Literature Review of the State of Nursing Education

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Healthcare is a rapidly growing and an eternally changing field. Technology is changing at a rapid pace, patients and family members are insisting on better quality of care, government officials and hospital administrators want nurses to contain costs, patients are being discharged from the hospital quicker, patient populations are getting older and presenting with more complex diseases, and patient acuity is increasing. All of these characteristics of the current healthcare system demand that new nurses arrive at their first job with critical thinking skills that allow them to provide safe and competent care in settings that require them to sift through an immense amount of data and incorporate this data into life-and-death decision making. Novice nurses must be able to apply their critical thinking skills in various settings under numerous conditions. I will define what critical thinking is, describe the role of critical thinking in nursing, and describe current teaching strategies and evaluation methods related to developing critical thinking skills in nursing students.

A review of literature was conducted on the topic of critical thinking by accessing CINAHL, MEDLINE, and Google Scholar. Due to a limited amount of research produced within the last five to ten years it was necessary to expand the search to as far back as 20 years to find some important studies completed on the topic. Beginning research on the topic of critical thinking provided many ambiguous definitions of what exactly critical thinking is. The definition that is my personal favorite was published by Paul (1993) and is as follows, "Critical thinking is thinking about your thinking while you're thinking in order to make your thinking better" (p.91). To make the problem of not having a clear, specific, definition worse most of the definitions that where developed where theoretical and not very practical for use by faculty in higher education settings. Before teaching strategies can be designed to promote critical thinking teachers and students need a clear understanding of what critical thinking is and is not. This large array of definitions of critical thinking and lack of clarity on the issue lead to the Delphi report in 1990. Simpson and Courtney (2002) write:

The multitude of ambiguous definitions of critical thinking led the American Philosophical Association to enlist the services of Peter Facione, a well known philosopher, in 1987 to make a systematic inquiry into the current state of CT and CT assessment. After acknowledgement by the APA in 1990 the report by Facione came to be known as the Delphi Report (p. 92).

The Delphi Report provided academia with a clear and in-depth definition of critical thinking. Facione's Consensus Statement Regarding Critical Thinking is as follows:

We understand critical thinking to be purposeful, self-regulatory judgment which results

in interpretation, analysis, evaluation, and inference, as well as explanation of the evidential, conceptual, methodological, criteriological, or contextual considerations upon which that judgment is based. CT is essential as a tool of inquiry. As such, CT is a liberating force in education and a powerful resource in one's personal and civic life. While not synonymous with good thinking, CT is a pervasive and self-rectifying human phenomenon. The ideal critical thinker is habitually inquisitive, well-informed, trustful of reason, open-minded, flexible, fair-minded in evaluation, honest in facing personal biases, prudent in making judgments, willing to reconsider, clear about issues, orderly in complex matters, diligent in seeking relevant information, reasonable in the selection of criteria, focused in inquiry, and persistent in seeking results which are as precise as the subject and the circumstances of inquiry permit. Thus, educating good critical thinkers means working toward this ideal. It combines developing CT skills with nurturing those dispositions which consistently yield useful insight and which are the basis of a rational and democratic society. (p. 3)

After 1990 the emphasis in the research changed from "What is critical thinking?" to "How do instructors teach critical thinking?" and "How do faculty members reliably and validly evaluate critical thinking?" Simpson and Courtney (2002) write, "Techniques of instruction need to promote active modes of learning in teaching students how to evaluate the depth of information imparted, develop analysis skills, communication and application of information in new and unique ways" (p. 94). So now the profession has some good definitions of what critical thinking is but we do not have many well researched strategies dealing with how to develop critical thinking in students and how to evaluate strategy outcomes. Research on how to effectively teach students to become critical thinkers and how to evaluate critical thinking reliably and validly continues to this day.

Well developed critical thinking skills are a necessity in the rapidly and continuously changing profession of nursing. Novice nurses must be able to solve complex problems independently, creatively, correctly, and in a timely manner. Moreover, for the most part nursing is not a field where arriving at solutions to complex problems via trial-and-error experimentation is acceptable. Employers and society expect novice nurses to make the correct decision the first time they are presented with a new problem. Additionally, sometimes these decisions must be made under intense pressure. Nurses also must be able to reflect critically on their decisions so that they can learn from the situations they were involved in and gain knowledge of how they might take more appropriate actions the next time the situation arises. Essentially nurses must learn early in their education how to become life-long learners and effective critical thinkers so that they may function as competent nurses for the rest of their careers.

Since the development of critical thinking skills is so important nursing educators in today's universities are met with the immense challenge of trying to find unique and engaging ways of teaching their students how to critically think and how to become life-long learners. Dexter et al. (1997) writes:

Nursing educators are being challenged to imbue in students lifelong habits of rational thinking in relation to their nursing practice. This emphasis was formalized recently when critical thinking was implemented as one of five outcome criteria required for National League for Nursing (1989) accreditation of undergraduate and master's nursing programs (p. 160).

This task can be challenging due to the fact that research into the best ways to teach and analyze critical thinking is still deficient. Chenoweth (1998) writes:

Because of the multiple learning needs of nursing students in any one curriculum, the results (of the study) suggest that it was difficult for respondents to suggest one approach that was more beneficial than another. Nor is there found to be a single strategy for all situations or students (p. 290-291).

Due to the rapidly changing healthcare profession nursing faculty can no longer just teach important nursing facts, they must instill in students skills that will allow the students to think critically in various situations and assess new information applicable to their practice for the rest of their careers. Glen (1995) writes:

Because learning is a life-long process the key issues for nurse educators is that nurses be taught how to think rather than what to think. If one teaches nurses how to think for themselves they will have the tools to meet the ever-increasing demands of a practice life-time (p. 175).

Therefore, nursing educators must not only be able to teach in way that engages each individual student's specific learning styles, they must also find a way to inspire students to become lifelong promoters of their own critical thinking skills.

Educators are not the only ones responsible for how well their students develop critical thinking skills. The process of developing into a critical thinker requires active participation of both the student and the teacher. Students should not expect that they can go through a nursing curriculum and passively gain critical thinking skills. In addition, students can not go through nursing school memorizing how to do technical skills and expect that when they get out into a real practice setting that a doctor or someone else will tell them when to utilize those skills. Employers expect new nurses to use their own accurate judgments to practice autonomously in a safe and competent manner based on correct knowledge of a patient's conditions. Students must remain open-minded, curious, self-confident, and eager to search for various solutions to complex problems they are presented with. Simpson and Courtney (2002) write, "Critical thinking is associated with elements such as knowledge, active argumentation, reasoning, initiative, intuition, application, analyzing complex meanings, identification of problems, envisioning alternatives, and making contingency-related value judgements" (p. 93). The students must develop attitudes that will make them push themselves to continue to acquire new knowledge and develop their critical thinking skills from their first day in the nursing program until they leave the profession. Motivation to continuously develop critical thinking skills and acquire new knowledge will result in a competent nurse that can efficiently assess the needs of patients and develop plans to effectively provide for those needs. Furthermore, a student that develops into a more open minded individual with sufficient critical thinking skills will be able to adapt more easily to challenges faced in all areas of his or her life.

Developing critical thinking skills via classroom instruction can be an overwhelming task even for the most experienced nursing educators. Educators must reassess their own teaching styles and develop creative classroom learning environments that engage students into actively developing critical thinking skills. Billings and Halstead (2009) write, "Active learning can be a very threatening situation. Faculty must create a risk-free environment that allows students to explore the content, make mistakes, reflect on the content, associate the content with experience, and transform the content into knowledge (McCabe, 1992)" (p. 240-241). There are numerous teaching strategies that can be utilized by nursing educators to provide effective learning experiences; each teaching strategy has its own advantages and disadvantages. Also, some strategies are better at imparting critical thinking skills than others. Some of the teaching strategies currently utilized are lectures, algorithms, debates, case studies, cooperative learning, demonstrations, story telling, games, imagery, concept mapping, portfolios, problem-based learning, questioning, journals, role play, self-learning modules, writing assignments, and group discussions just to name a few (Billings & Halstead, 2009; Simpson & Courtney, 2002). The specific strategies utilized must take into account the content to be taught, the types of learners to be taught, the philosophy underlying the broad curriculum outcomes, feasibility, and multiple other factors (Billings & Halstead, 2009). Until more research is completed on the topic of instilling critical thinking in students educators must make use of the strategies that they believe effectively provide students the most opportunities for developing critical thinking skills.

Clinical instruction also plays an extremely important role in the development of nursing students. Clinical experiences are where students will begin to utilize skills and develop habits that will form the foundation of their careers. The clinical setting allows the student to demonstrate his or her critical thinking skills and allows the instructor to observe and comment on those skills when necessary. The clinical practice setting is complex and constantly changing presenting many challenges for instructors and students alike. Nicholson, Gillis, and Dunning (2009) write, "Despite 40 years of nursing research history into the development of a valid and reliable method of assessing the clinical performance of nurses, there are no universally accepted tools. This remains a matter of concern for the profession" (p. 74). The various learning styles and ways of demonstrating skills by each individual nursing student can make the clinical instruction and learning process even more complicated. Additionally, the expertise and characteristics of the instructor and the feelings and thoughts of the student are important to consider when planning clinical assignments. Billings and Halstead (2009) write, "Clinical teaching involves the careful design of an environment in which students have opportunities to foster mutual respect and support for each other while they are achieving identified learning outcomes" (p. 287). Also, the clinical setting can be very anxiety provoking for some nursing students. To reduce anxiety about clinical practice nursing students should be given clear expectations about what is expected of them during each clinical experience. Clinical educators should also show their students respect and be supportive in an attempt to further reduce student anxiety. Some of the effective teaching strategies used in the clinical arena today are use of objectives, effective questioning, providing constructive feedback in a timely manner, peer teaching, pairing students for student-to-student instructions, exhibiting enthusiasm about the profession, establishing reward systems, and trying new and different teaching strategies (Billings & Halstead, 2009). Each strategy has its own advantages and disadvantages. In my experiences I have found that the use of multiple strategies produces the best results and is more likely to provide the students with a positive clinical experience.

Not only can teaching critical thinking be difficult but also evaluating critical thinking can be difficult. The literature is still lacking on what types of methods can be used to specifically, reliably, and validly evaluate critical thinking skills in nursing students. As I touched upon earlier, now that critical thinking is one of five outcome criteria required for National League for Nursing accreditation of undergraduate and master's nursing programs educators are not only met with the complex task of teaching critical thinking but also of evaluating critical thinking. Dexter et al. (1997) writes, "…the explicit incorporation of critical thinking outcomes and evaluation measures into nursing curricula has proved to be a complex task" (p. 160). A number of tools have been used in nursing to try and evaluate students' abilities to critically think. A few of these tools are the Watson-Glaser Critical Thinking Appraisal (WGCTA), the California Critical Thinking Skills Test (CCTST), and the California Critical Thinking Disposition Inventory (CCTDI) (Billings & Halstead, 2009). The WGCTA tests deduction, inference, recognition of assumptions, interpretation, and evaluation of arguments to arrive at a maximum score of 80 (Billings & Halstead, 2009). The CCTST was the first instrument that incorporated the findings from the Delphi Report to develop a standardized 34-item multiple choice test that provides an overall score for an individual's critical thinking skills that are thought to be necessary for college (Billings & Halstead, 2009). The CCTDI, which also incorporates the findings from the Delphi Report, is a 75-item instrument that measures students' attitudes, beliefs, and opinions relevant to critical thinking to provide an overall score and scores for each individual subscale (Billings & Halstead, 2009). Multiple research studies conducted on these tools have found all of them to be unreliable, inaccurate, and not specific enough to evaluate critical thinking skills in nursing students (Hicks-Moore & Pastirik, 2006). Much more research needs to be completed involving critical thinking theorists, nursing educators, and nursing students before a reliable and valid tool can be created to specifically evaluate the critical thinking skills of nursing students. Until the ideal tool is created nursing educators will have to utilize the best methods available to evaluate critical thinking skills. Some of the tools that are being utilized currently with good results are: concept maps, observation over time, comparing outcomes of skills against some set of criteria, questioning for critical thinking (Socratic questioning), conferences, problem-solving strategies, and written assignments/journals (Blake, 2005; Oermann, 1997; Facione, 1990; Hicks-Moore & Pastirik, 2006). Students will most likely be evaluated by all of these methods at some point in their nursing education. Research shows that although students find concept maps to be tedious, time consuming, and hard to get used to at first they eventually grow to find them very useful in helping them get the whole picture of a concept, understand information better, prioritize, and rationalize patient care better (Hicks-Moore & Pastirik, 2006). Instructors also like concept maps because they allow them to determine a student's level of knowledge, to clearly understand a student's thinking and analysis of data, and identify strengths and areas that need improvement (Hicks-Moore & Pastirik, 2006). Combinations of observation over time, questioning, conferences, problem-solving strategies, and written assignments have been shown to get students to apply previously acquired knowledge to the clinical setting, develop critical thinking skills, increase students' understanding of difficult concepts, and encourage the students to identify alternate courses of action and the consequences of each before they implement care (Oermann, 1997). Educators must use the methods that work best for a given student at a given time, use multiple methods, and change the methods at times so the student stays engaged in developing his or her own critical thinking skills.

In conclusion,