Thelma Riddell, MScN, RN, COHN(C)
ABSTRACT
The concept of critical thinking has been featured in nursing literature for the past 20 years. It has been de-scribed but not defined by both the American Associa-tion of Colleges of Nursing and the NaAssocia-tional League for Nursing, although their corresponding accreditation bod-ies require that critical thinking be included in nursing curricula. In addition, there is no reliable or valid mea-surement tool for critical thinking ability in nursing. As a result, there is a lack of research support for the as-sumptions that critical thinking can be learned and that critical thinking ability improves clinical competence. Brookfield suggested that commitments should be made only after a period of critically reflective analysis, during which the congruence between perceptions and reality are examined. In an evidence-based practice profession, we, as nurse educators, need to ask ourselves how we can de-fend our assumptions that critical thinking can be learned and that critical thinking improves the quality of nursing practice, especially when there is virtually no consensus on a definition.
T
he concept of critical thinking first appeared in the nursing literature in the 1980s. Nursing scholars took up the cause in large numbers in the following decade, as indicated by the 1,851 titles in the CumulativeIndex to Nursing and Allied Health Literature database from 1980 to 2005. Interest in critical thinking does not seem to be waning, given the 300 articles produced in the past 3 years alone. However, it appears that nurse edu-cators’ preoccupation with creating critical thinkers has led us in many directions, and away from the process it-self. The failure to identify and challenge our assumptions about critical thinking may have led to some erroneous conclusions. This article is intended not to dispute that critical thinking is a worthy goal for nursing education, but rather to challenge our assumptions and encourage nurse educators to reflect on how we collectively jumped on the critical thinking bandwagon in the first place. Fac-ulty from my School of Nursing provided their comments to exemplify some of their conceptions.
BACKGROUND
Brookfield (1987) described the key components of the concept of critical thinking as: “identifying and challenging assumptions,” “exploring and imagining alternatives” (p. 15), understanding the importance of context, and engag-ing in reflective skepticism. Identifyengag-ing and challengengag-ing assumptions involves probing, reflecting on, and question-ing one’s usual ways of thinkquestion-ing, as well as one’s morals, beliefs, values, and stereotypical notions. This process helps demonstrate the importance of the context wherein one’s assumptions are formed. Individuals develop “con-textual awareness” (Brookfield, 1987, p. 16) when they come to realize that their values and beliefs are socially and, to a large extent, culturally transmitted. The ability to consider and imagine alternatives to one’s programmed ways of thinking leads to the development of a critical mind-set that Brookfield called “reflective skepticism” (p. 21). Reflective skepticism is not cynicism, but rather the belief that ideas and practices must be subjected to care-ful testing against experiences. If one is to think critically about critical thinking, it is necessary to first examine one’s assumptions about the concept.
Received: October 29, 2004 Accepted: August 29, 2005
Ms. Riddell is Coordinator, BScN Program for Registered Nurses, The University of Western Ontario, London, Ontario, Canada.
The author gratefully acknowledges the assistance of Dr. Carole Orchard and Susan Anthony for their critiques of earlier drafts of this article.
A review of the nursing literature suggests that nurs-es and nurse educators make several assumptions about critical thinking: first, numerous iterations or definitions of the term are interchangeable; second, teaching critical thinking will produce graduates who are capable of it; and third, teaching critical thinking will improve clinical per-formance.
WHAT IS CRITICAL THINKING?
The literature contains many definitions for critical thinking, as well as supposed synonyms, such as critical decision making, critical analysis, critical awareness, crit-ical reflection, and clincrit-ical reasoning. While these are ele-ments of the critical thinking process, it is an oversimpli-fication of the concept to reduce it to such terms. Critical thinking requires an explanation rather than a definition. Even the gurus of critical thinking, such as Brookfield, Mezirow, and Paul, do not reduce it to a singular defini-tion, but rather describe it in terms of components and central features, phases, and characteristics by which it might be recognized.
Commonalities among the varying process descriptions of critical thinking include the following, all of which re-sult in a change in belief or course of action:
l Reflection (Bandman & Bandman 1995; Brookfield,
1987; Chenoweth, 1998; kataoka-yahiro & Saylor, 1994; Paul, 2004; Watson & glaser, 1980).
l Identification and appraisal of assumptions
(Brook-field, 1987; kataoka-yahiro & Saylor 1994; Mezirow, 1991).
l Inquiry, interpretation and analysis, and reasoning
and judgment (Bandman & Bandman, 1995; Brookfield, 1987; Mezirow, 1991; Paul 2004).
l Consideration of context (Brookfield, 1987; Cody,
2002; Mezirow, 1991).
given the complexity of the critical thinking process, it becomes obvious that many articles that promote meth-ods of teaching critical thinking are really encouraging activities such as reasoning or diagnostic reasoning, analysis or critique, problem solving, or argument. Few articles describe the need for reflection and identification of assumptions. Even authors who do talk about identify-ing assumptions fail to describe the process, which is a major omission considering the centrality of this activ-ity to critical thinking. Cody (2002) suggested that many nursing authors have engaged in "pseudo critical think-ing," based on the desire to incorporate the buzzword into their works, without making any substantive changes in content (p. 185). He posited that failing to incorporate one’s predispositions and life experiences and failing to consider context in nursing interactions and decisions harks back to the notion that there must be universal criteria for truth. This, in turn, perpetuates the idea of nurses as technicians using linear problem solving and analytical reasoning to find singular answers to complex problems. The alternative requires reasoning and reflec-tion to identify the evidence for one's beliefs, evaluate the
significance of that evidence, and change one's thinking accordingly (Cody, 2002).
Examining Assumptions
Examination of one’s assumptions is not a simple task. one of our faculty members likened it to “asking a goldfish to perceive the water.” Nevertheless, one of the most effec-tive means of helping others identify the assumptions un-derlying their thoughts, actions, and beliefs is the use of critical questioning (Brookfield, 1987). The goal of critical questioning is to prompt reflective analysis, and encourage others to develop independent habits of critical reflection. Critical questions must be specific to events, situations, or people, and must not be abstract or intimidating. For ex-ample, to encourage readers of this article to identify their assumptions about critical thinking, one should avoid an abstract question such as, “What are your assumptions about critical thinking?” A more appropriate critical ques-tion would be, “Think back over your classroom experi-ence in the last month and tell me about a discussion in which you were able to stimulate critical thinking in your students.” By describing the features and characteristics of this interaction, readers would be more likely to specify their values and assumptions about critical thinking.
Consider how one might respond to a question such as, “What are the assumptions underlying the mission state-ment of your school of nursing?” as opposed to “Think back to your last faculty meeting and describe a debate about an agenda item that made you say to yourself: ‘We real-ly walk the talk.’” or consider that you will be unable to teach your class for the next month: “Tell me about the im-portant qualities we should look for in your replacement.” Responses to these questions are likely to reveal one’s un-derlying assumptions. For example, is the replacement’s technical knowledge more important than that person’s ability to stimulate meaningful group discussion? It is pos-sible to discern general themes from responses to critical questions and reflect these themes back to the individual, or for individuals to detect the assumptions inherent in their own responses.
Reflective Thought
Mezirow (1991) called assumptions the “products of unreflective personal or cultural assimilation” (p. 118). As such, assumptions are subject to distortions that may limit one’s views of reality, impede differentiation, and restrict openness in how one sees the world. Becoming aware of one’s assumptions involves recognizing how one has been influenced by one’s culture and life experiences, and then learning to compensate for one’s limitations. Therefore, the need to reflect becomes a key element in developing the ability to think critically. Dewey (1933) defined reflec-tive thought as:
Dewey distinguished reflective thought as a sequen-tial process that begins with some doubt or confusion. He stated that individuals must sustain the state of doubt be-cause it is the stimulus to thorough inquiry and prevents jumping to conclusions.
Boud, keogh, and Walker (1985) made three significant observations about reflective learning. First, the learner has total control of this activity (i.e., only learners can re-flect on their own experience). Second, rere-flection is a pur-poseful activity, pursued with the intent of reaching a goal. Third, the reflective process is influenced by both affective and cognitive processes. Reflective learning clarifies the meaning of experience in terms of the self, resulting in a shift in perceptual perspectives (Boyd & Fales, 1983). It is not a linear process, but one “more comparable to alternat-ing current, flowalternat-ing back and forth” (Boyd & Fales, 1983, p. 105). This perspective was shared by Shields (1995), who described the complex relationship between the abil-ity to reflect, critical thinking, and critical knowing, a re-lationship made more complex because critical thinking itself is influenced by background, previous experience, and previous knowledge.
This previous knowledge and experience forms the ba-sis for Mezirow’s (1991) contention that critical thinking can be facilitated by skilled critical questioning to stimu-late three types of reflection. The first is content reflection, the “what” of the problem or a description of the content of a problem (e.g., “What knowledge do I have about criti-cal thinking?”). The second is process reflection, which is intended to identify the “how” of the problem (e.g., “How have I come to have this perception of critical thinking?”). Finally, premise reflection attempts to solve the “why” of the problem itself (e.g., “Why do I need to understand criti-cal thinking?”).
Content and process reflection have the ability to change beliefs by reinforcing them, elaborating on them, creating them, negating them, confirming them, identify-ing them as problems, or transformidentify-ing them (Mezirow, 1991). Premise reflection, on the other hand, can lead to more fully developed belief systems that are more inclu-sive, discriminating, open, or integrative of experience. It is important to realize that content and process reflection change belief schemes; premise reflection can change be-lief systems. Premise reflection can result in new or formed meaning perspectives termed “perspective trans-formation” (Mezirow, 1991, p. 111). The process of critical questioning can facilitate critical reflection for individuals or groups, but ideally, the eventual outcome will be indi-viduals who have learned to develop their own habits of critical reflection, thus becoming true critical thinkers.
Faculty’s Perceptions
Any theory of practice must be not only informed by an understanding of what others have written and said, but also individually chosen on the basis of experience (Cranton, 1994). Nurse educators must ask themselves, “What is my experience? Is critical thinking alive and well in my curriculum? How do I know?” With those questions
in mind, I interviewed several faculty members in our un-dergraduate program. My questions were:
l What is critical thinking?
l How do you teach or encourage critical thinking in
your students?
l What indicators do you look for to determine that
students are thinking critically?
Many of the faculty talked about the need to challenge assumptions. All agreed that critical thinking is more than problem solving, yet they found it difficult to describe. one faculty member stated that:
No one has sat there and figured it out, but it is ex-pected that you know...that critical thinking means look-ing at somethlook-ing on a variety of levels, with multiple ways of knowing and deep analysis to develop meaning, stretch your mind, your perception, and your perspectives.
other explanations included “not accepting the status quo” and “examining beliefs, values, and assumptions that students bring and attempting to become conscious of what they are.” Another said, “it’s hard to define, but I know it when I see it.”
When asked how they teach or encourage critical think-ing, the faculty responses centered on the manner in which students are questioned and challenged, such as through case studies, role playing, journaling, or Socratic question-ing. Some examples were:
• This...[situation] happened.… What do you think about it? How did you previously think about it? How will this affect your future practice?
• How does this change your way of looking at...how do I know what I know...what makes me think that?
one faculty member suggested we, as nurse educators, need to “demystify” critical thinking, that we “perpetuate the mystique by suggesting that critical thinking ability is not acquired until the fourth year of the program.” An-other stated that critical thinking is fostered by faculty modeling it in their interactions with students. Many faculty members focused on developing self-awareness in students.
our faculty expressed many differing views about in-dicators that students are engaging in critical thinking. They noted that in the early part of the nursing program, students’ responses are superficial, often resembling “laundry lists” of events. In time, students begin to de-scribe and identify their thought processes, identify the need for more information, generate alternative measures, and make comments such as, “I never thought about that before.” other positive indicators were expressions such as “it made me wonder about...” or when students say they have arrived at “a new way of thinking about...” and “seeing opportunities for nursing to make a difference.” All faculty agreed they seldom have a student iterate a “perspective transformation,” but that is generally what the students are describing.
Questions for Further Thinking
fac-ulty peers bring to the classroom? Have you focused on content reflection? Process reflection? Premise reflection? Have you committed to the concept of critical thinking be-cause you have been socialized to do so, or is it an informed commitment (Brookfield, 1987)? Have you questioned, an-alyzed, and reflected on the importance of critical thinking to your nursing curriculum?
CAN CRITICAL THINKING BE TAUGHT AND LEARNED?
The second major assumption suggested in the litera-ture about critical thinking is that it can be taught. Not-withstanding the suggestions by Mezirow (1991), Brook-field (1987), Cranton (1994), and others about how to facilitate the development of critical thinking in others, the above premise has not been supported by research. Ad-ams (1999) composed an integrative review of 20 research studies conducted between 1977 and 1995 that focused on changes in the critical thinking abilities of professional nursing students. Her assumption was that critical think-ing skills would increase durthink-ing nursthink-ing education. How-ever, she found that studies showed mixed results, neither confirming nor denying a relationship between critical thinking abilities and nursing education. Adams further noted that two earlier integrative reviews by Beck, Ben-nett, McLeod, and Molyneaux (1992) and Hickman (1993) showed similar results. An equally disturbing outcome of Adams’ review was that in 19 of the 20 studies reviewed, the suggested definitions of critical thinking were “syn-onymous with decision making and problem solving” (Ad-ams, 1999, p. 116). If Brookfield’s (1987), Mezirow’s (1991), and Cranton’s (1994) explanations about the complexities of the critical thinking process are accepted, we must question whether or not these studies were testing critical thinking at all. Adams (1999) suggested that the lack of both a single definition of critical thinking in nursing and a specific measurement tool appropriate for nursing were the two main reasons for the mixed results of the studies reviewed. The measurement tool used in most of the stud-ies was the Watson-glaser Critical Thinking Appraisal®
(WgCTA), and the appropriateness of this tool has been questioned as being more for generalized education than for professions such as nursing.
In search of a nursing-specific method for identifying critical thinking, Daly (2001) performed a mixed-method study incorporating the WgCTA and a qualitative as-sessment of critical thinking in nursing students. The qualitative component incorporated “a videotaped clinical simulation, a cognitive task, and stimulated recall strat-egy” (Daly, 2001, p. 120). Participants were asked to think aloud while performing a cognitive task. These verbaliza-tions revealed the structure and control of their reasoning, while the stimulated recall performed afterwards probed the breadth and depth of the knowledge behind their rea-soning processes. No significant differences were found in WgCTA scores before and after their nursing education program. In addition, the think-aloud results “reflected
an absolutist epistemology portraying limited evidence of critical thinking” (Daly, 2001, p. 120). Daly expressed concern that the “early closure that is characteristic of an absolutist epistemology” (p. 128) may impede reflective practice. Alternative perspectives and solutions to patient problems may be overlooked because practitioners may make judgments based on a limited search for alterna-tive possibilities. Daly (2001) suggested that educators may need to consider whether or not they are expecting too much regarding critical thinking in nursing students. While Daly’s study was performed in the united kingdom, where critical thinking skills had been emphasized in a recent review of nursing programs, similar results have been found in American schools.
Stone, Davidson, Evans, and Hansen (2001) surveyed deans or program directors of National League for Nurs-ing-accredited baccalaureate and higher-degree nursing programs in the united States to address the lack of re-search evidence that would justify using general critical thinking tests to measure nursing students’ critical think-ing ability. Specifically, they focused on the California Critical Thinking Skills Test (CCTST) and the California Critical Thinking Disposition Inventory (CCTDI), examin-ing the extent to which respondents believed these tests reflect the critical thinking domain important to nursing. Stone et al. (2001) found that 35% of the programs were using the CCTST as a measure of critical thinking in their programs, yet the critical thinking skills measured by the CCTST items were not viewed as being measured in a way that reflects critical thinking relevant to nursing. Specifi-cally, five of the seven items were rated as not even mod-erately reflecting nurses’ critical thinking. The authors’ conclusion was that nursing programs and accrediting bodies need to reexamine their methods of measuring and evaluating critical thinking (Stone et al., 2001).
The American Association of Colleges of Nursing (AACN), in their publication The Essentials of Baccalau-reate Education for Professional Nursing Practice (1998), declared critical thinking to be a core competency for grad-uating baccalaureate-prepared nursing students. Their perspective on critical thinking includes “questioning, analysis, interpretation, inference, inductive and deduc-tive reasoning, intuition, application, and creativity” (p. 9). The AACN further suggested that graduates should be capable of engaging in self-reflection about nursing prac-tice. However, the reflective component is excluded from their definition of critical thinking, as is any reference to examining assumptions. These AACN guidelines form the basis of the accreditation standards of the Commission on Collegiate Nursing Education (CCNE) (1998), which do not specify critical thinking in the key elements by which programs are evaluated.
standards are “rules to measure quantity, extent, value, and quality” (NLNAC, 2005, p. 12). The NLNAC (2005) also defines that its “criteria are statements, which iden-tify the variables that need to be examined in evaluation of a standard” (p. 12), yet it does not provide a definition of critical thinking. The rules require programs to teach critical thinking, but fail to define it. In fact, programs are expected to “select an activity and/or develop procedures, and/or instruments/tools to measure each component” (NLNAC, 2005, p. 17), but the NLNAC “does not mandate specific evaluation techniques, procedures, or use of spe-cific instruments for outcomes assessments by programs” (p. 16). What a dilemma for nurse educators. The NLNAC standards require programs to teach critical thinking, but neither define it nor suggest how it should be measured. How, then, can the accreditation process confirm wheth-er or not a program is developing critical thinkwheth-ers? This omission seems particularly relevant considering that the accreditation standards state that systematic evaluation of program quality is designed to determine “whether the various parts and the entire program are, in fact, achiev-ing its mission, goals, objectives, and outcomes” (NLNAC, 2005, p. 16).
The NLNAC confirmed for me that it does not have a test to measure critical thinking in nursing students. Schools are required to demonstrate how critical thinking is taught throughout the curriculum. Their expectation is that students are taught “to apply nursing theory and content to specific patient care situations” (B. grummet, personal communication, August 13, 2004). The applica-tion of theory and content is reminiscent of the “absolutist epistemology” described by Daly (2001). What about re-flection or the challenging of assumptions? In any case, the NLNAC only requires that critical thinking (whatever definition) be taught but not that it be learned.
Intuitively, it makes sense for nursing faculty to facili-tate the development of critical thinking skills in students. The lack of empirical support for the development of criti-cal thinking may be the result of an inadequate instru-ment to test it. Nevertheless, if nurse educators cannot agree on a definition and do not have a reliable means to measure it, then in an evidence-based practice profession, we need to ask ourselves, “Where are the data to support our assertion that critical thinking can be learned?”
DOES CRITICAL THINKING ENHANCE CLINICAL COMPETENCE?
Finally, the assumption that teaching critical think-ing will enhance clinical competence must be examined. Again, we, as nurse educators, intuitively believe this to be true, but the research evidence is currently lacking. Brunt (2005) composed an integrative review of 18 stud-ies conducted between 1992 to 2003, with both nursing students and practicing nurses, and found no relationship between critical thinking and clinical competence.
Hicks (1997) tested the relationship between clinical knowledge, critical thinking dispositions and skills, and
task complexity and the consistency of clinical decision making. He found no significant relationship between lev-els of clinical knowledge or clinical decision making con-sistency and levels of critical thinking disposition or skill in critical care nurses. However, Hicks (1997) did find that decision making consistency increased with years of direct patient care experience.
Martin (2002) studied nursing students, graduate nurses, and expert nurses, measuring their critical think-ing usthink-ing the Elements of Thought Instrument (ETI) and the quality of their decision making by a score derived from the ETI. Critical thinking and clinical nursing pertise were found to be higher with age and clinical ex-perience, but not with progression through the nursing education program. These findings are consistent with the mid-range Theory of Critical Thinking of Nurses (Martin, 2002), which states that:
as persons develop clinical nursing expertise from novice to expert nurse, through the use of knowledge and experi-ence, they also develop critical thinking and use it consis-tently to make objective and appropriate clinical decisions. (p. 244)
In summary, knowledge and experience influence criti-cal thinking, which, in turn, influences clinicriti-cal decision making.
It would seem to be a reasonable assumption that teach-ing critical thinkteach-ing will improve clinical performance. However, in the absence of any supporting evidence, we should maintain some degree of skepticism. our ideas and practices must be carefully tested against our experience and commitments made only after a period of critically re-flective analysis (Brookfield, 1987). Can we, as nurse edu-cators, truly say that we have critically reflected on the expectation that critical thinking can be taught or that it improves the quality of nursing practice, especially when we cannot agree on a definition?
In a 1997 editorial, Morin displayed the healthy “reflec-tive skepticism” extolled by Brookfield (1987) by question-ing the emphasis on critical thinkquestion-ing in nursquestion-ing education in the absence of conceptual clarity or reliable and valid measures. Tanner (1999) echoed Morin’s concern about the lack of evidence and called on nurse researchers to submit manuscripts examining ways to help students develop criti-cal thinking habits. Sadly, that criti-call has gone unanswered. Twenty years after the introduction of the concept to nurs-ing education, and 15 years after the NLNAC made it an accreditation standard, the questions remain: “Why are we doing this?” and “What is the evidence that supports this action?” (Tanner, 1999, p. 99). How and why did we collec-tively jump on the critical thinking bandwagon? until these questions are answered, either confirming or transforming our beliefs about critical thinking, we should reconsider the vigor with which we defend our assumptions.
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