Faculty Perceptions of Critical Thinking in Student Clinical Experiences Renee Twibell, DNS, RN; Marilyn Ryan, EdD, RN; and Mary Hermiz, EdD, RN

ABSTRACT Critical thinking is an essential skill for nurses who practice in complex health care systems. This study explored nursing faculty members’ perceptions of teaching critical thinking to baccalaureate student nurses in clinical settings. Six clinical faculty members were interviewed using an ethnographic approach. Findings focus on two domain analyses that describe the nature of critical thinking and strategies to effectively teach it. Faculty members conceptualized critical thinking as “putting it all together” through information seeking, reflecting, assigning meaning, problem solving, predicting, planning, and applying information. Faculty members perceived that they teach critical thinking through a number of approaches that include asking questions, reviewing written products, conducting clinical conferences, and evaluating student journals. The findings of this study have implications for faculty who seek a clearer definition of critical thinking in nursing and a rich description of strategies to teach this skill.

Received: May 28, 2003 Accepted: November 3, 2003 Dr. Twibell is Associate Professor, and Dr. Ryan is Professor and Associate Director of the Graduate Program, School of Nursing, Ball State University, Muncie, Indiana. Dr. Twibell is also Faculty Associate in Administration and Staff Nurse, Ball Memorial Hospital, Muncie, Indiana. Dr. Hermiz is Director and Professor, Tenwek School of Nursing, Kenya, Africa. Address correspondence to Renee Twibell, DNS, RN, Associate Professor, School of Nursing, Ball State University, Muncie, IN 47306; e-mail: [email protected].

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he 21st century promises continuous change and the need for adaptation to complex systems in society. Indeed, survival in society may depend on the ability of individuals and groups to investigate multiple alternatives and make wise choices. Individuals who flourish in complex situations possess distinguishing characteristics such as critical thinking skills, which include the capacity to evaluate and respond in novel circumstances and to self-reflect (Brookfield, 1991; Paul, 1993). The current health care environment reflects societal patterns of constant change and complexity. The rapid growth of knowledge and technology related to health and illness calls for nurses who are able to solve problems and make crucial decisions in clinical situations. Nurse educators must address the challenge of preparing nurses who can think critically (Jacobs, Ott, Sullivan, Ulrich, & Short, 1997; Sedlak, 1997). Critical thinking skills are now an expected outcome of nursing education programs. The American Association of Colleges of Nursing (1998), the National League for Nursing (1992), and the National League for Nursing Accrediting Commission (2002) identified critical thinking as an essential component of baccalaureate nursing education. Schools of nursing are required to produce outcome assessments of students’ competence in critical thinking as accreditation criteria. Since nursing is a practice profession, it is important for faculty to know the cognitive processes characteristic of expert nurses and to role model and teach critical thinking in clinical settings (Bell et al., 2002; Higuchi Smith & Donald, 2002). LITERATURE REVIEW Critical Thinking Critical thinking has been defined by many noted educators during the past century (Brookfield, 1991; Dewey, 71

FACULTY PERCEPTIONS OF CRITICAL THINKING

1910; Mezirow, 1990; Norris & Ennis, 1989; Paul, 1993; Watson & Glaser, 1964), with each definition emphasizing different aspects. As a result, the nature of critical thinking lacks consensus across academic disciplines (Myrick, 2002). Through a Delphi method with 46 experts, the American Philosophical Association developed a cross-disciplinary conceptual definition: We understand critical thinking to be purposeful, selfregulatory judgment which results in interpretation, analysis, evaluation, and inference, as well as the explanation of the evidential, conceptual, methodical, criteriological, or contextual considerations upon which that judgment was based. (Facione, 1990, p. 2)

In the discipline of nursing, the definition of critical thinking continues to lack consensus. For example, in a study by Videbeck (1997), 55 nursing programs used 10 different definitions of critical thinking and assessed it using a variety of tools. Results of a survey of deans and directors (n = 225) in baccalaureate and higher degree schools of nursing indicated unclear perceptions of critical thinking, suggesting it was a rational-linear problem solving activity reflective of the nursing process (Jones & Brown, 1991). Jacobs et al. (1997) defined critical thinking in nursing as: the repeated synthesis of relevant information, examination of assumptions, identification of patterns, prediction of outcomes, generation of options and choice of actions with increasing independence. (p. 20)

Alfaro-LeFevre (1999) defined critical thinking in nursing as purposeful, outcome-directed thinking based on principles of the nursing process and the scientific method. Miller and Babcock (1996) suggested that critical thinking for nurses was: purposeful thinking that takes into consideration focus, language, frame of reference, attitudes, assumptions, evidence, reasoning, conclusions, implications, and context when they matter in deciding what to believe or do. (p. 8)

Bandman and Bandman (1995) conceptualized critical thinking in nursing as: the rational examination of ideas, inferences, assumptions, principles, arguments, conclusions, issues, statements, beliefs, and actions. This examination covers scientific reasoning, includes the nursing process, decision making, and reasoning in controversial issues. (p. 7)

Gordon (2000) compared definitions of critical thinking between nurse educators (n = 201) and non-nurse scholars, where Facione’s (1990) definition served as the nonnursing definition. Unlike non-nurse scholars, nurse educators considered critical thinking to include planning, synthesizing, analyzing, and critiquing literature. Nurse educators also viewed decision making and problem solving as the same, or partly the same, as critical thinking. Non-nurse scholars were less likely to equate critical thinking, which was viewed as a non-linear process, with decision making and problem solving, which were viewed as linear processes. A recent and rigorous definition of critical thinking in nursing emerged from a Delphi study by Scheffer and 72

Rubenfeld (2000). An expert panel of 55 nurses from international sources agreed on the following conception: Critical thinking in nursing is 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. (p. 357)

The panel identified descriptors for each habit and skill. Further examination of this definition is necessary to confirm its usefulness for nursing. Strategies for Teaching Critical Thinking in Clinical Settings A number of noted education leaders have asserted that critical thinking is context bound (Brookfield, 1997; Meyers, 1986; Paul, 1993). One situation may trigger critical thinking, but a similar situation may not. Critical thinking is learned in social processes and through role modeling (Ironside, 1999). Therefore, critical thinking for nurses should be taught in clinical settings (Brookfield, 1997; Myrick, 2002). However, with little consensus on the definition of critical thinking, few strategies for teaching critical thinking in clinical settings have been refined and tested through research. The literature does reflect some beginning exploration of strategies for teaching critical thinking, including questioning (Wink, 1993b), clinical conferences (Rossignol, 1997; Smith & Johnson, 2002; Wink, 1993a), case studies (Jacobs et al., 1997), nursing care plans (Alfaro-LeFevre, 1999; Jacobs et al., 1997), coaching (Grealish, 2000; Myrick, 2002) and journaling (Brown & Sorrell, 1993; Patton et al., 1997). Most of these studies were limited to the examination of one or two strategies by quantitative design. The current study used qualitative methods to explore in-depth descriptions of faculty members’ perceptions related to teaching critical thinking in specific clinical contexts. PURPOSE The purpose of this study was to explore the perceptions of nursing faculty members as they teach critical thinking skills to baccalaureate student nurses in clinical settings. METHOD Ethnographic philosophy and methods can stimulate generation of new knowledge when issues and concepts lack clarity. Specifically, a multiple case study approach was selected to explore the perceptions of nursing faculty members about students’ critical thinking within clinical settings. The case study method focuses on holistic, intensive description and explanation of a bounded situation (Merriam, 1998). Journal of Nursing Education

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Setting and Sample The setting was a public school of nursing in the midwestern United States. Criteria for participants included faculty members with a minimum of 5 years of clinical nursing experience and 1 year of clinical teaching experience in a baccalaureate program. Participants currently supervised junior-level or senior-level nursing students in clinical experiences. By focusing on instructors who taught upper-division baccalaureate nursing students, the criteria increased the likelihood that students had the basic knowledge to develop critical thinking skills. Six clinical nursing instructors comprised the sample. All respondents were women and ranged in age from 40 to 55. Table 1 summarizes the respondents’ education and work experience. Respondents 1, 3, and 5 had advanced clinical certifications in specialty areas. Participants who taught beginning adult health, intermediate adult health, child bearing/child rearing, mental health, community health, and nursing management were chosen for this study. Data Collection Each participant was interviewed three times during one semester at 2-week intervals, shortly after a clinical experience with students. Each interview was audiotaped, transcribed, and analyzed. Sample interview questions included: • Think about a student who performed well in clinical experiences this week. Describe the student’s behaviors that evidenced progress toward satisfactory critical thinking. Describe the student’s words that evidenced progress in critical thinking skills. • What did you say or do to support this student’s critical thinking? Describe your actions or words that may have directed the student’s critical thinking. What characteristics of your instruction were intended to stimulate or support the development of critical thinking? Strategies to Ensure Rigor Rigor in research that uses qualitative methodologies is ensured by credibility, fittingness, auditability, and confirmability. In this study, one researcher conducted all of the interviews. Two researchers identified biases and analyzed the data individually without collaboration. Prolonged engagement with informants and persistent observation occurred through the three-step interview process. An audit trail of audiotapes, transcripts, domain and taxonomic worksheets, and a reflective journal maintained by the primary data collector allowed an evaluation of dependability and confirmability. Information about informants and their contexts provided a means of judging fittingness and transferability. Data Analysis Spradley’s (1979) developmental research sequence (DRS) guided data analysis. As a qualitative and ethnographic approach, the DRS systematically examines a person’s experience and its meaning from verbal descripFebruary 2005, Vol. 44, No. 2

TABLE 1 Respondent Characteristics Highest Educational Degree

Years of Nursing Practice

Years as Clinical Instructor

1

DNSc

27

11

2

EdD

36

24

3

PhD

21

17

4

DNS

26

16

5

MSN

20

2

6

MSN

17

4

Respondent Number

tions. Spradley’s full sequence consists of 12 steps, the first 8 of which guided this study. Several steps were combined or slightly modified. The interview data were analyzed by domain and taxonomic analyses, using worksheets recommended by Spradley (1979). The first step of domain analysis is identification of a cover term, which names a category of cultural knowledge. All domains have two or more included terms that have something in common and fit within the cover term (Spradley, 1979). For example, in this study, one cover term was “putting it all together” which included the terms “reflecting on experiences” and “assigning meaning.” Another step in domain analysis is identification of semantic relationships, in which cover terms are linked to all included terms, and included terms may be linked to each other (Spradley, 1979). Since every domain has a boundary, some terms are excluded from a domain. Table 2 describes five types of semantic relationships noted in this analysis. A taxonomic analysis followed, in which a classification or taxonomy emerged. Relationships between terms within a domain were further examined, and subcategories or levels of terms were uncovered (Spradley, 1979). Taxonomic analyses were conducted on data from each participant and then compared and combined across participants. Terms were reported in the final analysis if they were cited by at least half of the respondents. RESULTS Five domains emerged from the analysis. The cover terms were: • “Putting it all together.” • “Strategies to promote critical thinking.” • “Role of clinical instructors.” • “Beneficial characteristics of instructors.” • “Rewards for critical thinking” This article focuses on the first two domains, which contained the richest narrative descriptions and on which the strongest consensus existed across participants. Putting It All Together All 6 respondents described the core nature of critical thinking as “putting it all together,” similarly 73

FACULTY PERCEPTIONS OF CRITICAL THINKING

TABLE 2 Types and Examples of Semantic Relationships Type of Relationship*

Definition*

Example

Strict inclusion

X is a type of Y

Spatial

X is a part of Y

Clinical scenario is a type of strategy to teach critical thinking. Identifying relevant patient data is part of “putting it all together.”

Function

X is used for Y

Postconference discussion is used to stimulate critical thinking.

Means-end

X is a way to do Y

Questioning is one way to teach critical thinking.

Attribution

X is an attribute or characteristic of Y

Attentive listening is characteristic of a clinical instructor who stimulates critical thinking in students.

* Spradley (1979, pp. 110-111).

Domain

Included Terms

Subcategory Terms In-depth searching

Information seeking Asking questions Reviewing experiences broadly Reflecting

Evaluating Examining cognitive processes

Putting it all together

Identifying relevant data Assigning meaning Interpreting Problem solving

Predicting Knowing what to do next Planning Making decisions Applying to novel contexts Figure 1. Taxonomic analysis of the domain “putting it all together.”

expressed as “working it through,” “getting the big picture,” “thinking it through,” and “making a whole from the parts.” Respondents indicated that “putting it all together” meant synthesizing various elements into an integrated whole. Seven included terms and several subcategories for included terms composed the domain (Figure 1). Information-Seeking. Respondents agreed that students who think critically probe past superficial information about clinical situations. One respondent summed up the consensus on this included term as: “They don’t just accept what’s there…they start looking deeper than what is before them...then I know they are thinking critically.” Seeking additional information often included asking questions. One respondent emphasized, “When they ask 74

questions, they are really thinking...questioning is part of critical thinking.” Reflecting on Experiences. Participants reported that students were thinking critically when they reviewed multiple aspects of experiences, evaluated nursing care, and considered underlying thought processes. One respondent commented, “They reflect on what happened…. What went well? What did not go well?” Reflection occurred most often after a clinical experience but also occurred before and during experiences. Assigning Meaning. Participants agreed that “assigning meaning” meant identifying data as relevant and interpreting implications for patient care. All 6 respondents reported the primacy of this aspect of critical thinking. One respondent discussed behaviors that Journal of Nursing Education

TWIBELL, RYAN, & HERMIZ

Domain

Included Terms

Subcategory Terms Student cannot answer

Questioning

Students’ reactions Faculty clarification Write questions

Written products

Prompt verbal discussion

Strategies to promote critical thinking

Enhance quality Individual Group Clinical conferences Web based Use scenarios

Student journals

Pose questions

Figure 2. Taxonomic analysis of the domain “strategies to promote critical thinking.”

evidenced “assigning meaning” by “putting it all together”: Rather than look at things in fragments or look at just one piece, I really want students to start looking at all the cues and making a big picture of it. [When a student says] “Gee, [a patient] has diminished pedal pulses.” What does that mean? Once she figures out that that’s poor arterial circulation or the patient has arterial disease, then she’ll think, “I need to keep their legs warm.”... Putting together everything and then being able to understand what’s going to be done...that’s critical thinking.

One respondent described a student who could provide answers to individual questions but could not assign meaning to the answers. The respondent said, “She knew the answers, but she just could not put two and two together…. I said, ‘If you can just put it together, you are doing critical thinking.’” Problem Solving. Respondents considered problem solving to be an included term and a vital element of “putting it all together.” One sample behavior reported was that “they discuss and really look at the patient and come up with solutions for problems.” Predicting. Participants believed “putting it all together” included the ability to make guesses about developments in the immediate future. One respondent explained this included term with the student behavior of “anticipating what may happen next.” Planning. Another key characteristic of critical thinking was planning or knowing what to do next. One respondent noted, “It’s not just what it means, but what February 2005, Vol. 44, No. 2

they are going to do…. You’ve got information and now you need to make a decision.” Application to Novel Contexts. Another hallmark of critical thinking was described as applying knowledge in new situations. A sample behavior was that “they apply their knowledge to whatever situation they are in.” Strategies to Promote Critical Thinking A second domain that emerged from the data was labeled “strategies to promote critical thinking.” All respondents indicated that the instructor was an important factor in shaping students’ ability to think critically. Four specific strategies were identified as included terms, and each included term was further represented by at least one subcategory (Figure 2). Questioning. All 6 respondents reported that asking questions was the primary strategy for a clinical instructor to promote critical thinking. Respondents offered multiple questions that stimulated critical thinking across the phases of the nursing process (Table 3). One respondent offered the following narrative that incorporated key verbal questions in a context: She had a patient with a stroke…. I asked, “Tell me about your patient. Why is the patient in the hospital? How did the doctor arrive at the diagnosis? Tell me what a stroke is. Who is at high risk for stroke?”... So it turned out the patient has hypertension. I said, “OK, hypertension. Why does hypertension lead to stroke?” I had to ask many questions to help the student think.

A subcategory of the included term “questioning” was the role of the instructor when students are unable to 75

FACULTY PERCEPTIONS OF CRITICAL THINKING

TABLE 3 Questions Posed by Clinical Faculty to Teach Critical Thinking Phase of Nursing Process

Sample Questions

Assessment

• What else do you need to know about the patient? • Tell me about your patient. • What factors are contributing to this laboratory value? • What do these physical assessment findings mean?

Planning

• What nursing diagnosis does your assessment support? • Based on what you assessed, what should you do next? • What else will you do with the patient? • What might happen if you did that? • What is the likelihood of meeting this goal? • What can you delegate to other health team members? • What is your priority with this patient right now?

Implementation

• Why are we doing it this way? • What is the best action you can take right now? • How will you begin meeting the patient goals?

Evaluation

• How do you know the medication was effective? • How did your intervention affect the patient? • What evidence supports the effectiveness of this plan of care? • How did your patient benefit in the end?

answer questions. Several respondents indicated it was not helpful “to tell the student to go look it up. You can’t look up critical thinking.” One respondent noted, “Sometimes I just back off and ask [a more basic] question and then I lead to a higher level of question.” Another respondent concurred that students sometimes need a series of simple questions, rather than one general question. She said, “I simply asked, ‘What did you make note of in terms of how the patient looked?’” Another respondent suggested changing approaches: She [the student] just could not put it together. So I rephrased my question. I had to be a little bit more creative to find a way to make a scenario and to ask the right question.... It took me about four questions, but she was able to put everything together. And, to me, that is critical thinking.

Another subcategory of the included term “questioning” focused on students’ reactions to questions. Occasionally, students expressed frustration when they could not answer questions. One respondent described a 76

student’s negative reaction to a series of questions, stating, “She [the student] started making loud noises...and crying and telling me, ‘You’re asking me too many questions.... I just had so many problems today, and I could not handle the questioning.’” Conversely, most students reported increased understanding after an instructor’s questions, such as, “Now that I’ve gone through this, all the questioning makes sense.” Negative reactions can be reduced when faculty clarify with students the reasons for asking questions. One respondent told a student, “‘I’m going to ask you a couple of questions. They are not [intended] to make you feel like you don’t know anything. The intent is to get you to think.’... So I asked the questions, and...she [the student] said, “‘Oh, I like this. I like this.’” Written Products. A second included term in the domain of strategies to promote critical thinking was written assignments. All of the respondents described the review of nursing care plans as a strategy in developing critical thinking. Other written assignments that provided students with opportunities to think critically included a milieu assessment, clinical case study, and management problem analysis. Questions similar to those used in verbal conversations were written on the paperwork to prompt critical thinking. For example, one respondent wrote, “What does this test result mean for the patient?” and “Relate the pathophysiology to this patient.” Written products prompted valuable verbal discussions. One respondent reported a conversation with a student who could not formulate a nursing diagnosis on a written care plan: I said, “Why is your patient here?” And she [the student] said, “Well, he’s depressed.” I said, “What is the depression related to?” [The student said,] “Well, his wife died in January.” She thought a little bit, and she said, “Grief.” I said, “Yes!”...and she said, “Well, it was right in front of my nose.”

The quality of the written products was enhanced when faculty helped students with their thinking. For example, a respondent described helping students set realistic goals for a care plan: One of the student’s patients was delusional. Her [the student’s] goal was that he [the patient] would be delusion-free by the end of April. And I said, “He’s been here for how long?” [The student said,] “Twenty years.” And I said, “He’s been on medication and hasn’t been delusion-free, so what do you think the chances are?” And she said, “Probably won’t happen.”... Then we talked about her focus on helping him to remain reality based for a period of time, just a little bit longer than what he was before.… What I try to get the students to do is think about what their patients need (today).

Clinical Conferences. A third included term for this domain was clinical conferences, usually held before or after a clinical experience. All 6 respondents conducted clinical conferences to promote critical thinking among students. Some conferences were individual; some were small groups. Most conferences were held face to face, Journal of Nursing Education

TWIBELL, RYAN, & HERMIZ

while some were held in Web-based chat rooms. Often respondents posed clinical scenarios and then asked questions. One respondent recalled: In this particular scenario, there is a disaster, and the students have to decide who they’re going to send home [from the hospital]. That is a very difficult problem, and there are so many different things you have to consider on each patient…. What criteria are you going to use to make that decision?

Student Journals. A fourth included term in this domain was journals. Four respondents reviewed student journals to stimulate critical thinking. Again, questions were posed to “stretch” students’ thinking. Respondents did not perceive that journal entries were consistently reflective of higher-order thinking. DISCUSSION These findings suggest that clinical faculty can describe indicators of critical thinking in baccalaureate nursing students and that the nature of critical thinking, as perceived by the respondents, shares some similarities with earlier definitions. In addition, respondents agreed on four primary strategies for teaching critical thinking in clinical settings. Nature of Critical Thinking The findings regarding the cognitive skills of critical thinking were closely aligned with the definitions of Jacobs et al. (1997) and Gordon (2000) and were dissimilar from Scheffer and Rubenfeld’s (2000) definition. For example, respondents in this study viewed synthesis, or “putting it all together,” as a primary, overarching component of critical thinking. Similarly, Jacobs et al. (1997) and Gordon (2000) emphasized synthesis as an important skill. In contrast, Scheffer and Rubenfeld (2000) reported synthesis as a descriptor only in an early phase of the Delphi process and omitted it from the final definition and descriptor list. Likewise, assigning meaning was a key component in this study and was implied by Jacobs et al. (1997). Assigning meaning was missing from all rounds of Scheffer and Rubenfeld’s (2000) study. In addition, the findings of this study suggest that critical thinking resulted in planning for action, as noted by Jacobs et al. (1997) and Gordon (2000) but not noted by Scheffer and Rubenfeld (2000). In this study, critical thinking was not simply a cognitive exercise; it drove nursing intervention. Evidence of a plan of action convinced faculty that students were thinking critically. Definitions of critical thinking in other disciplines rarely include the idea of subsequent action. The findings of this study did support Scheffer and Rubenfeld’s (2000) results regarding reflection as critical thinking. Reflection was characterized in this study as “thinking hard” about a situation, language that parallels Scheffer and Rubenfeld’s (2000) notion of reflection as thinking to deepen understanding. In this study, reflecFebruary 2005, Vol. 44, No. 2

tion included the three types described by Boychuck (1999): anticipatory, “thinking on your feet,” and postexperiential. Consensus exists regarding prediction and information gathering as critical thinking skills, as noted in this study and those by Jacobs et al. (1997) and Scheffer and Rubenfeld (2000). These two skills seem to be similarly defined and described across studies. One limitation when comparing components of critical thinking across studies is the potential lack of consistency in the meaning of terms. What one researcher describes as “discrimination” may be labeled as “evaluation” or “logical reasoning” by another. In an effort to increase clarity, Scheffer and Rubenfeld (2000) offered descriptors of skills and habits of the mind, and this study offered subcategories of included terms. This study produced no findings from any respondents about identifying assumptions, biases, or methods of logical reasoning. These skills are frequently mentioned in other definitions of critical thinking (Bandman & Bandman, 1995; Jacobs et al., 1997; Miller & Babcock, 1996). Replication of this study in diverse settings may reveal these dimensions of critical thinking in nursing. Respondents in this study did not differentiate clearly between problem solving, decision making, clinical judgment, and critical thinking; most used the terms interchangeably. Jones and Brown (1991), Brigham (1989), and Gordon (2000) also reported that nursing faculty members viewed problem solving as critical thinking. Conversely, one respondent in this study offered that “some problems require critical thinking to solve, and some do not,” a view more closely aligned with Facione’s (1990). Critical thinking in nursing may differ somewhat from critical thinking in other disciplines because of dynamic clinical processes, the affective dimension of nursing practice, and the embodied nature of nursing knowledge. The discipline of nursing has embraced the concept of critical thinking as a valued process and outcome without clearly determining how it fits with other cognitive activities required for nursing practice. Nurse educators could benefit from a clarification of the shared and unique conceptual space of cognitive activities, including the nursing process, problem solving, decision making, clinical judgment, and critical thinking. Beyond theorizing, consensus on what types of cognitive skills support effective nursing care would be of even greater value. The findings of this study indicate that such skills are information gathering, synthesis, reflection, assignment of meaning, problem solving, predicting, planning, and applying knowledge to new contexts. Strategies to Promote Critical Thinking The findings suggest a variety of methods for promoting critical thinking. All respondents valued questioning, as recommended in other studies (Phillips & Duke, 2001; Sellappah, Hussey, Blackmore, & McMurray, 1998; Wink, 1995). Faculty most often asked questions as clinical sit77

FACULTY PERCEPTIONS OF CRITICAL THINKING

uations unfolded or in clinical conferences. The literature supports the importance of conferences in examining issues, practicing decision making, and integrating theoretical knowledge into practice (Bell et al., 2002; Girot, 2000; Smith & Johnson, 2002; Wink, 1995). However, faculty and students may not ask higher-order cognitive questions in conferences (Haffer & Raingruber, 1998; Rossignol, 1997; Wink, 1993a). Students’ fatigue late in a clinical experience can also reduce the effectiveness of questioning (Letizia, 1998). Faculty members stimulated critical thinking by writing comments on student papers and journals, which is supported by other authors (Brown & Sorrell, 1993; Burnard, 1995; Richardson & Maltby, 1995; Riley-Doucet & Wilson, 1997; Wagner & Ash, 1998). However, evidence of critical thinking may be missing from journal entries, and strict guidelines may help strengthen critical thinking (Patton et al, 1997). LIMITATIONS This study was primarily limited by the nature of the sample. All respondents were women, and all taught in one school of nursing. Clinical faculty from other schools in various parts of the world may have different perceptions of critical thinking and strategies by which to teach it. The generalizability of the results is further limited to baccalaureate programs, as the perceptions of faculty teaching in associate or graduate programs were not examined.

RECOMMENDATIONS AND FUTURE RESEARCH

This study should be replicated with samples from various geographic locations and with diverse demographic variables. Replication in samples from associate degree and graduate degree programs may yield contrasting results. Future study is also necessary to examine the following questions and issues that arose from the data analysis: • What do faculty perceive as the conceptual relationships between problem solving, decision making, clinical judgment, nursing process, and critical thinking? • What barriers prohibit faculty from effectively using strategies to develop critical thinking in clinical settings? • How do faculty expectations about critical thinking vary across curricular levels? • How can critical thinking be measured validly and reliably in clinical experiences? Development of critical

thinking in students

CONCLUSION

The successful preparation of nursing students for clinical practice depends on the effective teaching of know how to pose critical thinking skills. Faculty in this study reported that the primary cogniquestions that stimulate tions in critical thinking include synthesis, reflection, information gatherhigher-order cognitive ing, prediction, planning, assigning meaning, problem solving, and applyprocesses. ing new knowledge. Primary strategies to promote critical thinking in clinical settings are asking questions, conducting clinical conferences, and evaluating written assignIMPLICATIONS ments, including journals. Faculty can focus on asking effective questions and allowing students time to reflect Strategies for teaching critical thinking, particularly on experiences and assign meaning. While consensus is in clinical settings, are essential tools for nursing faculty. growing about the definition of critical thinking in nursDevelopment of critical thinking in students requires facing and how to teach critical thinking, the need for conulty to know how to pose questions that stimulate highertinued dialogue and research is evident. order cognitive processes. Faculty also need to be able to build from lower-level questions to higher-level questions REFERENCES and explain the questioning process. Questions may be posed in clinical conferences, challenging students to Alfaro-LeFevre, R. (1999). Critical thinking in nursing: A practiidentify parts of patient situations and then put them cal approach (2nd ed.). Philadelphia: Saunders. American Association of Colleges of Nursing. (1998). Essentials together with new insight and meaning. Strategies for of baccalaureate education for professional nursing practice. successful clinical conferences include using case studies Washington, DC: Author. and role playing, and examining alternative applications Bandman, E.L., & Bandman, B. (1995). Critical thinking in nursof theoretical knowledge to practice. Reflection and group ing (2nd ed.). Norwalk, CT: Appleton & Lange. Bell, M.L., Heye, M.L, Campion, L., Hendricks, P.B., Owens, discussion can also stimulate analysis of clinical probB.L., & Schoonover, J. (2002). Evaluation of a process-focused lems. Journaling can provide an avenue for students to learning strategy to promote critical thinking. Journal of reflect on experiences and provide faculty with an opporNursing Education, 41, 175-177. tunity to evaluate students’ critical thinking skills. The Boychuck, J. (1999). Catching the wave: Understanding the conbest approach is for faculty to use a variety of strategies cept of critical thinking. Journal of Advanced Nursing, 29, 577-583. to facilitate development of critical thinking skills in Brigham, C. (1989). Critical thinking skills in nursing students nursing practice.

requires faculty to

progressing through a nursing curriculum. Dissertation

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Journal of Nursing Education

TWIBELL, RYAN, & HERMIZ

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