STRATEGIES FOR PROMOTING CRITICAL THINKING IN NURSING EDUCATION

1 Introduction
Nursing education has changed dramatically since Florence Nightingale asserted the importance of education and moral standards to fulfill the nurses role. Based on these criteria, selected candidates were trained under a formalized training program of nurses (Russel, 2000). In the years of Nightingales system, nursing education was taken at hospitalth based. However, it has been transferred into the higher education sector in the late of 20

century (Russel, 2000; Sutton, 1996). According to Hart (1985), this transfer was influenced by the increase of expectation of high quality nursing care, the changes role of women in society followed by economic efficiency, political reasons and the needs of trained staff. Regarding the purposes of higher education, Quinn (2000) outlines two aims of education for undergraduate program. Firstly, the specific aims related to particular subjects like nurse and midwifery. Secondly, general aims for all undergraduate programs such as development in communication skill, problem-solving, critical thinking and evaluation. For postgraduate level, students are directed to asses and evaluate their professional practice. p. 79. Furthermore, Adams (1999) states that nursing education has to develop students ability to make decisions and solve problems which are necessary in providing high quality nursing care which is safe and promotes wellness. Again, according to Adams (1999) these skills are rooted from critical thinking which builds skills in making decisions and solving problems. Therefore, within the transfer of nursing education into university, nurse educators have to create appropriate curriculum and develop innovative teaching strategies to facilitate students critical thinking skills in learning process (Bell, et.al 2002). Requirement to

integrate critical thinking in nursing education was asserted since the National League for Nursing Accreditation Commission and The Commission on Collegiate Nursing Education in US has asked nursing schools to develop students critical thinking ability (Billings and Hastead, 2005). There are various meaning of critical thinking that has been formulated by experts over the years (Myrick, 2002). Watson and Glaser (1980) define critical thinking as elements of attitudes, knowledge and skill which involve inference; acknowledge the assumptions, deduction, interpretation and evaluation of arguments. Meanwhile, Girot ( as quoted in Banning, 2006) state that critical thinking is a complex cognitive process requiring higher order thinking and application to decision-making in practice. Alfaro-LeFevre (1995) describes that critical thinking in nursing field including outcome-directed, purposeful thinking; promote nurses to not focus on assumption but make a decision based on evidence, built on scientific approaches and principles; and needs methods to maximize potentiality of human and compensate for difficulties that come from human nature. Moreover, Edwards (2007) identify five concepts that include in critical thinking that are crit ical, analysis, thinking, synthesis and creative. In addition, based on American Philosophical Association Delphi report on critical thinking in 1990, it was concluded that dispositional characteristics of critical thinking (affective) is needed to develop this skill. It includes inquisitiveness, open-mindedness, systematicity, analicity, truth seeking, self-confidence and maturity (Walker, 2003). Even though the definition of critical thinking is diverse, there is no doubt that this skill is essential in nursing education. (Profetto-McGrath, 2005; Koch and Speers,1997). However, the implementation of teaching method to enhance critical thinking has several challenges and difficulties that have to be encountered.

In order to explore the challenges and useful strategies to promote critical thinking, in the following essay, the challenges in developing critical thinking would be presented followed by several strategies to promote critical thinking in nursing education.

2 The challenges in developing critical thinking

The application of critical thinking in nursing education has been introduced in the past few years which mean this concept is new in nursing education. Therefore; it is not easy to shift the former teaching-learning methods into a new curriculum. Nurse educators have experienced several challenges and difficulties in developing and assessing students critical thinking skills (King and Shell, 2002). Edwards (2007) identifies several problems that hamper development of critical thinking skill. The first problem is there are numerous of literature of critical thinking which is too theoretical and using complex language or jargon in the articles. It results in an ambiguity to understand and to apply critical thinking concept into clinical practice. Secondly, the various definition of critical thinking that caused by different perspective of authors in viewing critical thinking creates some doubtful among nurse educators. Further, Edwards (2007) assumes that the one cause of why critical thinking process is not employed in clinical practice is the confusion of the term critical thinking, reflective practice and decision-making. The other difficulties in promoting critical thinking skill are found by Girot (1995). Girots study reveal two problems. First, the students abilities to encourage cognitive skills are more emphasized in academic field rather than clinical practice. Second, in actual practice, students critical thinking ability are assessed mostly by practitioners who do not indicate expand this skill by themselves. Moreover, Billings and Halstead (1995)

acknowledge that mostly, faculty use traditional model in teaching which mainly dominate by teacher. They claim that this model is not contributed to encourage critical thinking. The use of teacher-centered in learning has produced students who are passive in learning process, whereas, the ability to think critically will be growth when students engaged actively in learning process (DeMarco, Hayward and Lynch, 2002). It is one of challenges for nurse educators to create strategies that bring students into active learning style. In addition, based on my own experience in Indonesia, the use of one-way communication in teaching process is still common. May be, it is because the influence of culture where students hesitate to communicate with teachers who is considered have to be respected. It still influences attitude of students and relationship with teacher either in classroom or in clinical practice. On the other hand, nurse educators attitude have an important role in learning process. Mostly, teachers act in an authoritarian manner which is not conducive in learning environment, while to develop critical thinking, disclosure relationship and consider students as colleague are necessary.

3 Strategies for Promoting Critical Thinking

An integrative review that was conducted by Adams (1999) revealed that no consistent indication that nursing education play a role to develop students ability to think critically. This finding shows that the results of critical thinking development do not come yet. In order to achieve the goals to develop students critical thinking ability, nurse educators have to review their curriculum and lesson plans continuously. Faculty also needs to shift their philosophy of teaching to support this process, while environment which free from risk to support students to become active learners should be constructed as well. (Billings and Halstead, 2005). Furthermore, some strategies in teaching-learning process have to be

expanded by finding reliable resources and employing relevant strategies to empower students. Another way to discover new strategies is by conducting some research in nursing education. The following are some innovative strategies to promote critical thinking based on a lot of research findings.

3.1 Active learning strategies.

Walker (2003) emphasizes that in critical thinking, an individual have to get involve in thinking process actively. Abilities to analyze and evaluate information and inferences indicate the engagement in critical thinking process. To develop these abilities certain characteristics and self awareness are needed. Moreover, Walker (2003) discusses several active learning strategies such as questioning, discussion, and written exercises.

3.1.1 Questioning
Nurse educators can use various questioning methods that enhance students to analyze and synthesize the facts and concepts. Walker (2003) identify several words or sentence to start the questions including the use of word explain, compare, why, what is the best and why, which is the best solution, do you agree or disagree. Another type to encourage students thoughts is by asking students who do not raise their hand. Further, he suggests to not using questions which have only one point of view. Similarly, an ethnographic study conducted by Twibell, Ryan and Hermiz (2005) reveals that in clinical instructor use multiple questioning to encourage critical thinking. The use of series of simple question is considered more useful rather than a general question. Skill to create high-level questions to stimulate critical thinking needs to be learned either by educators or students. Further, Profetto-McGrath, et.al (2004) undertook a study of the type of questions asking by nurse educators and students a baccalaureate nursing program in Canada during first three

years of program. In this study they found that the type of questions was form low-level questions including knowledge, comprehension and application). They suggested that nurse educators and students should learn to formulate high-level questions that call for analysis, synthesis and evaluation.

3.1.2 Classroom discussion and debate

Another strategy to enhance active learning according to Walker (2003) is classroom discussion and debate. The controversial issues in debate can develop critical thinking. Students are stimulated to perform strong arguments to defend their opinion. Galotti (as cited in Walker ,2003) discusses strategy to observe students reasoning skill that. In this method, students are instructed to work in pair and are given 4 reasoning tasks. Student who get the tasks have to talk a lot while another student have to observe and write the key words.

3.1.3 Writing: assignments/informal journals

Written assignments give students opportunity to think critically. Oermann (as cited in Walker 2003) state that the general rule for assignments which is used to promote critical thinking is assignments should not too long paper. In clinical practice, written assignments are also useful to develop critical thinking skill. For example: review of nursing care plans, a milieu assessment, clinical case study and management problems analysis (Twibell, Ryan and Hermiz , 2005). Billings and Halstead (2005) identify several steps in evaluating writing tasks, they are: arrange the assignment with the final grading in mind, review the whole paper rather than focus on grammar and style. Then, peer review of drafts, specifies criteria of grading, identify students learning needs by giving the flexibility of the topic. Finally, review of students draft as the beginning assessment is important, it also assists teacher to recognize if any problems emerges.

3.1.4 Case Study/Case-Based Instruction/Case Problem/Case Scenario

Case study is one of active learning strategies. According to Billings and Halstead (2005), definition of case study is in-depth analysis of a real-life situation as a way to illustrate class content; applies didactic content and theory to real life, simulate life or both(p. 296). By using this method, nurse educators have to create well-designed scenarios to provide opportunities for students to overcome the problems and relate it to their clinical practice. Moreover, explain that nurse educators have to analyze the scenario to determine the possibilities of students response in analyzing the scenario. Then, in class session nurse educators have to give relevant questions and motivate students who prefer passive learning. Giving corrections to misconceptions and provide a conclusion of the important parts. In addition, state that case-based instruction can be focused either on student individually or a group of students. Students can work together to find solutions of the complex cases. Nurse educators play a role as facilitator and encourage students to analyze, do active research, solve the problems and critiques other students their group. From the result of their study of case-based instruction, DeMarco, Hayward and Lynch (2002) found that this learning strategy enable students to solve the problems similar to the real world situation. It is considered stimulate students to think critically, solve the problems, make prioritize, work in team and value the task of nurse manager. Further, they conclude that case-based instruction raise students confidence about their lessons and expand students knowledge from clinical field to the classroom.

3.2 Mind Mapping/Concept Mapping

Billings and Halstead (2005) define mind mapping or concept mapping as learning complex phenomenon by diagramming the concepts and sub concepts. Similarly, Gul and

Boman (2006) present that concept map is a general approach to elucidate the opinion about an issue into a visual form. Further, King and Shell (2002) state that concept mapping is a useful teaching approach to develop critical thinking and the main goal of concept mapping is to synthesize pertinent data. Then, they illustrate the process of mind mapping. For example, in clinical practice the reason for seeking help is arranged as the center of map. Then other important data such as nursing diagnoses, sign and symptoms, nursing intervention and other patients needs are clustered and linked to the center. With the identification of concept and diagram, students start to analyze the case and try to find other information and relationships between components in the diagram and concept. By filling the gaps in diagram, students begin to prepare a decision. Hicks-Moore (2005) reports that students showed that the use of concept maps were useful in preparing their clinical practice and it enhanced them to think critically. In the same way, faculty recognized that this strategy was valuable because it allowed faculty to insight the level of student understands and assisted faculty in assessing students performance. On the other hand, the process in constructing concept mapping is assumed time consuming, particularly when students have to prepare it for more than one patient. Yet, it become easier when this method is practiced continuously (Hicks-Moore, 2005).

3.3 Problem-Based Learning (PBL)

According to Billings and Halstead (2005), problem-based learning is a method that applied to the whole curriculum. In addition, Wilkie (2000) defines PBL as an instructional method in which students work in small groups to gain knowledge and acquire problemsolving skills. (p.11) In PBL, students work in a small group and share the information with their friends. During the interaction, students should perform openness and honesty (Baptiste, 2003). Frost

(1996) describes that an issue in PBL is delivered before learning session by using videos, audio-tapes, a scenario or case notes. Tiwari et, al (2006) reports that students who were taught used PBL method had higher level of critical thinking disposition compared to students who attended lecture group. Moreover, students in PBL class felt that this method enhanced them to analyze problems, gain a critical methods to investigate data related to the issue and taught them work systematically. In addition, Quinn (2000) explains that PBL is more useful in computerassisted learning. Within the use of simulation and case method, students are motivated to formulate a set of care plan based on a basic data of patient in the computer. However, the implementation of PBL spends amount of time for creating problem situation, the exchanges roles between lecturer and students and students need clear explanation about the roles (Billings and Halstead, 2005).

4 Conclusion
Indeed, the ability to think critically is essential in nursing education and many efforts have been under taken by experts and scholars to develop it. Various strategies to promote critical thinking have been discovered by a number of researchers. However, there are a lot of constraints and challenges that requires our attention. The process to implement strategies to facilitate critical thinking needs time and hard works. The insight of concept of critical thinking is important and faculty which has the main role in developing critical thinking should provide relevant training for the nurse educators, create conducive learning environment and expand the curriculum that stimulate critical thinking for students.

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