What Have We Learned About Critical Thinking in Nursing?

Clinical Reasoning in Physical Therapy: A Concept Analysis

BACKGROUND

Physical therapy, along with most health professions, struggles to describe clinical reasoning, despite it being a vital skill in effective patient care. This lack of a unified conceptualization of clinical reasoning leads to variable and inconsistent teaching, assessment, and research.

OBJECTIVE

The objective was to conceptualize a broad description of physical therapists' clinical reasoning grounded in the published literature and to unify understanding for future work related to teaching, assessment, and research.

DESIGN/METHODS

The design included a systematic concept analysis using Rodgers' evolutionary methodology. A concept analysis is a research methodology in which a concept's characteristics and the relation between features of the concept are clarified.

RESULTS

Based on findings in the literature, clinical reasoning in physical therapy was conceptualized as integrating cognitive, psychomotor, and affective skills. It is contextual in nature and involves both therapist and client perspectives. It is adaptive, iterative, and collaborative with the intended outcome being a biopsychosocial approach to patient/client management.

LIMITATIONS

Although a comprehensive approach was intended, it is possible that the search methods or reduction of the literature were incomplete or key sources were mistakenly excluded.

CONCLUSIONS

A description of clinical reasoning in physical therapy was conceptualized, as it currently exists in representative literature. The intent is for it to contribute to the unification of an understanding of how clinical reasoning has been conceptualized to date by practitioners, academicians, and clinical educators. Substantial work remains to further develop the concept of clinical reasoning for physical therapy, including the role of movement in our reasoning in practice.

The need for academic electronic health record systems in nurse education

The nursing profession has been slow to incorporate information technology into formal nurse education and practice. The aim of this study was to identify the use of academic electronic health record systems in nurse education and to determine student and faculty perceptions of academic electronic health record systems in nurse education. A quantitative research design with supportive qualitative research was used to gather information on nursing students' perceptions and nursing faculty's perceptions of academic electronic health record systems in nurse education. Eighty-three participants (21 nursing faculty and 62 students), from 5 nursing schools, participated in the study. A purposive sample of 9 nursing faculty was recruited from one university in the Midwestern United States to provide qualitative data for the study. The researcher-designed surveys (completed by faculty and students) were used for quantitative data collection. Qualitative data was taken from interviews, which were transcribed verbatim for analysis. Students and faculty agreed that academic electronic health record systems could be useful for teaching students to think critically about nursing documentation. Quantitative and qualitative findings revealed that academic electronic health record systems regarding nursing documentation could help prepare students for the future of health information technology. Meaningful adoption of academic electronic health record systems will help in building the undergraduate nursing students' competence in nursing documentation with electronic health record systems.

Situation Awareness and Interruption Handling During Medication Administration

Medication administration error remains a leading cause of preventable death. A gap exists in understanding attentional dynamics, such as nurse situation awareness (SA) while managing interruptions during medication administration. The aim was to describe SA during medication administration and interruption handling strategies. A cross-sectional, descriptive design was used. Cognitive task analysis (CTA) methods informed analysis of 230 interruptions. Themes were analyzed by SA level. The nature of the stimuli noticed emerged as a Level 1 theme, in contrast to themes of uncertainty, relevance, and expectations (Level 2 themes). Projected or anticipated interventions (Level 3 themes) reflected workload balance between team and patient foregrounds. The prevalence of cognitive time-sharing during the medication administration process was remarkable. Findings substantiated the importance of the concept of SA within nursing as well as the contribution of CTA in understanding the cognitive work of nursing during medication administration.

Defining critical thoughts

Nursing education has long struggled to define critical thinking and explain how the process of critical thinking fits into the context of nursing. Despite this long time struggle, nurses and nurse educators continue to strive to foster critical thinking skills in nursing students as intuitively most nurses believe that critical thinking is necessary to function competently in the workplace. This article explores the most recent work of Dr. Stephen Brookfield and ties the concepts which are explored in Brookfield's work to nursing practice. Brookfield identifies that learners understand the meaning of critical thinking the best when the process is first demonstrated. Role modeling is a method educators can use to demonstrate critical thinking and is a strategy which nurses often use in the clinical area to train and mentor new nursing staff. Although it is not a new strategy in nursing education, it is a valuable strategy to engage learners in critical thinking activities.

Creating a culture of safety by coaching clinicians to competence

Contemporary discussions of nursing knowledge, skill, patient safety and the associated ongoing education are usually combined with the term competence. Ensuring patient safety is considered a fundamental tenet of clinical competence together with the ability to problem solve, think critically and anticipate variables which may impact on patient care outcomes. Nurses are ideally positioned to identify, analyse and act on deteriorating patients, near-misses and potential adverse events. The absence of competency may lead to errors resulting in serious consequences for the patient. Gaining and maintaining competence are especially important in a climate of rapid evidence availability and regular changes in procedures, systems and products. Quality and safety issues predominate highlighting a clear need for closer inter-professional collaboration between education and clinical units. Educators and coaches are ideally placed to role model positive leadership and resilience to develop capability and competence. With contemporary guidance and support from educators and coaches, nurses can participate in life-long learning to create and enhance a culture of safety. The added challenge for nurse educators is to modernise, rationalise and integrate education delivery systems to improve clinical learning. Investing in evidence-based, contemporary education assists in building a capable, resilient and competent workforce focused on patient safety.

A theoretically informed education program designed specifically for acute surgical nurses

AIM

The aim of the research was to evaluate the effectiveness of implementing the Respiratory Skills Update (ReSKU) education program using integrated teaching and learning strategies, in the context of organisational utility, on improving surgical nurses' practice in the area of respiratory assessment.

BACKGROUND

Technological advances and changes in healthcare delivery have necessitated that nurse educators adopt innovative teaching and learning strategies to better prepare acute care nurses for their increasingly complex roles. This 2007 study used a robust overarching theoretical framework to develop and evaluate an educational model using the ReSKU program as a basis for the content.

METHODS

The study was conducted in a 400 bed regional referral public hospital, in Australia. The research was guided by the work of Forneris (2004) to operationalise a critical thinking process incorporating the complexities of the clinical context. The theoretical framework used multi-modal, interactive educational strategies that were learner-centred and participatory. These strategies aimed to engage the clinician in dynamic thinking processes in clinical practice situations guided by coaches and educators.

CONCLUSION

The construct of critical thinking in practice combined with clinical reasoning and purposeful and collective reflection is a powerful educational strategy to enhance competency and capability in clinicians.

Do knowledge, knowledge sources and reasoning skills affect the accuracy of nursing diagnoses? a randomised study

BACKGROUND

This paper reports a study about the effect of knowledge sources, such as handbooks, an assessment format and a predefined record structure for diagnostic documentation, as well as the influence of knowledge, disposition toward critical thinking and reasoning skills, on the accuracy of nursing diagnoses.Knowledge sources can support nurses in deriving diagnoses. A nurse's disposition toward critical thinking and reasoning skills is also thought to influence the accuracy of his or her nursing diagnoses.

METHOD

A randomised factorial design was used in 2008-2009 to determine the effect of knowledge sources. We used the following instruments to assess the influence of ready knowledge, disposition, and reasoning skills on the accuracy of diagnoses: (1) a knowledge inventory, (2) the California Critical Thinking Disposition Inventory, and (3) the Health Science Reasoning Test. Nurses (n = 249) were randomly assigned to one of four factorial groups, and were instructed to derive diagnoses based on an assessment interview with a simulated patient/actor.

RESULTS

The use of a predefined record structure resulted in a significantly higher accuracy of nursing diagnoses. A regression analysis reveals that almost half of the variance in the accuracy of diagnoses is explained by the use of a predefined record structure, a nurse's age and the reasoning skills of `deduction' and `analysis'.

CONCLUSIONS

Improving nurses' dispositions toward critical thinking and reasoning skills, and the use of a predefined record structure, improves accuracy of nursing diagnoses.

Can one learn to think critically? - a philosophical exploration

Within nursing, critical thinking is a required skill that educators strive to foster in their students' development for use in complex healthcare settings. Hence the numerous studies published measuring critical thinking as a terminal outcome of education. However, an important comparison between different philosophical underpinnings such as person, truth and the nature of nursing, and how one defines and utilizes critical thinking in practice, has been absent from discussions about critical thinking and learning. When one views critical thinking with varying philosophical lenses, important questions are raised and discussion is expanded. These questions illuminate different perspectives of critical thinking and attempt to explore whether critical thinking can be learned in nursing. The implications of taking a single philosophical viewpoint and a pluralistic approach to understanding critical thinking and learning are explored.

Clinical judgment: the last frontier for evaluation

Nursing educators and preceptors often find it difficult to evaluate prelicensure students' clinical judgment development. Clinical judgment is critical to excellent patient care decisions and outcomes. The Lasater Clinical Judgment Rubric, a validated, evidence-based clinical judgment rubric, is described as a tool that offers a common language for students, nurse educators, and preceptors and a trajectory for students' clinical judgment development. The rubric has been used to provide feedback for reflective journals and a means for self-evaluation in addition to a guide for formulating higher level thought questions to shape students' thinking like a nurse.

The revised critical thinking skills scale for a life-and-death course: preliminary scale refinement

BACKGROUND

Death education involves acquiring knowledge, changing behavior, and developing proper views of life in both the affective and the value domains. Critical thinking that is honed through reflecting on life-and-death issues represents a way to reach these goals. Designing assessments able to measure college student content and critical thinking skills related to life-and-death issues is thus important. The Test of Critical Thinking Skills for Life-And-Death content (TCTS-LD) instrument requires the administration of additional tests to assess reliability and validity for future use in the assessment of perceptions on life and death.

PURPOSE

The purpose of this study was to refine the TCTS-LD.

METHODS

A cross-sectional, descriptive design was used to recruit 715 college students in southern Taiwan. Three structured scales were administered in class to the participants. Data were collected in 2004 and 2006. Confirmatory factor analysis was applied to validate the structure of scales.

RESULTS

Examination of the reliability of the three-factor and 15-item scale revealed a Kuder-Richardson coefficient of internal consistency of .54. The split-half reliability coefficients were .47 in the Spearman-Brown correlation and .40 in the intraclass correlation coefficient (ICC). The test-retest reliability coefficients (n = 22) were .58 in Pearson correlation and .56 in ICC. In addition to content validity verification by experts and face validity by students, the validity of this test was assessed using three methods, including (a) a comparable validity rating between this test and the TCTS-A (r = .34, p < .001; (b) a contrast-group technique with different responses to the instrument between those in education and nursing majors (t = 2.71, p < .01), with scores of 10.98 (SD = 2.42) and 9.82 (SD = 2.25), respectively; and (c) a confirmatory factor analysis confirming that TCTS-LD is related to the three dimensions of assumption, evaluation, and induction (χ = 81.800, p = .158, normed chi-square χ/df = 1.169, comparative fit index [CFI] = .976, Tucker-Lewis index = .984, root mean square error of approximation [RMSEA] = 0.015). Three factors explained 31.19% of total variance for the revised TCTS-LD.

CONCLUSIONS

The revised TCTS-LD scale improved performance and effectiveness to a certain degree. However, reliability and construct validity must be further tested to permit its use as an evaluation tool.

Determinants of the accuracy of nursing diagnoses: influence of ready knowledge, knowledge sources, disposition toward critical thinking, and reasoning skills

The purpose of this study was to determine how knowledge sources, ready knowledge, and disposition toward critical thinking and reasoning skills influence the accuracy of student nurses' diagnoses. A randomized controlled trial was conducted to determine the influence of knowledge sources. We used the following questionnaires: (a) knowledge inventory, (b) California Critical Thinking Disposition Inventory, and (c) Health Science Reasoning Test (HSRT). The use of knowledge sources had very little influence on the accuracy of nursing diagnoses. Accuracy was significantly related to the analysis domain of the HSRT. Students were unable to operationalize knowledge sources to derive accurate diagnoses and did not effectively use reasoning skills.

Exploring perceptions of a learning organization by RNs and relationship to EBP beliefs and implementation in the acute care setting

BACKGROUND/RATIONALE

Health care professionals are expected to provide patient care based on best evidence. The context of the acute care setting presents a challenging environment for registered nurses (RNs) to utilize research and implement best evidence in practice. No organizational infrastructure has been identified that offers acute care RNs the support needed for evidence-based practice (EBP). The value of "learning organizations" has long been understood by corporate leaders. Potentially, the dimensions of a "learning organization" may offer a supportive EBP infrastructure for acute care RNs.

RESEARCH QUESTIONS

(1) What is the relationship of the characteristics of the learning organization to registered nurses' beliefs regarding EBP? (2) Is there an impact of EBP beliefs on RNs' implementation of EBP?

METHODS

A descriptive, survey design study was conducted. Three established questionnaires were distributed to 1,750 RNs employed within six acute care hospitals.

RESULTS/FINDINGS

There were 594 questionnaires returned for a response rate of 34%. RNs rated their organizations in the mid-range on the dimensions of learning organization. Perceptions of the learning organization were found to be significant, although relatively small, predictors explaining 6% of knowledge beliefs, 11% of value beliefs, and 14% of resource beliefs. EBP beliefs explained 23% of EBP implementation reported by RNs.

DISCUSSION

The study results indicate relationships between RNs' reported perception of a learning organization and EBP beliefs, and between EBP beliefs and implementation. However, findings were mixed. Overall, nurses rated their organizations the lowest in the dimensions of "promote inquiry and dialogue" and "empower people toward a collective vision." Leaders have an opportunity to offer a more supportive infrastructure through improving their organization in these two areas. RN beliefs explained 23% of EBP implementation in this study with a residual 77% yet to be identified.

IMPLICATIONS

Acute care hospitals were perceived mid-range on learning organization dimensions by RNs, indicating an opportune area for leaders to strengthen their organizational infrastructure.

High-Fidelity Simulation and the Development of Clinical Judgment: Students' Experiences

Nursing education programs across the country are making major capital investments in alternative learning strategies, such as human patient simulators; yet, little research exists to affirm this new innovation. At the same time, nursing programs must become even more effective in the development of students' clinical judgment to better prepare graduates to take on increasingly complex care management. This qualitative study examined the experiences of students in one nursing program's first term of using high-fidelity simulation as part of its regular curriculum. On the basis of these experiences, it seems that high-fidelity simulation has potential to support and affect the development of clinical judgment in nursing students and to serve as a value-added adjunct to their clinical practica.

Critical thinking and clinical competence: results of the implementation of student-centered teaching strategies in an advanced practice nurse curriculum

The nursing profession has advanced dramatically over the past 50 years. People are living longer, technology is advancing at a rapid rate, and patients are presenting more critically ill. The recent move in the US and other countries away from secondary and tertiary care towards primary care will have a dramatic impact on the practice of nursing as the focus of treatment is aimed at prevention and maintenance of health. Budgetary constraints and a shrinking nursing workforce have added additional strain on the ability of nurses to remain clinically competent in this fast-paced healthcare environment. In addition, the demographics of students have shifted, with more adult and ethnically diverse students entering various nursing programs. These changes have compelled schools of nursing worldwide to revise their approach to student education to keep up with the challenge associated with these influences. Terms such as problem-based learning, critical thinking, evidence-based practice, and student-centered teaching strategies have replaced traditional terminology typically linked with education and practice. However, it appears that not all centers of nursing education have embraced the need to change to new methods of teaching and continue to teach as they were taught. This article will detail the approach used to develop and implement problem-based learning in an advanced practice nurse curriculum in the US. The results and recommendations for implementation are discussed based upon student and nurse educator feedback.

Comparison of native versus nonnative English-speaking nurses on critical thinking assessments at entry and exit

Diversity of language among healthcare employees and nursing students is growing as diversity increases among the general population. Institutions have begun to develop systems to accommodate diversity and to assimilate workers. One barrier to nonnative English-speaking nurse hires may be posed by readiness for the licensure exam and the critical thinking assessments that are now an expected outcome of nursing programs, and act as a gatekeeper to graduation and to employment. To assist in preparing for high-stakes testing, the Assessment Technologies Institute Critical Thinking Assessment was developed in compliance with credentialing bodies' educational outcomes criteria. This pilot study of 209 nursing students was designed to reveal any possible language bias that might act as a barrier to nonnative English speakers. Nursing students were entered as whole classes to the study to control for selection bias. A sample representative of national nursing enrollment was obtained from 21 universities, with 192 (92%) native English-speaking students and 17 (8%) nonnative English speakers participating in the study. All students were given the Assessment Technologies Institute Critical Thinking Assessment at entry and exit to their nursing program. Average scores on entry were 66% for nonnative speakers and 72% for native speakers. At exit, the nonnative speakers had closed the gap in academic outcomes. They had an average score of 72% compared to 73% for native speakers. The study found that the slight differences between the native and nonnative speakers on 2 exit outcome measures-National Council licensure examination (NCLEX-RN) pass rates and Critical Thinking Assessment-were not statistically significant, demonstrating that nonnative English speakers achieved parity with native English-speaking peers on the Critical Thinking Assessment tool, which is often believed to be related to employment readiness.

Cultivating interpretive thinking through enacting narrative pedagogy

Teachers and educational researchers in nursing have persisted in their attempts to teach students critical thinking and to evaluate the effectiveness of these efforts. Yet, despite the plethora of studies investigating critical thinking, there is a paucity of research providing evidence that teachers' efforts improve students' thinking. The purpose of this interpretive phenomenological study is to explicate how students' thinking can be extended when teachers use Narrative Pedagogy. Specifically, the theme Cultivating Interpretive Thinking refers to how teachers' use of Narrative Pedagogy moves beyond the critical thinking movement's emphasis on analytical thinking (i.e., problem solving). Cultivating Interpretive Thinking offers an innovative approach for teaching and learning thinking that attends to students' embodied, reflective, and pluralistic thinking experiences. Teachers who cultivate interpretive thinking add complexity to students' thinking to better prepare them for challenging, complex, and unpredictable clinical environments.