Assessment of critical thinking in nursing: How should critical thinking be assessed in the clinical setting?
Table of Contents List of Tables vi CHAPTER 1. INTRODUCTION 1 Introduction to the Problem 1 Background of the Study 2 Statement of the Problem 4 Purpose of the Study 5 Research Questions 5 Significance of the Study 6 Definition of Terms 7 Assumptions and Limitations 9 Theoretical Framework 11 Nature of the Study 14 Organization of the Remainder of the Study 16 CHAPTER 2. LITERATURE REVIEW 17 Introduction 17 Historical Perspective of Nursing 18 Critical thinking 22 Assessment 28 Critical Thinking Assessment Tools in Nursing 34 The Delphi Research Method 38 Conclusion 40
CHAPTER 3. METHODOLOGY 42 Research Design 44 Data Analysis 48 Limitations of Methodology 49 CHAPTER 4. DATA COLLECTION AND ANALYSIS 50 Introduction 50 Data Analysis 50 Results 73 Summary 74 CHAPTER 5. RESULTS, CONCLUSIONS, AND RECOMMENDATIONS 76 Introduction 76 General Implications 83 Discussion of results 84 Recommendations for Future Studies 87 Conclusion 88 REFERENCES 90 APPENDIX A. First Round Questions Data 98
APPENDIX B. Responses Round One Data 100 APPENDIX C. Round One Themes Data 111 APPENDIX D. Round One Themes with Round Two Questions Data 113 APPENDIX E. Round Two Results Data 117 APPENDIX F. Round Three to First Round Data 125
APPENDIX G. Other definitions 128 APPENDIX H Participants 129
List of Tables Table 1. Round One Question 1, Themes and Frequencies 53
Table 2. Round One Question 2, Themes and Frequencies 55 Table 3. Round One Question 3, Themes and Frequencies 56 Table 5. Round One Question 5, Themes and Frequencies 58
Table 6. Round One Question 6, Themes and Frequencies 59
Table 7. Round One Question 7, Themes and Frequencies 59
Table 8. Round One Question 8, Themes and Frequencies 60
Table 9. Round Two Question 1, Initial Premise Statements & Reponses 61
Table 10. Round Two Question 2, Initial Premise Statements & Reponses 62
Table 11. Round Two Question 3, Initial Premise Statements & Reponses 63
Table 12. Round Two Question 5, Initial Premise Statements & Reponses 65
Table 13. Round Two Question 6, Initial Premise Statements & Reponses 66
Table 14. Round Two Question 2, Initial Premise Statements & Reponses 66
Table 15. Round Two Question 3, Initial Premise Statements & Reponses 67
Table 16. Round Three Verification Data Question 1 69
Table 17. Round Three Verification Data Question 2 69 Table 18. Round Three Verification Data Question 5 69
CHAPTER 1. INTRODUCTON It is 2 a.m, and a nurse is quietly making an hourly round to check on patients. Two of them call out requesting immediate help. What does the nurse do? Potentially, this decision could have life changing consequences for the patients and the nurse. The ability to think critically and make judgments is essential for this nurse to ensure quality care for the patient. As critical thinking is an essential component of effective nursing practice, it is necessary for nurse educators to understand the process and be able to assess the student‟s ability to do so. Critical thinking as it relates to nursing can be defined as an essential component of professional accountability and quality nursing care. Critical thinkers in nursing exhibit these habits of the mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance and reflection. Critical thinkers in nursing practice the cognitive skills of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting and transforming knowledge. (Scheffer & Rubenfeld, 2000, para. 45) Unfortunately, accurate and valid assessment of critical thinking has not evolved as fast as definitions of the concept have. Many nursing education programs have not been able to show an improvement in the ability of nursing students to think critically regardless of implementing a variety of instructional strategies and curricula designed to accomplish this goal. Thus, research on critical thinking specific to nursing in the clinical setting is essential. Questions that need further investigation include; how do students develop critical thinking skills? What behaviors or dispositions indicate critical thinking? And how are these student performances assessed?
Background of the Study Traditionally, the format of nursing courses is twofold. One component, didactic education, is related to nursing concepts and theory and occurs in the classroom setting. A second component, pragmatic instruction, is related to the application of nursing skills and occurs in a variety of clinical settings. In a related manner, the theoretical basis of critical thinking education starts in the classroom, while the application of critical thinking or the transfer of knowledge to nursing practice occurs in the clinical learning environment. The clinical setting is an educational environment in a health care facility that requires unique instructional and assessment strategies (Brown, Collins & Duguid, 1989). For example, direct patient care allows student nurses to apply and transfer their learning from a theoretical, abstract level to real life situations. Each state has specific criteria or competencies. Performance or demonstration of these competencies must be performed in a clinical situation and involves interactions between various people in a spontaneous manner, not in the scripted manner of a classroom. Since a significant amount of nursing learning occurs at the clinical site, nursing education programs are required to ensure that assessment in this variety of settings is competent, valid and reliable. Clinical competencies that are hard to define or have complex definitions, such as critical thinking, are often assessed by inference through written projects or multiple choice examinations. If the student passes the assignment, it will be inferred that he or she is competent to think critically. There are significant problems assessing critical thinking with a written paper or multiple choice exams. For example, specific physical dispositions, such as body position of the student, associated with critical thinking, cannot be demonstrated on a written paper. These
written assessment methods do not directly measure the ability of the student nurse to “think on her feet” in a clinical setting, but they continue to be used. Problems associated with patient care do not present themselves in a multiple choice format with time for reflection and changing answers. Assessment of learning in a specific concept area is a systematic method to provide a range of information. This information is collected in a specific environment, such as the clinical learning situation. Critical thinking has been considered a nursing competency since 1997 (Shirrell, 2008). Today, students must demonstrate mastery of the related skills and dispositions in both the classroom and clinical settings before they graduate. Currently, the most common assessment of critical thinking in the clinical learning environment is a nursing process paper. This paper, based on nursing taxonomy such as The North American Nursing Diagnosis Association (NANDA), is designed to show the thinking process through a linear step-by-step progression. The nursing process paper does not demonstrate the complex conceptual process of critical thinking as needed by today‟s nurses. Over time the use of written nursing process papers has increased. However, this has become a prescriptive exercise involving minimal problem solving. Critical thinking is more than a linear sequential process; it is a dynamic circular transformation of data or didactic learning into knowledge with practical application. Since critical thinking is a cognitive process that cannot be directly observed, the purpose of this study was to determine the behaviors or outward visible signs that might allow the nurse educator to assess the student‟s level of critical thinking. Much has been written about critical thinking. No one questions the importance of this concept; however, nursing continues to need research data to provide the evidence based best practice on the assessment of clinical learning. This study
provided additional information by emphasizing several key points. These include the need for a variety of assessment methods, education of clinical faculty members and the need for strategies to handle the variety of clinical learning situation. Statement of the Problem Assessment of critical thinking in the clinical learning experiences provide unique challenges. There is a gap and lack of consensus, in the current research, regarding how critical thinking must be assessed in the clinical setting. This study provided clarity regarding the instruction and assessment of critical thinking in the clinical nursing environment. Using the Delphi method, a panel of nurse educators reached consensus to define the characteristics of evidence based procedure or process for the assessment of critical thinking skills of nursing students in the clinical setting. How do instructors know learning has occurred? What does the process of thinking look like? Nurse educators are responsible for validating that the student nurse is able to think critically and make evidence-based nursing decisions. Further, the nurse educators defined the observable behavioral indicators of critical thinking that nursing students must exhibit in the clinical setting. The cognitive process of thinking is not always directly observable, but each student exhibits characteristics that imply thinking. Finally, the panel defined the unique characteristics of the clinical setting that require students to use critical thinking skills. Do nursing students graduate with critical thinking skills that meet the minimum competency level needed by the healthcare community? The national licensure examination is considered by most nursing programs as the assessment method to demonstrate this competency; however, reports from employers and new graduate nurses show that the current educational systems have not prepared graduate nurses to critically think in the clinical setting. Allen, Rubenfeld, and
Scheffer (2004) asserted that there is a low correlation between critical thinking in the clinical setting and performance on standardized examinations. Developing critical thinking has been a major concern in nursing education; however, baccalaureate (BNS) and associate degree (AD) nursing students continue to graduate without the critical thinking skills necessary to begin safe and high quality nursing practice. Practical application of learning, including critical thinking, occurs in the clinical setting. Nursing students need to demonstrate critical thinking in a clinical setting and the assessment must accurately and reliably measure this competency. To provide evidence of nursing students‟ competency in critical thinking, nurse clinical educators need to accurately assess the student‟s demonstration of the learning outcomes, with validity and reliability. Purpose of the Study This Delphi study was conducted to provide clarity and generate best practice premise statements regarding the assessment of critical thinking in the clinical nursing environment. A panel of expert nurse educators worked to reach consensus on the characteristics of a process or evidence based procedure used for critical thinking assessment in the clinical setting. Further, the nurse educators defined the observable behavioral indicators of critical thinking that nursing students must exhibit in the clinical setting. Finally, the panel defined the unique characteristics of the clinical setting that require students to use critical thinking skills. Research Questions Three major concepts are involved in this study: assessment of critical thinking, the clinical learning situation and critical thinking itself. These concepts play key roles in nursing students‟ learning. For this study the general or main concepts transformed into research questions are,
1. What are the characteristics of evidence based procedure(s), or a process for the assessment of critical thinking skills of nursing students in the clinical setting as described by experts in the field? (What is the „best practice‟ for assessment of critical thinking skills for nursing students in the clinical setting?) 2. What are the observable behavioral indicators of critical thinking among nursing students in the clinical setting? 3. What are the unique characteristics of the clinical setting that require students to use critical thinking skills? Significance of the Study The significance of this study is to provide further evidence-based research into how to accomplish the assessment of critical thinking necessary for nursing practice. Critical thinking as a skill and career long learning technique is valued by the nursing profession, and it is needed for nurses to succeed in practice. Bachelor of Science in Nursing (BSN) and Associate Degree (AD) nursing programs are evaluated in part on outcomes such as the students‟ ability to think critically. To determine whether they are succeeding in developing critical thinking capabilities in their graduates, nurse educators need effective assessment methods and tools. The current assessment methods do not provide reliable, valid and testable methods of ensuring that nursing students are capable of critical thinking. A working definition of critical thinking in nursing has been established, but it has not been adopted as a professional standard. A consensus of professional nurses and nurse educators regarding the assessment method of critical thinking in the clinical setting would provide the next step in improving critical thinking in nursing education programs. By accurately assessing a student‟s level of critical thinking as
part of a formative assessment, student remediation and instructional changes could be provided prior to completion of the nursing program. This study was designed to better define characteristics that comprise effective assessment of the critical thinking skills of student nurses in the clinical setting. By using the knowledge provided by the panel of experts. Thus, this study synthesized, analyzed, compared and refined earlier work to produce a set of premise statements. This included recommendations, or best practice ideas, concerning the assessment of nursing students‟ critical thinking in the clinical setting. Definition of Terms Assessment: a formal or informal process that involves a purposeful effort to gain information regarding the degree a student has attained learning outcomes. It may occur during the learning, (formative assessment), or at the conclusion of the learning, (summative assessment). Assessments are linked to learning objectives and should be planned from the beginning of the educational curriculum development process (Gronlund, 2006). Clinical sites: a formal or informal situation that engages the nursing student, the instructor and a patient in a healthcare setting. Consensus: an agreement reached by a group through a process of opinion sharing, dialogue, and deliberation. A consensus is not necessarily a 100% agreement but a decision that could be supported by the group. Consensus will be established when 80% of the participants agree or somewhat agree. For this study, n=12 so 9.6 or 10 participants that agree will meet consensus.
Critical thinking: a disciplined, self-directed cognitive process leading to high quality decisions and judgments through the analysis, assessment and reformulation of thinking (Giancarlo & Facione, 2007). Dispositions (habits of the mind): behaviors that are reliably linked to specific cognitive and affective processes. These dispositions include perseverance, open-mindedness, flexibility, confidence, creativity, inquisitiveness, reflection, intellectual integrity, intuition and contextual perspective (Scheffer & Rubenfeld, 2000). Habits of the mind: the cognitive skills of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting, confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open- mindedness, perseverance and reflection, and transforming knowledge. (p. 45) Performance assessment: the learner is required to demonstrate or perform a level of competency by behavior, achievement of understanding and skills and doing the required intervention (Gronlund, 2006). Situated Cognition: a theory of instruction that suggests learning is naturally connected to an authentic activity, and context (Brown, Collins, & Duguid, 1989). It involves a specific learning theory and a perspective of human learning. This learning occurs in a specific environment or learning situation (Hasan, 2002). See Appendix G for other definitions.
Assumptions and Limitations Assumptions are elements of the study that are not directly controllable. They are ideas or presumptions that are taken for granted or thought to be true. Assumptions that might impact the study were addressed prior to the initiation of the study (Burns & Grove, 2001). 1. The panel of nurse educators will be able to reach consensus on a definition of critical thinking and the associated behaviors and skill set. 2. The panel members are qualified to provide information related to the instruction of critical thinking in the clinical setting and how it should be assessed. As demonstrated by their educational credentials and experience refer to Appendix H. 3. The panel members provided honest, truthful answers and responses to the Delphi procedure. Limitations The Delphi research method is lengthy and requires a time commitment to produce accurate and valid results (Hasson, Keeney & McKenna, 2000; Skulmoski, Hartman & Krahn, 2007). Therefore, the research method must be developed and the study designed to address this limitation. The results of the study could be increasingly questionable if membership or the participants were reduced or if there is a large change in participants. Fifteen participants indicated and started the study and thirteen completed the entire study. A level of potential withdrawal rate was assumed; however, this was accounted for by a larger number of initial panel members and participant alternatives. The alternatives were selected at the start of the study.
Another limitation of the Delphi study is researcher‟s biases and level of expertise with data management. The first round consists of qualitative open-ended questions. The data that results from these questions must be tallied, organized and analyzed very carefully. The misinterpretation of a concept could impact the accuracy of the transitions between rounds. The quality of the research and the results are directly linked to the level of expert participants. To address these limitations specific criteria were developed. The experts were nurse educators who have passed the Certified Nurse Educator (CNE) examination and have experience in nursing education. All of the participants had a minimum of a master‟s in nursing degree, with 10 doctoral prepared educators. The eligibility requirements for CNE, according to the National League for Nursing, include active registered nurse license, a master‟s or doctoral degree with a major emphasis in education, nine or more credit hours of graduate-level education courses, and two years or more of full-time employment in the academic faculty role and passing the certification examination. Another potential area of basis or limited unique responses was the CNE credential itself. A national professional nursing organization provides the curriculum and examination standards for the education received by CNEs. Originally there was a concern that this could result in similar responses based on the knowledge needed to pass the examination. After careful review of these data, the education of the participants did seem to affect their responses. For example, all of the participants were familiar with the work of Benner and the novice to expert nursing theory. Therefore many of the responses reflected aspects of Benner‟s theory of nursing.
Theoretical Framework Holistic nursing focuses on the entire person, not just one aspect of their being (Dossey, Keegan, Guzzetta & Kolkmeier, 1995). For example, a person has a body made up of many physical elements including a mind and a spirit. The assessment of clinical learning requires a similar philosophy. Based on a holistic framework, this study uses the accumulated knowledge and wisdom of established nursing professionals. Holism in nursing and education considers healing and learning as a lifelong journey into an understanding of the wholeness of the human existence (Dossey et al., 1995). Within the theory of holism, assessment of clinical critical thinking examines how humans interact, relate to and act in their world, in this case, how student nurses act, relate to and interact with their world (the clinical environment) and their patients. Holistic Nursing Holistic nursing theory has become an accepted nursing and learning theory (Dossey et al., 1995). It is an approach to nursing education and patient care that views the body-mind-spirit processes as essential for health. Healing is considered a life long journey into an understanding of the wholeness of the human existence (Dossey et al., 1995). Based on the theory of phenomenology, holistic nursing examines how humans interact, relate to and act in their world. Transferring this philosophy to nursing education means that teaching and learning is approached from a realistic perspective, based in current knowledge, evidence based practice and the art of caring (Watson, 1998). Part of the theoretical framework for this study includes elements of holistic nursing, qualitative description and inductive reasoning methods. Working from the basic philosophy that people have the ability to think critically and find solutions to their own problems, holistic
learning theory, as it relates to nursing education, acknowledges that a concept is more than just what is immediately apparent and that any concept is intricately linked to other concepts (Dossey et al., 1995). Situated Cognition The learning theory used as a foundation for this study reflects the social nature of nursing and learning; it provides flexibility, is inclusive and integrates aspects of holistic nursing. Situated cognition learning theory describes how learning and assessment of that learning occur in specific situations. It is a general theory of how knowledge is gained and practically applied (Hasan, 2002). Situated cognition, as a learning theory was developed by Jean Lave, in 1998, of Cambridge University, UK. According to the situated cognition learning theory, understanding and practical application of knowledge are not separate concepts, but occur in social settings (Lave & Wenger, 1991). Lave and Wenger also describe learning as a result of community and activity within a community or culture. Learning should not be separate from the context of application. In contrast to learning through authentic experience, classroom experiences include abstract ideas and concepts. This theory of learning combines aspects of social learning theory, constructivism, apprenticeship models of learning and novice to expert nursing theory described by Patricia Benner, in Expertise in Nursing Practice. John Dewey (1938) advocated for learning in specific areas and believed that learning was a social process. Lev Vyotsky‟s social learning theory and „zone of proximal development‟ discusses authentic tasks as part of the learning experience. Situated cognition learning theory describes learning as complex, and individual, but linked to the social situations and interactions between people (Brown et al., 1989). Clinical
learning experiences are examples of situation cognition. Learning occurs in a specific social situation with interaction between different groups of people. Situated cognition incorporates concepts from various learning theories. For example, Vyotsky‟s work is clearly represented as transformative learning theory and with a new role for educators. This theory views the educator as a facilitator of learning rather than the traditional lecturer. According to Choi Jeong-Im and Michael Hannafin (1989), in Situated Cognition and Learning Environments: Roles, Structure and Implication for Design a paradigm shift from traditional written exams to other assessment methods is required to respond to reflect the various learning styles of students. Assessment “should focus on the individuals‟ cognitive process and transfer of knowledge” ( Jeong-Im & Hannafin, 1995, p. 42) therefore the assessment of learning would be a competency showing the student‟s ability to transfer knowledge from theory to practice. Knowledge has meaning within the context of a system such as a clinical situation and that learning is reproduced and nurtured in a community. For nursing students that community is healthcare. Part of the theory of situated cognition states that the assessment of learning should occur in the same situation where the learning happened. All assessment of learning in a community or healthcare situation must be authentic, reflective of real situations, and completed in the practice setting (Wiggins, 1998). Cognitive apprenticeship supports learning in a domain by enabling students to acquire, develop and use cognitive tools in authentic domain activity. Learning occurs, both outside and inside school, advances through collaborative social interaction and the social construction of knowledge. (Brown et al., 1989, p. 32)
To demonstrate knowledge in nursing practice the student must transfer abstract knowledge, or theory, into critical thinking problem solving methods that can be applied in practical situations (Winn, 1993). “Theory becomes reality” as the student is given the opportunity to develop a cognitive link between the classroom case example and the actual specific case they care for during a clinical experience (O‟Connor, 2006, p. 2). The clinical settings are specific situations which are examples of situated cognition theory. Learning is linked to the location. In nursing education clinical knowledge is linked to specific situations, specific disciplines and must provide a method to transfer knowledge to related healthcare situations. For example, the same process to take an oral temperature is used in an acute care setting and in home care. Students learn what portion of theory is relevant in a specific situation while experiencing clinical learning situations. Nature of the Study The study was conducted using the Delphi research method. The Delphi method provides insight into a known problem through the use of a panel of experts and a series of surveys or questionnaires (Hasson et al., 2000). The responses from the panel of experts provided direction for further refinement of the issue being examined. The panel members were able to consider and reconsider their opinion as the group moved toward consensus of opinion. Since the quality of the research and the results of a Delphi Study are directly linked to the level of knowledge of the expert participants, specific criteria for membership of this panel were developed. The panel member was defined as a person who has extensive knowledge and/or experience in a) nursing practice, b) nursing education, or c) assessment of nursing student learning. Other essential criteria for panel membership included a willingness to share expertise
and a belief in the importance of developing critical thinking assessment methods. The panel should consist of a minimum of ten (10) participants and a maximum number of sixteen (16) (Hasson et al., 2000). Potential members for the panel were recruited from The National League for Nursing‟s published list of Certified Nurse Educators (CNE) and represented different regions throughout the United States. The results of a Delphi study become increasingly questionable if membership becomes reduced or if there is a large change in participants. A level of potential withdrawal rate was assumed for this study; however, because of the larger number of initial panel members and alternative participants, the required 80% of the original participants completed the entire study. The initial survey for this study was exploratory in nature and was developed based on information and themes compiled as a result of a literature review (Appendix A and Appendix B). The review provided background information and basic theory regarding assessment and clinical learning experiences. Thus, the panel examined and considered options that expanded and create new knowledge. The surveys were disseminated and completed through e-mail and SurveyMonkey. The surveys were analyzed and data condensed until the predetermined, operationally defined level of consensus of 80% agreement among expert panel members was reached. Common themes were identified and additional rounds of surveys were conducted using a Likert scale until a consensus was reached by the panel. The qualitative questions followed by a Likert scale survey provided validity and rigor to the study. This method allowed review of the data from a different perspective. All survey questions were directly linked to the initial research questions. The qualitative data did show significant similarity in the themes; therefore, an additional clarifying survey was not initiated (Appendix C). A second reader reviewed the
original themes for content and correct meaning from the original responses to the first round survey. The themes were presented to the participants for further verification prior to moving to round two. After the qualitative data had been analyzed and an initial premise statement generated, the second round started. The second and third rounds were developed from the premise statements generated in round one, refer to Appendix F. As there was no guarantee that 80% consensus would be reached during the initial survey, the provision for additional survey rounds, was built into the study design. Rounds two and three were allowed up to three additional rounds to complete their objectives. After three sub-rounds, an evaluation of the questions was completed. Following the third round, premise statements were developed and reviewed with participants for clarity. Two additional sub-rounds were used following round three. The data from these additional rounds provided less information than the initial third round. The process and transition from one round to the other proceeded very smoothly. The amount of data collected during the survey rounds demonstrated the interest in critical thinking, in the nurse educator community. Organization of the Remainder of the Study Chapter two examines the literature related to the research questions. Chapter three describes the methods and procedures used in relation to the framework of the study, Chapter four presents the data analysis and results and Chapter five offers conclusions and recommendations.