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7. CriticaI Thinking in Nursing Prepared by: Lilet Basilio R.

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Introduction

Health care organizations have made dramatic advances and transformations during
the last few decades, resulting in rapid growth of technology and theory. Some of the
changes facing nursing today are an expansion in technology, consumer demand for
quality care, pressure for cost containment, decreased length of stay in hospitals,
and complex disease processes. These changes have been associated with
incumbent ethical and moral dilemmas, which are borne out, in the daily practice of
nurses. More marked changes are predicted in the coming decades, such as the
development of technology prolonging an individual's life span, which compounds the
aging population situation and increases the burden of escalating healthcare
expenditure.

f nurses are to deal effectively with complex change, increased demands and
greater accountability, they must become skilled in higher-level thinking and
reasoning abilities. Nurses are now required to provide skilled, multidimensional care
in multiple, often unfamiliar environments or settings. Consequently, nurses should
be prepared to function as safe, competent, intuitive and innovative clinicians in an
environment where new information and clinical situations are constantly changing.

The next few paragraphs will introduce you to the concepts of critical thinking and its
common characteristics that, when used, will become habit and will enhance your
ability to think critically.
istoricaI Perspective
Florence Nightingale is generally cited as the founder of modern nursing. There is
evidence that Nightingale subscribed to methods of teaching that required critical
thinking. Her students where required to keep casebooks in which they recorded,
analyzed, and reflected upon activities on the ward. She regarded these diaries as
useful because they required higher order thinking and superior powers of
observation. (Seymer, 1960)
Nightingale emphasized the need for analytical skill development, however, nursing
schools and instructors in the United States did little to foster thinking skills until the
late 1800s. n 1898 an American nurse named Adelaide Nutting published an
analysis of nurse training in the United States. She reported that nursing schools
were doing little, if anything, to train the minds of students to observe, think or reason
accurately. Nutting's report had enacted laws and regulations setting forth minimum
requirements for nursing practice and education that included criteria related to
thinking and decision making.
During the 1920's , the lecture was the primary method used to teach nursing
students. However, some nurse educators advocated the use of discussions, written
assignments, and time for thinking (Henderson 1982).
Although these activities were limited primarily to ethical situations, they did require
students to think about, not just memorize, the material. The concept of thinking and
problem solving were also introduced. n a handbook for nursing students, Jensen
1929 describes a method to analyze the patient 's admission, care while hospitalized,
and discharge.
n 1927 the National League for nursing education (NLNE) published a revised
curriculum guide for nursing schools that outlined important characteristics for
nursing students. Good judgment, keen insight, use of discrimination, and the ability
to detect physical and mental changes, draw conclusions, and make applications to
other situations were some of those identified characteristics. The NLN Curriculum
Guide revisions of 1937 and 1942 place even greater emphasis on critical inquiry,
independent thinking, good judgment, and resourcefulness (NLN,1937,192). These
characteristics are accepted today as components of critical thinking.
Despite the emphasis placed on thinking by nursing leaders of the '20s, 30s, and
'40s, t was not until the late 1950's that a change in curricular structure actually took
place. n 1935 Louise McManas proposed asset of functions unique to the
professional nurse, today known as the nursing process and nursing diagnosis.
McMans maintained that nurses who were taught the nursing process could be
assumed to possess the ability to think reflectively and use higher analytical skills
such as reasoning, judging, and drawing inferences. Today his assumption is highly
debated. Many assert that the teaching nursing process is not, by itself, enough to
produce critical thinkers.
Nurse educator and administrators in the 1960s began to turn their attention toward
critical thinking and the use of critical thinking terminology. The first report supporting
the need for critical thinking concepts in nursing education was published in 1961 by
institute of research, art of the teachers college of Columbia University. By 1963 an
article appeared in the Journal of Nursing education that clearly reflected the thinking
of the period. t emphasized the importance of providing students with experiences
that would encourage their development of critical thinking skills (Barbus, 1963).
Even so, the '60s, '70s, and 80s found few educators calling for critical thinking;
widespread acceptance and implementation was lacking.
Most recently, NLN representatives have begun to promote the use of activities that
foster student thinking abilities. This move follows the national trend of the '80s to
promote critical thinking at all levels of education. The NLN's most recent ccreditation
standards require nursing schools to provide evidence of student achievement of
critical thinking. The need to include critical thinking in he nursing school curriculum
is no longer an issue. Nutting's vision is now a reality.

hat is CriticaI Thinking?
Critical Thinking has as many definitions as there are authors writing about it.
However, the following definitions are the most prevalent in critical thinking literature:
1. Critical thinking is reflective and reasonable thinking that is focused on what
to believe or do (Ennis, 1985).

2. Critical Thinking is an attitude of inquiry involving the use of principles,
abstractions, deductions interpretations, and analysis of arguments
(Matthews, 1979).

3. Critical Thinking is disciplined, self-directed thinking that exemplifies the
perfections of thinking and displays mastery of intellectual skills and abilities;
it is the art of thinking about your thinking while thinking in order to make your
thinking better.

4. Critical Thinking is an investigation whose purpose is to explore a situation,
phenomenon, question, or problem to arrive at a hypothesis or conclusion
about it that integrates all available information and can, therefore, be
convincingly justified (Kurfiss, 1988).

5. Critical Thinking is a rational investigation of ideas, inferences, assumptions,
principles, arguments, conclusions, issues, statements, beliefs, and actions
that covers scientific reasoning and includes the nursing process, decision
making, reasoning in controversial issue (Band-man &Bandman,1995).


CriticaI Thinking Attitudes
Critical thinking includes attitudes as well as cognitive skills. Robert Ennis (1985)
referred to critical thinking attitudes as "dispositions. Richard Paul (1990)
referred to them as "traits of mind. These attitudes motivate and justify the use f
cognitive skills. Attitudes place the thinker in the right frame of mind for thinking.
A critical thinker, as opposed to an ordinary thinker, will use one or more affective
attitudes when thinking about what to believe or how to perform. Once, you have
engaged in exercises that focus your attention on attitudes, you will become
aware of how often your thinking is affected by them. Seven interdependent
attitudes or dispositions that are essential for becoming a critical thinker (Paul,
1990) are shown in he following page.
. Intellectual Humility
ntellectual Humility involves knowing and accepting limits of your own
knowledge. Obviously no one can know everything. What sets critical thinkers
apart is that they understand the limits of their own language and recognize when
they need to seek more information.
Humility also involves being sensitive to your own prejudices and your own
biases. A person who is prejudiced or biased has an opinion for or against
something without having an adequate basis for that opinion.
2. Intellectual Courage
ntellectual courage involves the willingness to listen to and fairly evaluate the
ideas, view points, and beliefs of others even though you may not agree with
these ideas or beliefs.
. Intellectual Empathy
ntellectual empathy necessitates imagining yourself in the place of another in
order to fully understand that other.
4. Intellectual Integrity
When you hold your own evidence to the same standard of proof to which you
hold others, you are demonstrating intellectual integrity
5. Intellectual Perseverance
ntellectual Perseverance is similar to other forms of perseverance.
Projects that enforce or test intellectual perseverance may have the following
qualities:
A high degree of difficulty and requiring a long time to complete, such as
collection of data about the functions of all community agencies in your area and
the populations they serve.
Multiple dimensions or a difficult problem that has no one right answer or
solution.
6. Faith in Reason
Faith in reason means believing that it is in the best interest of humankind for
every person to develop the best possible thinking skills. The critical thinker
supports this assumption and believes that all people can learn to think and
reason critically.
7. Intellectual Sense of Justice
The trait implies that, as a critical thinker, you will assess all view points similarly
without regard to vested interests or feeling or the vested interests or feelings of
friends, community or nation.


CriticaI Thinking SkiIIs
The cognitive component of critical thinking are referred to as abilities or skills
that an individual may or may not choose to use.
Divergent Thinking
One of the most prevalent cognitive components of critical thinking is divergent
thinking. This is the ability of an individual to analyze a diversity of opinions and
judgments (Perry,1978). When practicing nurses obtain histories from their
clients, they must separate out all irrelevant data, analyze pertinent data, and
explore possibilities in order to draw accurate conclusions. When they follow this
process, they are using the cognitive skills of Divergent thinking
Specific questions that enhance divergent thinking may include the following:
Of the above data which are most relevant to your care of this client?
How do you know if this drug is effective? neffective?
How will the care of this client with COPD help you care for your clien with
congestive heart failure?
What can be inferred about this group of data?

Reasoning
Reasoning involve the general principles of logic. Crtical tinker should be able to
discriminate between observation and inference, between fact and conjecture ,
and draw conclusions for themselves. Two types of reasoning are essential to
critical thinking inductive and deductive.
Reflection
Reflection means to ponder, contemplate, or deliberate something. t takes time
and cannot be done during an emergency. Reflection entails the ability to
recognize that critical thinking is multi dimensional, rather linear, process. Critical
Thinkers are free to integrate new ideas or insights at any time or change their
opinions when new evidence has been presented. Reflective thinking integrates
past experiences into the present and explores potential alternatives.
Creativity

Guiding Students' CriticaI Thinking

When students are accustomed to being passive learners by merely memorizing and
recalling information, it may be difficult at first to engage them in active learning
situations that require critical thinking skills (Brown & Kelley, 1986). nstructors
should be aware of students' initial resistance and guide them through the process to
create a learning environment where students feel comfortable thinking through an
answer rather than simply having an answer. For example, peer coaching techniques
can engage students in active learning and critical thinking opportunities
(Ladyshewsky, 2006). Assign students to two-person teams; one student is the
problem-solver, and the other is the peer coach. Using the Six Steps to Effective
Thinking and Problem Solving, or "DEALS" (Facione, 2007), the problem-solver
works through a case study or activity by responding to questions from the peer
coach. The DEALS are to dentify, Define, Enumerate, Analyze, List, and Self-
Correct:
dentify the Problem: What is the real question we are facing?
D Define the Context: What are the facts that frame this problem?
E Enumerate the Choices: What are plausible options?
A Analyze Options: What is the best course of action?
L List Reasons Explicitly: Why is this the best course of action?
S Self-Correct: Look at it again ... What did we miss?
This problem-solving technique guides students through the critical thinking process
and utilizes learner collaboration. Similar strategies include integrating project-based
learning activities that require students to apply their knowledge by constructing a
real-world product. As a final guide to student practice, use peer assessments to
facilitate students' critical thinking and meta-cognitive skills (Hou, Chang, & Sung,
2007).

Strategies That Enhance CriticaI Thinking

A character in one of Sue Grafton's novel noted, "Thinking is hard work, which is why
you don't see a lot of people doing it. ndeed, Critical Thinking is not easy, and the
development of such skills takes effort. But there are many strategies nurse
educators can use to enhance or promote critical thinking of students and nurses in
practice. Before discussing specific teaching/learning and evaluation strategies,
however it is important to think about foundational principles.

A Critical Thinking approach to education requires that teachers and learners alike
view learning as shared responsibility. t is the educator's responsibility to create an
environment that supports this concept.

When learning is viewed as shared responsibility, the teacher's role is that of mentor
and facilitator. Learners define their own learning needs (goals), take responsibility to
use a variety of resources to meet those needs, and evaluate their progress towards
meeting those goals. Such an environment is egalitarian and democratic, learners
are empowered, and they feel as if they share in control of the learning process.

As a mentor and facilitator, particularly one who is attempting to promote that critical
thinking of learners, it is the educator's responsibility to "push and challenge
learners while supporting them. Our purpose in teaching critical thinking is to alter
learners' dispositions toward being closed to alternatives and perspectives that are
different from or in conflict with their own. This is very difficult, if not impossible, to do
through lecture. Therefore, one strategy to promote students critical thinking is to do
less lecturing.

iscussion

Lecture should be limited to a small percentage of the class time, and educators
should focus on depth of understanding more than on breadth of content. ndeed, the
focus on content should be streamlined so that only the most significant concepts
and principles are addressed. Our classes need to move from straight lecture or
lecture with comments and questions that are directed to the teacher to focused
interactions between teacher and student and, indeed, among students themselves.
The highest level of discussion often occurs when teacher and students engage in
thoughtful dialogue about an unannounced topic.

During discussions that enhance critical thinking, the teacher role models critical
thinking and answers questions only when learners are unable to do so for
themselves. Learners' questions may be answered by one another or by the teacher
who thinks out loud to formulate a response, rather than merely answering a
question as an all-knowing expert. An even more effective strategy is for learners to
discover answers to their own questions by thinking through the question, what they
know about the topic, the assumptions they may be making about it, the gaps in
knowledge on the topic, and so on. The teacher, then, serves to redirect the
discussion, bring out salient points and summarize.

The use of discussion as a teaching/learning strategy is unpredictable, and it may
make the classroom "a relatively chaotic affair. n addition, some of what is said by
learners during a discussion may be erroneous or incomplete, and it needs to be
corrected by the teacher. But a discussion is a controlled chaos, and it presents an
excellent opportunity for teachers to give up control so that they can help learners
realize the strengths and flaws in their thinking.

Research with students (Bloom, 1953) has demonstrated that (1) discussion actively
hold their thoughts to the immediate situation more than lecture does (i.e., their
thoughts do not drift to unrelated topics), and (2) irrelevant and passive thoughts
about the person speaking are less, their thoughts about themselves with respect to
the topic are significantly less, and thoughts that involved synthesis of ideas and
attempts to solve problems or question raised are far less. ndeed, using discussion
as a teaching/learning strategy can be most effective in promoting students' critical
thinking.

Asking effective Questions

"Questions are powerful motivators of inquiry and Socratic questioning is the heart of
critical thinking (Kurfiss,2005). When teachers do ask questions of learners- in the
classroom, in the clinical area, in conferences, in one on one interactions- those
questions need to be of a higher level if they are to promote critical thinking. The
asking of factual questions should be minimized. n addition, teachers need to be
careful with question that has as many answers as there are different human
preferences. Neither of these types of questions promotes critical thinking.
nstead, the questions we ask our learners should require reasoned responses, and
they should help learners explore and understand various points of view. Educators
should pose questions that probe thinking for clarity; questions that hold individuals
accountable for their thinking; and questions that move learners from mere
enactment of the nursing role to the internalization of questions they need to ask
themselves to become astute practitioners (Colucciello,1997).

Much has been written about using the Socratic method (Paul & Elder, 1995,1996) in
our classrooms, a method that relies heavily on probing, thought provoking questions
being posed by the teacher. n this method, all thoughts are treated as if they are all
in need of further development and refinement, regardless of how reflective they may
be. The teacher responds to all comments and questions with more questions, all for
the purpose of helping learners seek to understand the ultimate foundations for what
is said.
Finally one specific strategy has been identified that relies heavily on effective
questioning; structured controversy. With this approach, controversy is purposefully
introduced and used to enhance thinking, as well as both cognitive and affective
learning. Learner groups argue for and against an issue, much as is done in a
debate, but they go one step further. After presenting the arguments, they used
reasoned judgment, not merely factual knowledge, to reach a consensus that they
can support with evidence. Such a strategy can be used to explore various issues
facing the nursing profession, but it can also be used in the examination of patient
care situation.

Text Interaction

Students in nursing programs use many textbooks as learning resources, and faculty
assign extensive amounts or reading in such texts. But how do students learn to get
the most out of all that reading? What guidance do teachers give students that
encourage them to think critically about what they are reading, compare it to other
things they have read or experiences they have had, be alert to inappropriate
conclusions, and so on. The strategy of text interaction may provide some assistance
With text interaction, students interact with readings before class. They raise
questions about what is presented, note assumptions that are being made, point out
conflicting information, recognize when conclusions are being drawn without
adequate evidence having been provided, note questions they have that are not
answered in the text, and so on. ndeed, the interaction results in much more than a
mere outline of the contents of the pages read.

Teachers can use these analyses in any number of ways. For example, students can
be asked to submit their text interactions at the beginning of class, they can be called
upon to share one item from their notes with the class, or they can be asked to use
their notes in small group discussion with their peers. The point is to help students
interact with, not merely "plow through, a textbook or an article. The goal is to help
them think about what they are reading so that they can develop the questioning
attitude or spirit of inquiry that characterizes a critical thinker.

ProbIem Based Learning

One of the newer strategies being used to promote critical thinking is problem-based
learning. With this approach, learning occurs when individual attempt to manage
problems much like those that are found in clinical practice. n this process,
individuals learn content (e.g medications or pathophysilogy) when it is needed to
solve a problem, not when the teacher thinks they should learn it. Learners typically
address the problems in teams, and teachers are expert resources available to
learners as they struggle with fining information, judging its worth, dealing with its
inconsistencies or incompleteness, making decisions in uncertainty, using evidence
to support conclusions, and implementing other critical thinking skills.

Problem based learning may be used as a teaching/learning strategy in a particular
course or set of courses or as the design for the entire curriculum. n the latter
instance, there may be no courses as we come to know them. nstead, students'
teams work collaboratively to complete a series of problems through which they will
learn the concepts faculty deem most significant. However, they will learn those
concepts at different speeds, in different sequences, and in different learning
circumstances.

Concept Mapping

Concept Maps are metacognitive tools that assists learners to see their own thinking
and reasoning about a topic as they depict relationships among factors, note causes
and effects, identify predisposing factors, formulate expected outcomes, and so on.
Concept maps direct learners to consider the context in which a situation occurs, and
they help learners make purposeful judgments.

Learners would be expected to include concepts of licensure, specific agency or
broad health policies, the educational preparation of the nursing workforce, the
nature and extent of the nursing workforce's experience, finances, changing patient
care needs, competencies needed by the nursing workforce, responsibilities of ther
health team members (including ancillary health personnel), historical traditions and
so on.

Concept mapping is a technique that allows students to understand the relationships
between ideas by creating a visual map of the connections. Concept maps allows the
student to (1) see the connections between ideas they already have, (2) connect new
ideas to knowledge that they already have, and (3) organize ideas in a logical but not
rigid structure that allows future information or viewpoints to be included.
Nursing students face a great need to understand the larger questions and problems
of their chosen field. Meaningful learning is most likely to occur when information is
presented in a potentially meaningful way and the learner is encouraged to anchor
new ideas with the establishment of links between old and new material (All &
Havens, 1997). Concept mapping is an effective teaching method for promoting
critical thinking and is an excellent way to evaluate students' critical thinking because
it is a visual representation of a student's thinking.

The concept map is an effective teaching tool that is fun, interactive, and effective. t
can be used in a variety of settings. The concept map mirrors more closely real
clinical situations by being dynamic as priorities shift. t is an innovative teaching tool
that engages the student and prepares the student for future clinical decision-making
in a complex and diverse healthcare environment.


Teaching and EvaIuating with Concept Maps
Concept mapping is very useful in student preparation for clinical experiences. When
used for the assessment and care of a patient with multiple health problems, data
gathered allows the student to create a concept from the concepts or data collected.
A common way to begin a concept map is to center the "reason for seeking care" or
medical diagnosis on a large blank paper. Assessment data are arranged and linked
to the center concept according to how the student thinks they fit bets. As concepts
or data are added, links and relationships become evident and may change.
Grouping and categorizing concepts give a holistic aspect to clinical decisions (King
& Shell, 2002).
The concept map enables students to synthesize relevant data such as diagnoses,
signs and symptoms, health needs, learning needs, nursing interventions, and
assessments. Analysis of the data begins with the recognition of the interrelatedness
of the concepts and a holistic vie of the client's health status as well as those
concepts that affect the individual such as culture, ethnicity, and psychosocial state.
Once the preliminary concept map is complete, answering additional questions
enable the student and instructor to make connections between concepts and begin
formulating judgments and decisions. Once complete, the student and the instructor
see all components simultaneously, providing a deeper and more complete
understanding of the client's total needs. Development of the concept map forces the
student to act upon previous knowledge, connect it with new knowledge, and apply it.
t requires the student to have a mental grasp of the situation, rather than relying on
rote memory. Review of the map with the student gives the instructor an opportunity
to evaluate the student's thinking and an opportunity for immediate feedback on
discrepancies and "missing links" (King & Shell, 2002).

Other strategies:

Case Studies

Provide learners with open-ended problems that have more than one desirable
outcome. Learners are required to judge the advantages and disadvantages of
various options, compare alternative solutions, and justify their choice of actions. Use
of case studies in which information is revealed in stages, much like it is in the real
world, can be very effective in guiding learners' thinking (Azzarello & Wood, 2006).

CoIIaborative Learning

Provides opportunities for teams of learners to complete assignments. n such
approaches (which can be structured in an almost unlimited way) , the talents of
each learner are used to sole problems, learners critique each other's work, and they
learn from one another.

One-Minute Papers (Cross,1981)

Afford learners one of the easiest and most enjoyable ways to think critically on a
continues basis. At the start of each class session, participants are given a single
sheet of paper. They are asked to respond to each statement sometime before the
end to submit their papers before leaving. Feedback by the educator should focus on
clarifying areas of confusion, answering questions, and commenting on the quality of
the responses. The latter point helps learners think about their thinking, their ability to
listen and understand, and their ability to process what they are hearing.

Microthemes

One example of writing to learn strategies, are one- and two page written analyses or
thought papers about controversial topics related to the course that are completed
regularly, perhaps even on weekly basis. nitially, the teacher critiques the thinking
and arguments presented in each paper, but as time goes by, learners follow the
example set by the teacher to critique their own or each others papers.

Are short written assignments that require students to think through ideas and apply
concepts and then demonstrate that thinking through highly focused writing. They
are ideal critical thinking and problem-solving assignments. The limited scope of the
assignment forces students to be direct and precise. t also, of course, limits what
the instructor has to read.
Microthemes are usually no more than a page or two (typed, double-spaced), usually
on a fairly specific assigned topic. They can be used as in-class activities to clarify or
critique concepts, as quizzes, or as homework assignments. They can be graded on
a scale from 1 (failing) to 5 (outstanding) or with standard grades.

Focused RefIection

Through Journaling and other means, is used widely in nursing education to
document experiences, identify future learning needs, reflect on one's values and
assumptions, and strengthen multiperspectival thinking (Diekelmann,2003). When
faculty used journal entries as windows to students mind and hearts, and take
advantage of the opportunity to dialogue with them through comments made in a
journal, this strategy can be quite effective in promoting critical thinking.

Service Learning

Provides students with an opportunity to engage in and partner with community
groups, often those that are quite different from what students have encountered
previously. Such exposure and interaction is intended to enhance cultural
competence, build civic and social responsibility, and promote critical thinking. t may
challenge students to delve more deeply into clinical content and experience with
which they are unfamiliar ', gain new insights, and become more aware of their
insecurities and knowledge gaps.