Development and Psychometric Properties of the Nursing Critical Thinking in Clinical Practice Questionnaire

Development of a Critical Reflection Mentorship Program to Enhance Critical Thinking Among Novice Nurses

BACKGROUND

The increasing complexity of care and the decrease in overall nursing experience pose a threat to patient safety and clinical outcomes in health care. Within the local environment, a critical need was identified to connect expert bedside nurses with novice nurses to support the development of critical thinking.

METHOD

This article describes the development and pilot evaluation of a critical reflection mentorship program, Beyond the Bedside. The program was developed and deployed in three inpatient units within an adult academic health center. Critical thinking was evaluated using the Nursing Critical Thinking in Clinical Practice Questionnaire (N-CT-4 Practice) pre- and postprogram implementation.

RESULTS

Five nurses participated in the pre- and postevaluation, and the N-CT-4 Practice mean scores were significantly higher after program implementation.

CONCLUSION

Education leaders should prioritize programs that support critical thinking among novice nurses, and the Beyond the Bedside program can be adapted for use in other health care settings. [J Contin Educ Nurs. 2024;55(9):456-460.].

Relationship between critical thinking ability and medication safety competence among clinical nurses: A multicenter cross-sectional study

AIMS AND OBJECTIVES

This study investigated the relationship between clinical nurses' critical thinking ability and medication safety competence, as well as the factors related to medication safety competence.

BACKGROUND

Nurses can have an active role in promoting medication safety. However, the main factors associating with nurses' competence in medication safety are uncertain.

DESIGN

This was a descriptive, multicenter cross-sectional survey study.

METHODS

A total of 1196 nurses from four different tertiary hospital in China were included in this study. A demographic information questionnaire, the Critical Thinking Diagnostic for nurses, and the Medication Safety Competence Scale for nurses were used to survey. Descriptive statistics, comparisons, correlation and regression analysis of the collected data were performed using SPSS 26.00 software. The study was reported using STROBE checklist.

RESULTS

Included nurses obtained satisfactory scores on the critical thinking and medication safety scales and subscales. There was a strong statistically significant positive correlation between critical thinking ability and medication safety competence. Multiple linear regression analysis indicated that personal critical thinking scores and working years were positively associated with nurses' medication safety scores, accounting for 62.50% of the variance.

CONCLUSION

Clinical nurses' critical thinking ability is positively associated with medication safety competence.

RELEVANCE TO CLINICAL PRACTICE

As critical thinking ability positively predicts nurses' medication safety competence, hospitals and nursing administrators should consider continuing nursing education and training to improve critical thinking skills, thereby promoting medication safety competence among clinical nurses.

Critical thinking level in nursing degree students according to sociodemographic and academic variables: A correlational study

AIMS

To determine the level of critical thinking of undergraduate nursing students during their clinical practice, as well as to identify the relationship between sociodemographic and academic variables.

BACKGROUND

Nursing degree programs should prioritize the development of critical thinking skills in their curriculum and regularly assess students to ensure the acquisition of core competencies.

DESIGN

Multicenter, descriptive, cross-sectional, correlational, descriptive study. Participants included were students from the Degree in Nursing enrolled during the academic year 2020-2021. Students were selected by convenience from three universities located in Catalonia, Spain. Data were collected from 429 students, with 98 being excluded due to incomplete data.

METHODS

Data were collected by administering the Nursing Critical Thinking in Students Questionnaire and an ad hoc form of sociodemographic and academic characteristics. The STROBE guidelines checklist were followed. The study involves a secondary analysis of data from a previous study that presented psychometric analysis.

RESULTS

No significant differences were observed in total Critical Thinking scores across various parameters including academic year, current situation, work experience in healthcare, previous academic training, family situation, or recent stressful events. On average, students demonstrated moderate critical thinking scores. However, statistically significant relationships emerged between critical thinking scores and gender (p=0.046), institution attended for undergraduate studies (p=0.019) and having satisfactory social relationships despite experiencing stressful events (p=0.330).

CONCLUSIONS

The study delves into the correlation between critical thinking skills and sociodemographic and academic factors, identifying students who may benefit from specific interventions and advocating for adaptable educational methods. It emphasizes the pivotal role of trust in fostering critical thinking in nursing education and suggests a connection between critical thinking and strong social relationships. In conclusion, evaluating critical thinking is crucial for addressing healthcare challenges, validating teaching strategies and promoting continuous improvement in nursing education.

Insight from the association between critical thinking and English argumentative writing: catering to English learners' writing ability

Introduction

English argumentative writing (EAW) is a 'problem-solving' cognitive process, and its relationship with critical thinking has drawn attention in China. This is because fostering EAW proficiency is a crucial element but a challenging task for Chinese high school English teaching and learning. The present study examined how critical thinking is related to Chinese high school students' EAW performance. The study identified eight critical thinking disposition (CTD) subscales and aims to determine whether EAW and CTD are correlated.

Methods

A questionnaire modified from the Chinese Version Critical Thinking Disposition Inventory (CTDI-CV) and the Evaluation Criteria for English Argumentative Writing (ECEAW) were employed in this study. Both instruments were administered to 156 students from Grade 12. A purposive sampling of high school students was used in this study. Student EAW performance was scored by two experts based on the Evaluation Criteria for English Argumentative Writing.

Results

A significant relationship was found between students' CTD and EAW abilities. Furthermore, among the eight CTD subdispositions, cognitive maturity, truth-seeking, analyticity, and justice were found to be positively correlated with EAW, and they all were found to be the main predictors of EAW proficiency among high school students.

Conclusion

Zhangzhou high school students' CTDs were overall positive, and students' EAW performance correlated significantly with the overall CTD and its four subdispositions of cognitive maturity, truth-seeking, analyticity, and justice. These four subdispositions showed a significantly predictive validity on EAW performance as well.

Factors associated with the critical thinking ability among nursing students: An exploratory study in Iran

BACKGROUND AND OBJECTIVE

Critical thinking is a crucial skill in nursing that nursing students should apply in their work environment. It involves analyzing, evaluating, and interpreting information. It is used in various topics such as disease diagnosis, treatment planning and implementation, monitoring, and evaluation of results, problem-solving, and decision-making in emergencies. This study in Iran aimed to evaluate factors associated with nursing students' critical thinking ability.

STUDY METHOD

Following the STROBE guidelines, an analytical cross-sectional study was conducted in Ardabil province, northwest Iran. The study collected data through convenience sampling at nursing schools in Ardabil province, with a sample of 246 nursing students participating. The data collected from a demographic information form and the Persian version of the Nursing Critical Thinking in Clinical Practice Questionnaire were analyzed using SPSS version 22.0 software.

RESULTS

The study found that the overall mean score of clinical critical thinking among nursing students was 313.87 ± 25.80 (range = 109-436). Based on this score, most students reported low (63%) or moderate (37%) clinical critical thinking levels. The highest and lowest mean scores between dimensions were related to the intellectual and cognitive (127.99 ± 13.30) and technical (17.25 ± 3.43), respectively. Multiple linear regression analysis revealed that semester and college were predictors of clinical critical thinking among nursing students. The selected predictors accounted for 19.3% of the total variance in clinical critical thinking scores (F = 9.396, p < 0.001).

CONCLUSION

The study results showed that nursing students could have performed better in critical thinking ability. The study suggests that nursing education programs should prioritize teaching critical thinking skills in clinical settings as it is an essential subject in nursing education. With significant changes in nursing clinical environments, enhancing clinical critical thinking can improve nursing student performance clinically. Therefore, one of the crucial learning objectives in a clinical nursing course is to develop clinical critical thinking skills for nursing students.

The relationship between critical thinking and job performance among nurses: A descriptive survey study

AIM

This study investigated the relationship between nurses' critical thinking skills and job performance and whether critical thinking and its subdomains predict job performance.

BACKGROUND

It is expected that nurses may use critical thinking skills to provide evidence-based quality patient care in health care settings. However, there is limited evidence about whether critical thinking is related to job performance among nurses.

DESIGN

This was a descriptive, cross-sectional survey study.

METHODS

The study included 368 nurses working in the inpatient wards of a university hospital in Turkey. The survey included a demographic information questionnaire, the Critical Thinking Scale in Clinical Practice for Nurses and the Nurses' Job Performance Scale. The collected data were analysed using descriptive statistics, comparisons, reliability and normality tests, correlation and regression analysis.

RESULTS

Participating nurses got average scores from the critical thinking and job performance scale and sub-scales, and there was a positive, mid-level and statistically significant correlation between the scale scores. According to the multiple linear regression analysis results, personal critical thinking, interpersonal and self-management critical thinking and the total critical thinking scores positively affected the job performance scores of nurses.

CONCLUSION

As critical thinking predicts nurses' job performance, managers of hospitals and nursing services should consider training programs or activities to increase nurses' essential thinking competencies, thus improving clinical nurses' performances.

Critical thinking among institutional academic advisors and sociodemographic, professional and academic variables: A multicenter correlation study

BACKGROUND

In nursing education, essential skills include Critical Thinking (CT). There is scant evidence on how nurse educators could promote CT in students in a clinical context.

OBJECTIVE

To analyse the level of CT and correlated variables in healthcare nurses overseeing the clinicals of nursing undergraduates.

METHODS

The study population were all nurse educators for clinicals at hospitals with nursing undergraduates. To evaluate the CT skills of nurses the Nursing Critical Thinking in Clinical Practice Questionnaire (N-CT-4 practice) was administered. Frequencies, percentages and measures of central tendency and scatter were obtained. A bivariate analysis was performed to analyze the correlation between the nurse educators' CT level and the sociodemographic, professional and academic levels. The nonparametric Mann-Whitney and Kruskal-Wallis tests were used to compare two independent groups. Statistical significance was defined as P < .05.

RESULTS

The total number of participants was 639. The highest mean CT level was seen in clinical nurses involved in undergraduate nursing instruction and with experience of up to 10 years (mean CT score = 372 (33.3), p = .007). Global CT levels were similar in women and men (mean CT score: 364 (31.9) in women and 358 (40.5) in men, p = .187), with statistically significant differences only observed in the intellectual and cognitive indicator (P = .022).

CONCLUSIONS

CT levels are high in teaching healthcare professionals in the clinical environment.

Building consensus on critical thinking assessment tool for undergraduate nursing students in a socialist low-middle income country: A delphi study

Aim

We aimed to build consensus on a holistic critical thinking (CT) assessment tool involving cognitive skills and disposition for undergraduate nursing students in a socialist low-middle income country, Lao People's Democratic Republic (Lao PDR).

Background

University degree nursing education program in Lao PDR has been started since 2011 to strengthen the ability to think as professional nurse, and nursing regulations have progressively developed last decade. However, there are still few studies assessing the CT ability of nursing students in Lao PDR.

Design

Delphi study.

Methods

We conducted three rounds of Delphi survey of 14 panel members consisting of nursing faculty members and clinical supervisors. The first and second survey rounds involved a combination of a series of questionnaires and face-to-face interviews to obtain ideas or opinions about descriptions of the CT assessment tool. The third round was the meeting with 13 panel members to reach a consensus on the descriptions of the CT assessment tool.

Results

The number of descriptions changed from 29 to 30 under seven assessment criteria of the cognitive skills and from 34 to 32 under 10 assessment criteria of the habits of mind as disposition. The panel provided active comments on the descriptions in terms of social, cultural, and educational backgrounds. Especially the descriptions of criteria applying standards and creativity were discussed from practical viewpoints such as the hierarchical social structure in hospital, limited educational resources, and the cultural value of harmony.

Conclusions

The holistic CT assessment tool that resulted from the consensus is anticipated to help Laotian nursing educators to assess undergraduate nursing students' CT ability more efficiently with confidence at both the university and hospitals continuously. Subsequent implementation of the CT assessment tool in a socialist low-middle income country is warranted.

Does Self-Directed Learning with Simulation Improve Critical Thinking and Motivation of Nursing Students? A Pre-Post Intervention Study with the MAES© Methodology

Motivation and critical thinking are fundamental for the development of adequate learning. The purpose of the present study was to assess the motivation for learning and critical thinking among nursing students before and after self-directed simulation-based training using the MAES© methodology. A cross-sectional and descriptive quantitative study was conducted with a sample of third-year nursing students. The instruments utilized were the Spanish-adapted version of the Motivated Strategies for Learning Questionnaire (MSLQ-44), and the Critical Thinking for Nursing Professionals Questionnaire (CuPCPE). The students improved their levels both of motivation components, (such as self-efficacy, strategy use, self-regulation) and critical thinking components (such as personal characteristics, intellectual and cognitive abilities, interpersonal abilities and self-management, and technical abilities). These improvements could be a result of the intrinsic characteristics of the MAES© methodology (as a team-based, self-directed, collaborative and peer-to-peer learning method).

Critical thinking among clinical nurses and related factors: A survey study in public hospitals

AIMS AND OBJECTIVES

The study investigated clinical nurses' critical thinking levels in public hospitals and related factors.

BACKGROUND

Since health care environments have become more complex, the critical thinking skills of clinical nurses are more important in daily problem-solving and decision-making processes. However, little research was conducted on this topic among clinical nurses.

METHODS

It was a cross-sectional study at five public hospitals between December 2018 and January 2019. The study followed the STROBE guideline. Data were collected from 559 nurses by a survey consisted of a data form and the Turkish version of the Nursing Critical Thinking in Clinical Practice Questionnaire.

RESULTS

Nurses' mean critical thinking scores were moderate level. Total critical thinking scores of the clinical nurses significantly differed according to education, hospital type, shift work, professional category and role. There was a significant effect on the total critical thinking scores of the clinical nurses according to variables.

CONCLUSION

This study found that critical thinking levels of nurses' working in clinical settings in public hospitals were moderate level. Hospital type, shift work, professional and educational level and role were significantly associated with clinical nurses' critical thinking levels.

RELEVANCE TO CLINICAL PRACTICE

This study provides evidence related to the levels of critical thinking of clinical nurses working in public hospitals. Since the critical thinking scores of the manager nurses, daytime working nurses' and nurses with bachelor's and master's degree education are higher, hospital managers may benefit from the study to implement effective strategies to improve the competence of critical thinking levels of nurses.

Development of critical thinking skills of undergraduate students throughout the 4 years of nursing degree at a public university in Spain: a descriptive study

OBJECTIVE

To analyse the critical thinking skills of students enrolled in the four academic years of the nursing degree at a public university belonging to the European Higher Education Area.

DESIGN

Cross-sectional, quantitative, descriptive study. Using the Critical Thinking Questionnaire to analyse the critical thinking skills in their substantive and dialogic dimension.

SETTING

Faculty of Nursing, Valladolid Public University in Spain, belonging to the European Higher Education Area.

PARTICIPANTS

The sample consisted of 215 first-year, second-year, third-year and fourth-year undergraduate nursing students.

MAIN OUTCOMES

The students of the four academic years were positively disposed towards critical thinking. The students of the final courses obtained higher average scores.

RESULTS

The study sample was 215 students, 19.1% men/80.9% women. The average score in the substantive dimension (3.81±0.53 points) was higher than that in the dialogic dimension (3.48±0.51 points) (p<0.001). They had a greater ability in listening and speaking (3.77±0.61 points) with respect to writing (3.65±0.61 points) and reading (3.52±0.43 points) (p<0.001). There are significant differences in the critical thinking average scores across academic years.

CONCLUSIONS

Nursing students displayed a greater critical thinking ability in its substantive dimension compared with the dialogic one. This reflects a greater ability in actions related to provide reasons and evidence that support their point of view. Identifying critical thinking skills in nursing students will help establish specific teaching methodologies focused on improving these skills.

Cultural adaptation and validation of an instrument about nursing critical thinking skills

OBJECTIVES

to validate the Nursing Critical Thinking in Clinical Practice Questionnaire regarding cultural aspects and metric properties.

METHODS

a methodological research carried out through cross-cultural adaptation, face and content validity, dimensional construct and known groups validity, test-retest reliability and internal consistency. 511 nurses from four hospitals participated in the study, of which 54 participated in retest.

RESULTS

the instrument validation for Brazilian Portuguese maintained equivalences, according to the original version. The dimensional validity demonstrated adjustment to the tetrafactorial structure of the original version (GFI=0.69). There were statistically significant differences in critical thinking skills between nurses with graduate degrees and who undertook training, reading articles, developing research and working in an institution with a longer time implementation of the Nursing Process. The instrument showed temporal stability (ICC 073-0.84; p<0.001) and adequate internal consistency (α=0.97).

CONCLUSIONS

the instrument proved to be valid and reliable for the studied population.

Evaluation of the validity and reliability of the Nurses' Responsibility in Healthcare Quality Questionnaire: An instrument design study

Nurses' awareness and acceptance of their professional responsibilities across the full breadth of safety and quality-related practices and behaviors are critical for high quality healthcare delivery. The purpose of this study was to develop and psychometrically test a new instrument to measure nurses' perceptions of their responsibilities related to healthcare quality. Participants were registered nurses, enrolled in a postgraduate program at an Australian university, who completed the Likert scale instrument with items developed from nurses' professional practice standards. Steps of pilot testing, item reduction, and confirmatory factor analysis resulted in a five-subscale, 55-item instrument with acceptable goodness-of-fit indices and good internal consistency reliability. Test-retest reliability demonstrated acceptable temporal stability. The Nurses Responsibilities in Healthcare Quality Questionnaire demonstrated acceptable validity and reliability. The instrument may assist education providers and health service managers to identify gaps between nurses' beliefs and professional role expectations, and evaluate the impact of educational and clinical initiatives designed to develop nurses' knowledge, skills, and attitudes related to healthcare quality.

Factors associated with the critical thinking ability of professional nurses: A cross-sectional study

Aim

To measure the level of critical thinking among Vietnamese professional nurses and to identify the related factors.

Design

A cross‐sectional design was used.

Methods

The total sample included 420 professional nurses. Data were collected from July to September 2019 in three public hospitals located in Southwestern Vietnam. The level of critical thinking was measured using the Vietnamese version of the Nursing Critical Thinking in Clinical Practice Questionnaire. The data were analysed using the independent Student's t tests, ANOVA, Pearson's correlation and regression analysis.

Results

Most of the participants had a low (48.3%) or moderate (45.5%) level of critical thinking. Age, gender, ethnicity, education level, health condition, duration of working as a nurse, duration of working in the current hospital, having heard the term “critical thinking” and work position had an impact on the critical thinking ability. Work position and gender explained 11% of the total variance in critical thinking ability.

The Vietnamese version of the nursing critical thinking in clinical practice questionnaire: Translation and psychometric evaluation

Aims

This study translated and evaluated the validity and reliability of the Vietnamese version of the Nursing Critical Thinking in Clinical Practice Questionnaire (N‐CT‐4 Practice (V‐v)).

Design

Forward‐ and back‐translation approach developed by Sousa and Rojjanasrirat (2011).

Methods

545 nurses were recruited based on convenience sampling and asked to complete the N‐CT‐4 Practice (V‐v) questionnaire for psychometric testing. Data were collected during June 2019 in three public hospitals located in Southwestern Vietnam. We evaluated translation equivalence, the item content validity index, floor/ceiling effects, construct validity, internal consistency reliability and test–retest reliability.

Results

The N‐CT‐4 Practice (V‐v) questionnaire retained the meaning of the original English version and was clear, explicit and easy for nurses to understand. The item content validity index was 1.0. There were no floor/ceiling effects. The Cronbach's alpha was 0.98. The intraclass correlation coefficient was 0.81. Confirmatory factor analysis indicated that this Vietnamese version fit the proposed model.

Psychometric properties of the critical thinking disposition assessment test amongst medical students in China: a cross-sectional study

BACKGROUND

Critical thinking disposition helps medical students and professionals overcome the effects of personal values and beliefs when exercising clinical judgment. The lack of effective instruments to measure critical thinking disposition in medical students has become an obstacle for training and evaluating students in undergraduate programs in China. The aim of this study was to evaluate the psychometric properties of the CTDA test.

METHODS

A total of 278 students participated in this study and responded to the CTDA test. Cronbach's α coefficient, internal consistency, test-retest reliability, floor effects and ceiling effects were measured to assess the reliability of the questionnaire. Construct validity of the pre-specified three-domain structure of the CTDA was evaluated by explanatory factor analysis (EFA) and confirmatory factor analysis (CFA). The convergent validity and discriminant validity were also analyzed.

RESULTS

Cronbach's alpha coefficient for the entire questionnaire was calculated to be 0.92, all of the domains showed acceptable internal consistency (0.81-0.86), and the test-retest reliability indicated acceptable intra-class correlation coefficients (ICCs) (0.93, p < 0.01). The EFA and the CFA demonstrated that the three-domain model fitted the data adequately. The test showed satisfactory convergent and discriminant validity.

CONCLUSIONS

The CTDA is a reliable and valid questionnaire to evaluate the disposition of medical students towards critical thinking in China and can reasonably be applied in critical thinking programs and medical education research.

Clinical nurses's critical thinking level according to sociodemographic and professional variables (Phase II): A correlational study

Critical thinking ability is one of the basic competencies of clinical nurse and is widely accepted as being associated with the provision of quality care, however, the few evidence-based data related to the relationship between level of critical thinking ability and nurses' sociodemographic and professional characteristics. The aim of this study was to identify the level of critical thinking among nurses in clinical practice according to sociodemographic and professional variables. Descriptive cross-sectional and correlational study was carried out in a sample of 339 nurses from medical, surgical and critical care units at a tertiary care hospital. This study is related to a previous publication that presents psychometric analysis. Data were compiled using the Nursing Critical Thinking in Clinical Practice Questionnaire and ad hoc form for the recording of sociodemographic and professional characteristics. The statistical analysis of the data was performed using frequency, Mann-Whitney U Test, Kruskal-Wallis Test, and Pearson's correlation coefficients. Nurses reported moderate levels of critical thinking. Older nurses, with 11-15 years of experience in the actual unit, with continuous shift work, a permanent contract and master's degree indicated a higher level of critical thinking. Critical thinking skills are related to certain socio-demographic and professional variables, particularly age, years of experience, shift work, type of contract and educational level.

Critical thinking: A comparative analysis between nurse managers and registered nurses

AIM

To analyse the levels of critical thinking among nurse managers and registered nurses and to explore the association between these levels and socio-demographic and occupational factors.

BACKGROUND

Critical thinking is an essential skill in advanced clinical nursing. However, few studies to date have explored critical thinking levels in nurse managers or compared them with those recorded in registered nurses.

METHODS

A randomized sample of 44 nurse managers and 295 registered nurses from a tertiary hospital in Barcelona participated in this study. The Nursing Critical Thinking in Clinical Practice Questionnaire was used to measure the level of critical thinking. The data were analysed using multivariate analysis by logistic regression.

RESULTS

Levels of critical thinking were higher in nurse managers than in registered nurses. Age, work shift schedule and educational level were associated with a higher level of critical thinking in nurse managers and were predictor factors.

CONCLUSIONS

This study identified age, work shift schedule and educational level as factors that impact on the acquisition of critical thinking skills among nurse managers.

IMPLICATIONS FOR NURSING MANAGEMENT

This study provides substantive evidence of the levels of critical thinking among nurse managers. When introducing strategies to enhance these skills, the associated occupational factors should be taken into account.

Measuring critical thinking in pre-registration midwifery students: A multi-method approach

OBJECTIVE

Test the concurrent validity of three newly developed tools (student self-rating, preceptor rating, and reflective writing) that aim to measure critical thinking in midwifery practice.

DESIGN

A descriptive matched cohort design was used.

SETTING

Australian research intensive university offering a three year Bachelor of Midwifery programme.

SAMPLE

Fifty-five undergraduate midwifery students.

METHODS

Students assessed their ability to apply critical thinking in midwifery practice using a 25-item tool and a 5-item subscale in Motivated Strategies for Learning Questionnaire. Clinical preceptors completed a 24-item tool assessing the students' application of critical thinking in practice. Reflective writing by students was assessed by midwifery academics using a 15-item tool. Internal reliability, and concurrent validity were assessed. Correlations, t-tests, multiple regression and confidence levels were calculated for the three scales and associations with student characteristics.

RESULTS

The three scales achieved good internal reliability with a Cronbach's alpha coefficient between 0.93 and 0.97. Matched total scores for the three critical thinking scales were moderately correlated; student/preceptor (r=0.36, p<0.01); student/reflective writing (r=0.38, p<0.01); preceptor/reflective writing (r=0.30, p<0.05). All critical thinking mean scores were higher for students with a previous degree, but only significant for reflective writing (t (53)=-2.35, p=0.023). Preceptor ratings were predictive of GPA (beta=0.50, p<0.001, CI=0.10 to 0.30). Students' self-rating scores were predictive of year level (beta=0.32, p<0.05, CI=0.00 to 0.03).

CONCLUSION

The student, preceptor, and reflective writing tools were found to be reliable and valid measures of critical thinking. The three tools can be used individually or in combination to provide students with various sources of feedback to improve their practice. The tools allow formative measurement of critical thinking over time. Further testing of the tools with larger, diverse samples is recommended.