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Tanner 2005 Critical Thinking.pdf

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I f ever there were a hot topic in nursing education, it would be critical thinking. Since 1993, the Journal of Nursing Education has published six issues focused on critical thinking in nursing, a total of more than 50 articles. And for each article published, another three to four were submitted but not accepted for publication. Clearly, critical thinking has captured our attention and interest. What have we learned? The articles on critical thinking that have been published in JNE during the past 12 years have included several integrative reviews of the literature, reports of original research, and descriptions of education- al innovations addressing four major questions. Here, I offer my analysis of the answers to these questions, and some thoughts about future directions. What Is Critical Thinking? Definitions of critical thinking have been offered through integrative reviews of non-nursing literature, philosophic analyses, conceptualizations based on nursing process and similar discipline-specific notions of thinking, Delphi studies of nursing faculty perspectives, or qualita- tive studies of educatorsÕeducational practices. Scheffer and Rubenfeld (2000) reported a Delphi study of critical thinking, with a conceptualization that included both skills of critical thinking and habits of mind. This was an impor- tant beginning step in providing a discipline-specific per- spective on critical thinking. Interestingly, in the 5 years since this important study was completed, we have yet to see publications in which the new conceptualization derived from the Delphi study has been used to guide instrument development or further research in nursing education. In a provocative philosophic analysis, Ford and Profetto- McGrath (1994) contrasted competing views of critical thinking (an instrumentalÐproblem-solving view not unlike that generated by the Scheffer-Rubenfeld Delphi study, and a praxis view). These authors argued for a prax- is in which critical thinking is conceptualized as challeng- ing taken-for-granted assumptions and practices and requiring action, involvement, and risk-taking. It is the type of critical thinking that exposes the interconnections among health care policy and political and economic inter- ests, and enables nurses to recognize when they are being used to support the interests of powerful others. It is the type of critical thinking that asks the key question: Who benefits and whose ends are being met by particular nurs- ing actions? It is more like the critical thinking John Dewey (1916) described as requisite for citizenship and democracy. In the past 12 years, few studies have taken up this view of critical thinking. How Can We Best Measure Critical Thinking? Part of the conceptualization issue may derive from the measures available to study critical thinking. I know this may seem like the cart pulling the horse, but letÕs examine the evidence. All of the studies of critical thinking in nurs- ing that have examined the relationships between critical thinking and other variables (e.g., clinical decision making, NCLEX-RN ¨ performance, practice performance) have used one of many standardized measures, most frequently the Watson-Glaser Critical Thinking Appraisal (Watson & Glaser, 1952) and, more recently, the California Critical Thinking Disposition Inventory (Facione & Facione, 1992). Both are measures of general critical thinking, drawing on definitions developed outside of the nursing context. These measures, while reportedly reliable and valid measures of ship to important aspects of nursing practice. What Is the Relationship of Critical Thinking to Clinical Practice? Literature reviews reported by Kintgen-Andrews (1991), Hicks (2001), and Staib (2003) have shown that there is no consistent relationship between measures of critical thinking and clinical decision-making or clinical judgment. These authors suggested at least two explana- tions for these findings: that the measures of clinical judg- ment and/or critical thinking are inadequate, and more important, that there may actually be no relationship between general skills of critical thinking and the more dis- cipline-specific clinical judgment. Other studies have examined the relationship between NCLEX-RN performance and general measures of critical thinking. For example, in this issue, Giddens and Gloeckner confirm the findings of previous studiesÑthat February 2005,Vol.44,No.2 47 What Have We Learned About Critical Thinking in Nursing? EDITORIAL

Journal of Nursing Education significant differences exist in general critical thinking between those who pass the NCLEX-RN and those who fail. What Are Effective Instructional Strategies for Improving StudentsÕCritical Thinking Skills and Dispositions? Among the more discouraging study results are those that have repeatedly demonstrated no significant relation- ship between nursing education and general critical think- ing skills. In fact, in several studies, such as the one by Nokes, Nickitas, Keida, and Neville in this issue, critical thinking performance has declined following a specific edu- cational intervention, or following the full nursing program (Staib, 2003). Many reports published during the past decade suggest that particular teaching strategies improve critical thinking but do not offer evidence to support the claim. Many explanations may account for the failure to demonstrate significant improvement in critical thinking as a result of instruction, including: ¥The measures of critical thinking are not valid or are insufficiently sensitive to actual changes. ¥The length, power, or focus of instruction is insuffi- cient to produce changes (i.e., it needs to be continued for a longer period of time). ¥Critical thinking is a fixed trait not subject to improvement, particularly in adults. ¥Nursing instruction has not been adequately devel- oped to cause improvement in critical thinking. Conclusion So what have we learned about critical thinking? The evidence to date suggests: ¥Critical thinking and clinical thinking (i.e., decision making, clinical judgment) are different constructs, and the evidence does not support a relationship between these skills. ¥Our measurement of critical thinking has not kept pace with our conceptualizations of it. ¥We have not been able to demonstrate a significant improvement in critical thinking as a result of instruction. I think it is time to move on. Continuing to use the term critical thinking to refer to an important educational out- come may no longer serve us. I believe nurse educators want their graduates to be capable of general critical think- ing as praxis, that is, to demonstrate the capability to ana- lyze assumptions, challenge the status quo, recognize limi- tations in health care, and take action to improve it. We can work with our colleagues in liberal arts to create curricula that can help students gain such skills. But we also want our graduates to be capable of clinical thinking, which involves skills that may be unrelated to critical thinking. These are the skills of clinical judgment and decision making, and they require solid theoretical knowledge and the ability to notice clinical signs, interpret observations, respond appropriately, and reflect on actions taken. Studies of nursing-specific clinical thinking and health care-specific critical thinking are essentialÑto examine how students develop these skills, what they look like in professional practice, how studentsÕperformance of them can be assessed, and how their learning of the skills can be supported. References Dewey, J. (1916). Democracy and education. New York: Macmillan. Facione, P.A., & Facione, N.C. (1992b). Test manual: The California Critical Thinking Disposition Inventory. Milbrae, CA: California Academic Press. Ford, J.S., & Profetto-McGrath, J. (1994). Amodel for critical thinking within the context of curriculum as praxis. Journal of Nursing Education, 33, 341-344. Hicks, F.D. (2001). Critical thinking:Toward a nursing science per- spective. Nursing Science Quarterly, 14 (1), 14-21. Kintgen-Andrews, J. (1991). Critical thinking and nursing educa- tion: Perplexities and insights. Journal of Nursing Education, 30, 152-157. Scheffer, B.K., & Rubenfeld, M.G. (2000). Aconsensus statement on critical thinking in nursing. Journal of Nursing Education, 39, 352-359. Staib, S. (2003). Teaching and measuring critical thinking. Journal of Nursing Education, 42, 498-508. Watson, G., & Glaser, E.M. (1952). Watson-Glaser Critical Thinking Appraisal. New York: Harcourt, Brace and World. Christine A.Tanner,PhD,RN,FAAN Editor EDITORIAL