12-lead electrocardiogram. Mrs. Gonzales is transferred to the coronary care unit for potassium replacement and treatment of her new-onset atrial fibrillation.

Antecedents

Antecedents are the characteristics or factors that must be present for the concept to occur (Walker & Avant, 2011). These characteristics must be taken into account when attempting to teach and improve critical thinking skills. This concept analysis identified three antecedents to critical thinking: self-awareness, self-motivation, and knowledge base.

Self-Awareness

Self-awareness is the ability to recognize one's own preferences, biases, learning styles, strengths, and limitations (Alfaro-LeFevre, 2017). It is represented in the literature by terms such as open mindedness (Banning, 2006; Chan, 2013; Flores et al., 2012; Kerby, 2008), reflection (Banning, 2006; Brudvig, Dirkes, Dutta, & Rane, 2013; Florence, 2014; Kerby, 2008; Kokkidou, 2013; Mundy & Denham, 2008), intellectual humility (Gupta & Upshur, 2012; Kokkidou, 2013; Papathanasiou et al., 2014), intellectual courage (Gupta & Upshur, 2012), flexibility (Chan, 2013; Paul, 2014), self-confidence (Banning, 2006; Flores et al., 2012; Kerby, 2008; Papathanasiou et al., 2014; Paul, 2014), and self-correction (Flores et al., 2012; Kokkidou, 2013).

When thinkers reflect on their thinking, the above characteristics are the result. They develop confidence in what is known, and humility about what is unknown. According to Gupta and Upshur (2012), this is uniquely important in the health care field, where professionals act as part of a team responsible for large amounts of ever-changing evidence. There must be a reliance on coworkers to bring expertise in areas that are not as expertly known by the thinker. Likewise, confidence is imperative, as nurses and physicians sometimes must stand up for unpopular solutions. Similarly, reflection and self-correction go hand in hand. As one reflects on decisions and actions, they can determine new and better ways to respond in the future based on outcomes from the situation.

Self-Motivation

Motivation is an intriguing attribute to analyze. Because critical thinking is an active process that requires self-direction, motivation becomes more apparent than cognitive skill within the literature. It is reflected in the following terms: questioning (Chan, 2013), motivated (Gupta & Upshur, 2012), purposeful (Banning, 2006; Brudvig, et al., 2013; Flores et al., 2012; Mundy & Denham, 2008), self-regulatory (Banning, 2006; Brudvig et al., 2013; Flores et al., 2012; Kokkidou, 2013; Mundy & Denham, 2008; Paul, 2014), inquisitiveness (Banning, 2006; Kerby, 2008; Paul, 2014), curiosity (Banning, 2006; Kokkidou, 2013; Papathanasiou et al., 2014), and perseverance (Kerby, 2008; Papathanasiou et al., 2014; Paul, 2014). One dissenting voice to this discussion was that of Weissberg (2013), who questioned whether or not motivation was enough to influence students who did not possess a certain cognitive ability. Despite this outlier, the consistency in the literature points to the overwhelming importance of self-motivation and curiosity in critical thinking. Thinkers seek to fill in the blanks, find the new evidence, collaborate with others, and find the answers. Critical thinking does not seek the easiest solution, but rather the best.

Knowledge Base

Although self-awareness and self-motivation play key roles in laying the foundation for critical thinking, having a knowledge base on which to draw sound conclusions remains an important part of this process. Benner, Hooper-Kyriakidis, and Stannard (2011) noted that for the beginning student, knowledge acquisition is imperative in order to grasp the relevance of clinical situations. However, critical thinking does not end with this acquisition of knowledge, as the student must then be given the opportunity to use what they have learned in the classroom through clinical and simulation experiences (Benner et al., 2011). The practice of connecting the dots between classroom theory and clinical application is what will ultimately lay the foundation for critical thinking within the new graduate population.

Consequences

The application of critical thinking skills by nurses results in decisions that benefit the overall well-being of a patient. This improved well-being reveals itself in the form of improved patient safety, improved outcomes, and development of a holistic plan of care (Kaddoura, 2013). Nurses also benefit from practicing critical thinking skills, as these skills positively influence job satisfaction (Zurmehly, 2008). Nurses who critically think collaborate more effectively with other health care professionals and tend to exhibit an aura of calmness during stressful situations. This occurs because critically thinking nurses practice expansive thinking, which allows them to gather data in an objective manner, question the status quo, analyze and evaluate the situation, and formulate a plan that best fits the dynamics of the current situation (Kaddoura, 2013). According to Florence (2014), these individuals then begin to “grow in the understanding of the truth” (p. 354) as they strive to deliver the best possible care to their patients, while contributing to the knowledge and skill that is the profession of nursing. As a result, this practice of thinking improves patient outcomes for generations to come.

Discussion

These authors were initially motivated to perform a concept analysis of critical thinking to arrive at a definition that would frame future pedagogy. What the authors discovered instead was the lack of a single concise definition and that developing one may not be a tangible goal. This analysis did help to identify the antecedents and attributes of functional critical thinking, such as the personal traits of curiosity, tolerance for ambiguity, and motivation. Based on conclusions drawn from the literature, the authors believe that these traits can be developed regardless of cognitive ability. However, traditional pedagogy in higher education often focuses on cognitive ability through testing, as it rewards rote memorization but does not achieve complex thinking (Flores et al., 2012).

As a result, the focus for SLOs should be on operational competencies in which the novice nurse takes the time to adequately investigate the situation and then determine the best solution to the problem based on the analysis of that data. The development of critical thinking strategies should be emphasized within curricula. Nurses who are unskilled in critical thinking become reliant on intuitive reflex, which is particularly dangerous for new nurses, who lack the experience and skills needed to perform rapid and prioritized care. This places new graduate RNs at increased risk for errors because they lack the experience necessary to make rapid decisions without first gathering and analyzing data (Acquaviva, Haskell, & Johnson, 2013). Cassum et al. (2015) noted that “critical thinking skills are not completely natural or inherent, rather they are developed through time and learning experiences” (p. 60). Therefore, it is imperative that nursing students are taught the foundational skills needed to successfully implement critical thinking upon graduation.

Curricular Implementation Plan

Moving forward, this concept analysis will be used as a framework to revise SLOs throughout the undergraduate curriculum, beginning with program completion outcomes. These revisions will then be threaded through level, course, lecture, and assignment SLOs. The defining attributes and antecedents, as displayed in Table 1, provide operational descriptors that better clarify the outcomes. An example of a current program completion outcome states, “Graduates will assess health status and health potential, diagnose, plan, implement, and evaluate holistic nursing care with patients and others in the health care setting.” Based on conclusions drawn from the concept analysis, this outcome could be revised to reflect the attributes and antecedents: “Graduates will identify and validate relevant data that will be utilized to identify priority diagnoses and the most effective interventions that will be implemented to achieve positive patient outcomes in collaboration with the patient and others in the health care setting.” The revised SLO can then be used by educators to better guide practices and evaluation strategies.

Summary of Attributes and Antecedents Associated With Critical Thinking

Table 1:

Summary of Attributes and Antecedents Associated With Critical Thinking

Similar steps will be completed in the revision of clinical and simulation evaluation tools. Currently, course SLOs are used as a framework for student evaluation in the clinical and laboratory setting. Revisions will be made to the SLOs based on the antecedents and attributes (Table 1), with additional clarification to the evidence of successful outcome achievement. For example, an entry-level clinical course outcome states, “Students will utilize the nursing process to develop care plans that meet basic care needs for residents in an extended care facility.” Revision of this course SLO could become: “Students will utilize relevant questioning to obtain comprehensive assessment data, which will be clustered to identify two priority problems and associated nursing interventions.” This revision allows faculty to specifically evaluate the interviewing and assessment strategies, beginning interpretation, and linkages between interventions and problem resolution.

Following the outcome revision, a review of learning and evaluation strategies that best fit the updated SLOs will be incorporated. Throughout the literature, certain strategies were frequently cited as being effective in teaching and evaluating these skills. Learning tools such as case studies and simulation provide opportunity for faculty to role model thought processes. It is also recommended to include scenarios that reflect increased technology, human error, and prioritization (Dolansky & Moore, 2013). This challenges students to find solutions to the worst case scenarios. In the clinical setting, this can be done by posing cognitive unmooring questions, which ask students to consider what assessments and interventions should occur to prevent a patient's decline in status (Acquaviva et al., 2013, p. 100). This can be accomplished by providing assignments that challenge students to prioritize care, identify risks, and detect changes to patient status (Dolansky & Moore, 2013). Students need the opportunity to apply content to promote critical thinking development; however, faculty must be mindful of overloading students with assignments that do not facilitate this goal. When SLOs reflect the qualities of motivation, self-reflection, and processing skills, faculty can assess for the functional attributes of critical thinking and improve the development of these skills in students.

Areas for Future Study

As programs continue to strive to facilitate the development of critical thinking within their graduates, it is important to remember that active learning strategies must be used. Thus, the clinical setting does appear to be the most effective environment in which to integrate and evaluate this thinking. In addition, “barriers to implementation, including an already maximized curriculum, a growing faculty shortage, the need for faculty development in the competency content areas, and the generally slow pace of curricular change” (Chenot & Daniel, 2010, p. 561) make it difficult to flip the classroom in such a way that provides small group interaction and feedback from faculty. Therefore, studies that focus on determining which types of activities lay the best foundation for critical thinking skills, as well as which best prepare students for critical thinking, would be extremely beneficial.

Conclusion

Throughout this concept analysis, critical thinking has been found to be a complex, but necessary, skill for newly graduated nurses to obtain. Due to its strong affiliation with improved patient outcomes, both employers and nursing faculty seek to develop ways to enhance critical thinking skills for new graduates. It has been demonstrated throughout this analysis that a person who thinks critically recognizes situations requiring further thought and is both self-aware and motivated to engage in cognitive processing skills that result in a decision that improves patient outcomes. A faculty member's ability to measure the functional development of these skills can be achieved by focusing on the core attributes of self-motivation, self-reflection, knowledge development, and processing skills. By focusing on the development of these key attributes, nursing faculty may be better prepared to create SLOs that operationalize critical thinking. The authors conclude that operational critical thinking can be developed and, for the sake of patient well-being, must become the focus of pedagogical practices in nursing.

References

  • Acquaviva, K., Haskell, H. & Johnson, J. (2013). Human cognition and the dynamics of failure to rescue: The Lewis Blackman case. Journal of Professional Nursing, 29, 95–101. doi:10.1016/j.profnurs.2012.12.009 [CrossRef]
  • Alfaro-LeFevre, R. (2017). Critical thinking, clinical reasoning, and clinical judgment: A practical approach (6th ed.). Philadelphia, PA: Elsevier.
  • Banning, M. (2006). Nursing research: Perspectives on critical thinking. British Journal of Nursing, 15, 458–461. doi:10.12968/bjon.2006.15.8.20966 [CrossRef]
  • Benner, P., Hooper-Kyriakidis, P. & Stannard, D. (2011). Clinical wisdom and interventions in acute and critical care: A thinking-in-action approach (2nd ed.). New York, NY: Springer. doi:10.1891/9780826105745 [CrossRef]
  • Brudvig, T.J., Dirkes, A., Dutta, P. & Rane, K. (2013). Critical thinking skills in healthcare professional students: A systematic review. Journal of Physical Therapy Education, 27(3), 12–25. doi:10.1097/00001416-201307000-00004 [CrossRef]
  • Cassum, S.H., Gul, R. & Portillo-McGrath, J. (2015). Facilitators and deterrents of critical thinking in classrooms: A multi-disciplinary perspective in higher education in Karachi, Pakistan. International Journal of Nursing Education, 7(2), 60–64. doi:10.5958/0974-9357.2015.00075.6 [CrossRef]
  • Chan, Z.C. (2013). A systematic review of critical thinking in nursing education. Nurse Education Today, 33, 236–240. doi:10.1016/j.nedt.2013.01.007 [CrossRef]
  • Chenot, T.M. & Daniel, L.G. (2010). Frameworks for patient safety in the nursing curriculum. Journal of Nursing Education, 49, 559–568. doi:10.3928/01484834-20100730-02 [CrossRef]
  • Dolansky, M.A. & Moore, S.M. (2013). Quality and Safety Education for Nurses (QSEN): The key is systems thinking. Online Journal of Issues in Nursing, 18(3), 1.
  • Facione, P.A. (1990). Critical thinking: A statement of expert consensus for purposes of educational assessment and instruction (Delphi Report No. ED315423). Millbrae, CA: The California Academic Press.
  • Fesler-Birch, D.M. (2005). Critical thinking and patient outcomes: A review. Nursing Outlook, 53, 59–65. doi:10.1016/j.outlook.2004.11.005 [CrossRef]
  • Florence, D.C. (2014). A history of critical thinking as an educational goal in graduate theological schools. Christian Higher Education, 13, 352–361. doi:10.1080/15363759.2014.949164 [CrossRef]
  • Flores, K.L., Matkin, G.S., Burbach, M.E., Quinn, C.E. & Harding, H. (2012). Deficient critical thinking skills among college graduates: Implications for leadership. Educational Philosophy and Theory, 44, 212–230. doi:10.1111/j.1469-5812.2010.00672.x [CrossRef]
  • Foundation for Critical Thinking. (n.d.). Defining critical thinking. Retrieved from http://www.criticalthinking.org/pages/defining-critical-thinking/766
  • Gupta, M. & Upshur, R. (2012). Critical thinking in medicine: What is it?Journal of Evaluation in Clinical Practice, 18, 938–944. doi:10.1111/j.1365-2753.2012.01897.x [CrossRef]
  • Kaddoura, M. (2013). New graduate nurses' perceived definition of critical thinking during their first nursing experience. Educational Research Quarterly, 36(3), 3–21.
  • Kerby, L.L. (2008). Critical thinking in nursing. Leader to Leader: Nursing Regulation & Education Together, 1–2. Retrieved from https://www.ncsbn.org/2008_spring.pdf
  • Kokkidou, M. (2013). Critical thinking in school music education: Literature review, research findings, and perspectives. Journal for Learning through the Arts, 9, 1–18. doi:10.21977/D9912644 [CrossRef]
  • Krupat, E., Sprague, J.M., Wolpaw, D., Haidet, P., Hatem, D. & O'Brien, B. (2011). Thinking critically about critical thinking: Ability, disposition or both?Medical Education, 45, 625–635. doi:10.1111/j.1365-2923.2010.03910.x [CrossRef]
  • Miller, S., Tice, C. & Harnek Hall, D. (2011). Bridging the explicit and implicit curricula: Critically thoughtful critical thinking. Journal of Baccalaureate Social Work, 16, 33–45.
  • Moore, T. (2013). Critical thinking: Seven definitions in search of a concept. Studies in Higher Education, 38, 506–522. doi:10.1080/03075079.2011.586995 [CrossRef]
  • Mundy, K. & Denham, S.A. (2008). Nurse educators—Still challenged by critical thinking. Teaching and Learning in Nursing, 3(3), 94–99. doi:10.1016/j.teln.2008.02.007 [CrossRef]
  • Papathanasiou, I.V., Kleisiaris, C.F., Fradelos, E.C., Kakou, K. & Kourkouta, L. (2014). Critical thinking: The development of an essential skill for nursing students. Acta Informatica Medica, 22, 283–286. doi:10.5455/aim.2014.22.283-286 [CrossRef]
  • Paul, S.A. (2014). Assessment of critical thinking: A Delphi study. Nurse Education Today, 34, 1357–1360. doi:10.1016/j.nedt.2014.03.008 [CrossRef]
  • Risjord, M. (2009). Rethinking concept analysis. Journal of Advanced Nursing, 65, 684–691. doi:10.1111/j.1365-2648.2008.04903.x [CrossRef]
  • Rowles, J., Morgan, C.M. & Burns, S. (2013). Faculty perceptions of critical thinking at a health sciences university. Journal of the Scholarship of Teaching and Learning, 13(4), 21–35.
  • Victor-Chmil, J. (2013). Critical thinking versus clinical reasoning versus clinical judgment: Differential diagnosis. Nurse Educator, 38, 34–36. doi:10.1097/NNE.0b013e318276dfbe [CrossRef]
  • Walker, L.O. & Avant, K.C. (2011). Strategies for theory construction in nursing (5th ed.). Norwalk, CT: Appleton & Lange.
  • Weimer, M. (2011). Critical thinking: Definitions and assessments. Teaching Professor, 25(10), 8.
  • Weissberg, R. (2013). Critically thinking about critical thinking. Academic Questions, 26, 317–328. doi:10.1007/s12129-013-9375-2 [CrossRef]
  • Zurmehly, J. (2008). The relationship of educational preparation, autonomy, and critical thinking to nursing job satisfaction. The Journal of Continuing Education in Nursing, 39, 453–460. doi:10.3928/00220124-20081001-10 [CrossRef]

Summary of Attributes and Antecedents Associated With Critical Thinking

Attributes: Associated DescriptorsAntecedents: Associated Descriptors
Gathering and investigating: Identification of all relevant data as a foundation for decision making; relevant questioning; evaluation of truth and validity; inquisitive and curious; active inquirySelf-awareness: Recognition of one's own preferences, strengths and weaknesses; open-minded; reflective; intellectual humility; flexibility; self-confidence; self-correction
Analyzing and evaluating: Determination of the best course of action based on data; examination of data; evaluation of personal bias; prioritization of data; prediction of outcomes of various decisionsSelf-motivation: Internal desire to seek answers to questions, find new evidence, and collaborate with others; purposeful questioning; self-regulation; curiosity; perseverance
Applying and problem-solving: Implementation of the determined best course of action in order to achieve the best outcome; risk-taking; rapid processing; confidence; proactiveKnowledge base: Acquisition of knowledge needed to draw sound conclusions; connect theory and practice; utilization of learned information
Authors

Dr. Cooke is Clinical Instructor of Nursing, Ms. Stroup is BSN Program Director, School of Nursing and Health Sciences, Malone University, Canton, and Ms. Harrington is Registered Nurse, Emergency Department, Cleveland Clinic Union Hospital, Dover, Ohio.

This study was supported by Malone University, Canton, Ohio.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Lori Cooke, MEd, RN-BC, Clinical Instructor of Nursing, School of Nursing and Health Sciences, Malone University, 2600 Cleveland Ave NW, Canton, OH 44709; e-mail: lcooke@malone.edu.

Received: July 03, 2018
Accepted: January 08, 2019

10.3928/01484834-20190321-05

Sign up to receive

Journal E-contents