Nurse Education Today 33 (2013) 558–563

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Nurse Education Today

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Critical thinking and creativity in nursing: Learners' perspectives

Zenobia C.Y. Chan ⁎School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Hong Kong

⁎ Tel.: +852 2766 6426; fax: +852 2364 9663.E-mail addresses: hszchan@inet.polyu.edu.hk, zenob

0260-6917/$ – see front matter © 2012 Elsevier Ltd. Allhttp://dx.doi.org/10.1016/j.nedt.2012.09.007

s u m m a r y

a r t i c l e i n f o

Article history:

Accepted 18 September 2012

Keywords:Critical thinkingCreativityNursing educationLearners' perspectiveQualitative method

Background: Although the development of critical thinking and the development of creativity are major areasin nursing programme, little has been explored about learners' perspectives towards these two concepts,especially in Chinese contexts.Objectives: This study aimed to reveal nursing learners' perspectives on creativity and critical thinking.Design: Qualitative data collectionmethods were adopted, namely group interviews and conceptmap drawings.Settings: The process of data collection was conducted in private rooms at a University.Participants: 36 nursing students from two problem-based learning classes were recruited in two groups for thestudy.

Methods: After data collection, content analysis with axial coding approach was conducted to explore the nar-rative themes, to summarise the main ideas, and to make valid inferences from the connections among criticalthinking, creativity, and other exogenous variables.Results: Based on the findings, six major themes were identified: “revisiting the meanings of critical thinking”;“critical thinking and knowledge: partners or rivals?”; “is critical thinking criticising?”; “revising the meaningsof creativity”; “creativity and experience: partners or rivals?”; and “should creativity be practical?”.Conclusions: This study showed that learners had diverse perspectives towards critical thinking and creativity, andtheir debate on these two domains provided implications on nursing education, since the voices of learners arecrucial in teaching. By closing the gap between learners and educators, this study offered some insights on nursingeducation in the new curriculum, in particular to co-construct nursing knowledgewhich is student-driven, and toconsider students' voices towards understanding and applying creativity and critical thinking in nursing.

© 2012 Elsevier Ltd. All rights reserved.

Introduction

This study explored nursing students' perceptions towards criticalthinking and creativity. Although the developments of these two skillsare crucial in preparing professional nurses in the future (Lauder et al.,1999; Kalischuk and Thorpe, 2002; Neuman et al., 2009; Emmanuelet al., 2010), few studies have been conducted to explore learners' per-spectives towards these two concepts in nursing education, particularlyin Chinese contexts (Cooke and Moyle, 2002; Hall and Mitchell, 2008;Klunklin et al., 2011). To depict learners' views on critical thinkingand creativity in a holistic and comprehensive manner (Hydo et al.,2007; Lillyman et al., 2011), a total of 36 nursing students from twogroups were recruited for a class interview and a concept map creation.

Literature

Critical Thinking

While different disciplines struggle with a concise definition of criticalthinking (Marquis and Huston, 2006; Rolfe, 2008), little literature on

ia.chan@polyu.edu.hk.

rights reserved.

critical thinking was available in nursing education; yet nursingstudents' ability to think critically has been frequently analysed(Duchscher, 2003). According to the existing literature, critical thinkingcan be defined as clear and rational thinking, which consists of clarifica-tion, simplification, and organisation. In particular, clear thinking is anability to think precisely, systematically and structurally, which can helpavoiding linguistic pitfall and hence, construct logical arguments. Rationalthinking includes scientific reasoning, strategic thinking and logic whichenable learners to predict, explain and influence empirical phenomena.It allows one to verify whether the premises of an argument are true, rel-evant, and acceptable before evaluating its reasoning strength (Rolfe,2008; Lau, 2011). However, rather than prescribing the above definitionsof critical thinking to the participants, this study allowed them to revisitthe meaning and their perceptions of critical thinking in nursing educa-tion and practices.

It is important to help learners to develop critical thinking ability innursing care and education. With patients' increasingly complex healthneeds, nursing students should be equipped with integrated skills andtransferrable competency, critical thinking and rapid decision-makingskills (Lauder et al., 1999). The environment of healthcare systemhas also transferred from a process-oriented system (i.e. proceduresdependent and provider dominated) to an outcome-driven andevidence-based system that can be influenced by exogenous factors

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(Huber, 2010). Furthermore the nursing curriculum is largely theorybased. To help nursing students to put theory into practice hasalways been a challenge for nursing educators (Binding et al.,2010). Therefore Duchscher (2003), and Lisko and O'Dell (2010)emphasised that one primary goal of nursing education should beto help learners to develop critical thinking ability through experi-ence, inquiry, and reasoning.

Creativity

Regarding patients' safety, nurses should always follow the pro-cedures of providing healthcare services. Despite this, the role of crea-tivity in nursing care should not be overlooked since it is one of theessential components in solving problems. The definition of creativityis very broad and Lau (2011) summarised the meaning of creativityby three principles: (i) new rearrangement of old ideas; (ii) selectionof useful ideas; and (iii) exploration of connections among ideas.These three principles of creativity are relevant to nursing education.Due to their lack of life experience, nursing students are often tooyoung to empathise with older adults or critical patients. Humansimulations and other creative teaching modalities could help trans-ferring textbook knowledge to real-life situations so that nursingstudents could learn to value patients, develop new ways to carefor them, and eventually become successful decision makers in theclinical environment (Marquis and Huston, 2006; Robertson, 2006).Another reason for promoting creativity in nursing education isthat, nursing educators have to elucidate statistical analysis, abstractconcepts and interpretations. How to achieve optimal learning andretain students' long termmemories of materials becomes a challeng-ing task. Beitz and Robinson (1997) suggested that using creativeteaching approaches could enhance the productivity of traditionallecture approaches and therefore, learners of the new generationin health professions should develop general and lifelong attributesof thinking critically and creatively (Maslin-Prothero, 1997). Existingscholars have made much contribution to developing theoriesand practices of critical thinking and creativity competence; however,the validity of these contributions from learners' perspectivesparticularly in Chinese contexts remains uncertain. Although thedifferences of nursing programmes between western and easterncultures have been reduced due to the globalisation process andadvanced technology of information exchange (Wang, 2003), criticalthinking and creativity may not be highly appreciated in nursingeducation in Chinese contexts. Since learners may have differentunderstanding and expectations towards critical thinking and crea-tivity in nursing education, this study aims to fill the gap betweenlearners and educators by revealing learners' perspectives towardscritical thinking and creativity in nursing education.

Methods

Design

This study adopted a qualitative research approach to explorenursing students' perspectives towards critical thinking and creativitythrough group interviews and concept map drawing. The use ofsemi-structured interviews enables interviewers to elicit informationon specific topics by making reference to participants' own experi-ence while drawing concept maps is a common participant-orientedstrategy in nursing and psychological research that facilitates freereflection on personal experiences (Ausband, 2006; Guez et al.,2010). Through drawings, participants often reveal more diverseand deeper views subconsciously (Andrews and Ridenour, 2006).Therefore, the data collection strategies adopted in this qualitativeresearch consisted of class interviews and concept map drawing.

Sample and Setting

A total of 36 year one and year two students (including 10 malesand 26 females) were recruited from two problem-based learningclasses of Bachelor of Science in Nursing Programme at one Univer-sity. Each group of participants then attended a two-hour interviewfacilitated by the researcher and a trained research assistant in a pri-vate room before they were asked to create concept maps for criticalthinking and creativity respectively within an hour. Before the study,ethical approval of audio recording was obtained from the HumanSubjects Sub-committee of the University and a consent form withan information sheet was signed by all participants in advance.

Data Collection and Analysis

Since group interviews canprovidediverse perceptions via discussionamong participants (Gerrish and Lacey, 2006), two class interviewswereconductedwith a total of 36 learners. Participantswere also asked to cre-ate concept maps to apply decision-making ability in showing the rela-tionship between main themes and sub-concepts (Noonan, 2011). Thedata collected were transcribed verbatim and translated in English. Thenarratives were examined by the researcher and the research assistantthrough content analysis and main ideas were summarised in narrativethemes (Krippendorff, 2004; Hall and Irvine, 2009). To discover the caus-al connection among critical thinking, creativity, and other exogenousvariables, such as experience and knowledge, an axial coding approachwas adopted (Strauss and Corbin, 1998). To ensure that data analysiswas conducted in a rigorous and comprehensive manner, regular meet-ings were held to discuss categories selection and data saturation.

Results

Based on the content analysis of data, learners' perspectives oncritical thinking were summarised in the following three themes:“revisiting the meanings of critical thinking”; “critical thinking andknowledge: partners or rivals?”; and “is critical thinking criticising?”;while their perspectives on creativity were thematised as: “revisitingthe meanings of creativity”; “creativity and experience: partners or ri-vals?”; and “should creativity be practical?”. The quotes were identi-fied with the code Y denoting the year in programme and S denotingthe student number. Two concept maps were selected to depictlearners' perspectives on critical thinking and creativity.

Revisiting the Meanings of Critical Thinking

Although critical thinking is a popular term in education, someparticipants admitted that they did not know what it means. By mak-ing reference to their own experience, the other participants general-ly thought critical thinking should involve logical reasoning and thatin order to help understand the world and solve various problems,critical thinking should emphasise on making an argument withsound evidence rather than merely expressing an opinion:

• “Our instructor told us that if we want to show that we havethought thoroughly in our written reports, we could simply addour own opinion. But if we want to demonstrate our critical think-ing competence, we have to support our arguments with reasonor evidence.” (Y1S13)

Some participants added that critical thinking is not an exclusivecompetence of highly-educated people but that everyone can thinkcritically on different scales. A majority of participants echoed thatcritical thinking refers to multi-dimensional perspectives of highquality thinking:

• “My teacher said critical thinking should be renamed as ‘multi-dimensional thinking’. A coin has two sides or even more. One

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shows the critical thinking skill when he/she argues with a differentviewpoint on a certain matter. What we are doing is also a kind ofcritical thinking as different answers are given.” (Y1S9)

Since one can understand an issue fromdifferent perspectives, someparticipants thought that critical thinking may involve creativity bybreaking the traditional way of thinking and accepting others' views:

• “Critical thinking may sometimes involve creativity. It allows you totry to accept others' perspectives and think about these perspectivesso that you are not limited to one particular way of thinking.” (Y2S2)

The above three transcripts revealed that participants generallyfound that critical thinking involves logical reasoning, sound evi-dence, and multi-dimensional perspectives. Some participants linkedcritical thinking with creativity, proposing that creativity allows oneto accept others' views and make a more thorough judgement.

Critical Thinking and Knowledge: Partners or Rivals?

As critical thinking cannot be easily defined, participants debatedwhether fundamental knowledge was essential for demonstratingcritical thinking skills. Participants who supported that knowledgewas a prerequisite of critical thinking argued that if they had no con-cepts about an issue, they could not judge the validity of an argumentand therefore, would be easily influenced by others:

• “I think you will be critical in a particular aspect if you are familiarwith that area. For example, I was a chemistry student, so I ammore critical on chemistry-related issues. I haven't studied biologybefore, so I can't give any comments on that area.” (Y2S12)

Conversely, a few participants did not find knowledge essential incritical thinking:

• “Don't believe everything you read in books. Books may only pointout parts of the story. We should doubt the validity of books, evenfor those written by doctors.” (Y2S3)

To sumup, the participants did not reach a consensus aboutwhethercritical thinking and knowledge are partners or rivals. Some partici-pants found knowledge a prerequisite for making a sound judgement,while others argued that believing in established knowledge could pre-vent one from questioning the validity of arguments.

Is Critical Thinking Criticising?

Another debate on critical thinking was whether critical thinkingis equivalent to criticising. A number of interviewees clearly pointedout the difference between them:

• “Critical thinking refers to making sound judgement with evidence,so it doesn't necessarily mean criticising.” (Y1S3)

However, some participants were hesitant in applying criticalthinking because they did not want to “criticise” others:

• “I don't think we need to be critical all the time. We must believe insome facts in order to criticise one thing. If you believe in nothingbut try to criticise everything, it will be vague.” (Y1S10)

In the end, no conclusion could be drawn from the interviews regard-ing whether critical thinking and criticising were interchangeable. Morespecifically, while some participants clearly stated the difference betweencritical thinking and criticising, others seemed to have implicitly equatedthese two concepts during the discussion. Once the interview ended, eachgroup of participants was asked to create a conceptmap to illustrate theirperspectives towards critical thinking. One of the maps produced ispresented in Fig. 1.

This group of participants summarised the concept of critical thinkingas: interpret and organise relevant information; based on some

information; think out-of-the-box; analysis; logical, make sense; thinkfrom others' viewpoints; think about others' opinions; strategy; drawconclusions after reading different sources; think in different perspec-tives; read, evaluate and think in a differentway; screen some relevant in-formation; based on situation; comprehensive thinking of the scenario;(xv) linkage of objectives; and know how to improve. Among thesephrases, the definitions of critical thinking were shared among mostparticipants. Some phrases implied that critical thinking and knowledgeare partners rather than rivals while three phases were related to thepractice of critical thinking in problem-based learning classes. Althoughtwo phrases were related to the debate about critical thinking andcriticising, no mutual agreement could be made explicitly from this con-cept map.

Revisiting the Meanings of Creativity

After sharing their perspectives towards critical thinking, the par-ticipants expressed their views about creativity. They first presentedvarious definitions of creativity and described with consent thatcreativity should be uncommon, out-of-the-box, and non-traditional:

• “I think creativity is to think differently, just as using sketch books in ourpreviouspresentation.Wehadused PowerPoint and role play todopre-sentations, so we asked ourselves how to present our project this time.We should make changes or it would become very boring. We thengathered and thought about the way of presentation. In fact, no prog-ress was made at the beginning and we just sat there and drew somepictures. Suddenly, we had the idea of showing our own drawingsand it worked! Of course, we needed to think differently in order tobe creative.” (Y1S14)

Most participants related creativity with happiness, and men-tioned that one should be attracted to his/her work in order to en-hance the creativity of it:

• “I think ‘happiness’ is one of the elements in creativity. For instance,when our group wrote the poem in today's class, we had lots of fun.But it didn't mean we were not serious in learning.” (Y2S11)

• “You have to attract and impress people by being creative. To achievethis, you yourself should believe that your work is creative. In otherwords, at least you should be attracted bywhat you are doing.” (Y2S12)

From the above transcripts, although the definitions of creativity re-vealed by the participants were similar to those in existing literature in-cluding descriptions such as uncommon and non-traditional thinking,most participants associated happiness with creativity. This new per-spective could have stemmed from their learning experience withteaching innovations in problem-based learning classes.

Creativity and Experience: Partners or Rivals?

Similar to the discussion on critical thinking, participants debatedways of how to think “out-of-the-box”. Some argued that rules orexperiences may prevent someone from thinking creatively or beingopen-minded to accept new ideas:

• “The doctrines of Buddhism always emphasise ‘emptiness’. In thissense, it doesn't mean ‘nothing’. Instead, once you are relieved ofburdens, you can accept new things more easily. Just like what wealways say, we should think ‘out-of-the-box’.” (Y1S16)

However, other participants emphasised the importance of expe-rience and observations from external environment in enhancingcreativity:

• “I think creativity depends on inspiration, which comes from theexternal environment we know. If you just stay in a room andthink, you may not think of something creative.” (Y1S15)

Fig. 1. Concept map of critical thinking.

Table 1Suggestions for faculty education approaches from learners' perspectives.

Suggestions generated from learners' perspectives

Critical thinkingRevisit the meanings of critical thinking with learnersAssociate critical thinking with creativityConsider the cognitive logicalmodels in connecting knowledge and critical thinkingConfront the issue of interchanging the concepts of critical thinking and criticisingEliminating learners' psychological barriers of applying critical thinking

CreativityRevisit the meanings of creativity with studentsIncrease the enjoyment of learning from teaching innovationsConsider the cognitive logical models in connecting experience and creativityFuture research on balancing between creativity and applicability in nursing

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In the end, nomutual agreementwas reached ofwhether creativityand experience are partners or rivals. One participant made referenceto Buddhist philosophy and stated that experience may prohibit onefrom accepting new ideas, while another participant objected thisargument but proposed that experience could provide inspiration forgenerating creative ideas.

Should Creativity be Practical?

Another interesting debate occurred when participants discussedthe practical value of creativity. Some participants believed that thepractical outcomes of applying creativity should determine the valueof the creative ideas:

• “I think everyone has creativity but the value of this ability dependson how you apply it. If you can put your creative idea into practice,it means that your creativity is mature enough.” (Y1S17)

On the contrary, some participants thought that the ultimateachievement was irrelevant to the practice of creativity:

• “I think creativity should be something unrestrained, even thoughwhat you think may not be achieved in the end.” (Y1S1)

In the end, no conclusion could be made regarding the issueof whether creativity should be practical. Some participants wereconcerned with the practical contribution from a creative idea, whileothers did not care much. After the discussion, each group created aconcept map to present their perspectives towards creativity. Fig. 2shows the concept map of one of the groups.

This group described the concept of creativity as: action that noone did before; new; think out of a mixed idea and put newmaterialsinto it; don't follow the old way; an effective method for learning; dif-ferent from others; innovative; think out-of-the-box; brain storming;think differently from normal; interesting; new style; make up newthings yourself; not traditional; happy; funny; something new; canstimulate others' ideas happily; and sing a song. Most phrases writtenwere in general agreement with the existing literature in definingcreativity. Four phrases were related to happiness, which is a rathernew concept as compared with previous studies. Three phrases

were related to the practice of creativity in problem-based learningclasses.

Discussion

Based on the data collected, several implications to nursing educa-tion are proposed in relation to: (i) revisiting the meanings of criticalthinking and creativity; (ii) influence of knowledge and experienceon critical thinking and creativity, and (iii) psychological and practi-cal concerns of critical thinking and creativity (Table 1).

Revisiting the Meanings of Critical Thinking and Creativity

While nursing educators concern more on learners' development ofcritical thinking and creativity competence, the voice of learners isequally important for curriculum enhancement; therefore this studyrevealed learners' perspectives towards critical thinking and creativity.Although a small number of participants failed to define the term“critical thinking” explicitly, most of them could recall from previouslearning experience and suggested that critical thinking is regarded ashigh quality thinking with multi-dimensional perspectives, reasons,and evidence. Some participants associated critical thinking with crea-tivity, a perspective widely shared by nursing educators who proposedcreative ways to develop critical thinking skills. For example, Morrisonand Catanzaro (2010) recommended the use of simulation to improve

Fig. 2. Concept map of creativity.

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the integration of critical thinking among learners. Another creativeway of enhancing critical thinking is by using reflective writing in clin-ical nursing education to develop this competence through integratingdifferent concepts (Binding et al., 2010). With the many ways of en-hancing critical thinking skills, learners are encouraged to value the im-portance of critical thinking and practise it in academic and nursingenvironments (Duchscher, 2003).

Compared with critical thinking, it was easier for participants tocome up with mutually accepted definitions of creativity with de-scriptions such as thinking out-of-the-box, non-traditionally, and un-commonly. Different from traditional definitions, some participantsassociated creativity with happiness, which may be due to theirlearning experience in problem-based learning classes. Such findingsuggests that various teaching strategies could alter a learner's per-ception of creativity. If students enjoy teaching innovations, theirmotivations to learn and willingness to practise creativity will beenhanced. Revisiting the meanings of critical thinking and creativityfrom learners' perspectives implies a need for nursing educators toreflect on the fundamental concepts of these two domains in orderto design a suitable nursing programme for learners.

Influence of Knowledge and Experience on Critical Thinkingand Creativity

The participants demonstrated their critical thinking skills throughdiscussions regarding critical thinking and creativity. The two discus-sions onwhether knowledge and experience inhibit the capacity of crit-ical thinking and creativity revealed similar concerns from participants.Some participants believed that facts, humanity, social norms and mo-rality are the foundation of analytical reasoning and creative thinking.One participant felt that inspiration usually comes from careful observa-tion while another participant revealed that the chemistry knowledgelearnt in secondary school allowed her to be apt at practising criticalthinking skills on chemical issues. On the other hand, some participantsobjected the view that personal experience and established knowledgeenhance critical thinking and creativity. One participant cited the con-cept of emptiness in Buddhism and argued that knowledge and experi-ence may become a burden for making full use of creativity.

Contrary to the participants' diverse perceptions towards theinfluence of knowledge and experience on critical thinking and crea-tivity, many educational scholars advocated experiential learningtheory in enhancing critical and creative thinking skills and agreed

on the contribution of experience and research in converting substan-tial cognitive frameworks and enhancing creativity (Lisko and O'Dell,2010; Huber, 2010). Lau (2011) further proposed that creativity relieson raw materials such as knowledge and information. Therefore, onecould start thinking with a feature list of a particular item, and seewhether these features could be altered. Because of the gaps betweenlearners' and educators' perceptions of critical thinking and creativity,some question the feasibility of adopting cognitive logic models toconceptualise experience into application of creativity and criticalthinking in the existing curriculum (Ellermann et al., 2006); hence,nursing educators should evaluate the differences between learners'expectations and the existing trainings of critical thinking and crea-tivity, and consider whether the construction and practice of cogni-tive logical models should be enhanced or reformed in nursingeducation. Since one of the major roles of teaching is to supportlearners to develop critical thinking and creativity to discover knowl-edge themselves, nursing education should place more importanceon learners' needs and expectations on knowledge co-construction.

Psychological and Practical Concerns of Critical Thinking and Creativity

The remaining discussion regarding critical thinking and creativityfocused on psychological and practical concerns. Although some par-ticipants mentioned that critical thinking does not equal to criticising,many participants implicitly interchanged these two concepts duringthe discussion. Even though nursing programmes among various con-texts have been increasingly similar, due to influence of Chinese tradi-tional culture of harmony and compliance, some participants worriedthat it was inappropriate to apply critical thinking and “be critical allthe time”. This concern was well noted by Rolfe (2008). He pointedout that nursing scholars were often too nice to “attack” others by pro-viding critical comments and such attitude might hamper the devel-opment of critical thinking among nursing academics themselves,which in turn, affects nursing education. Therefore nursing educatorsshould confront the issue of interchanging the concepts of criticalthinking and criticising, and encourage learners to apply critical think-ing skills by eliminating their psychological barriers.

During the group interviews, the participants presented differentviews towards the practical value of creativity. Some participantsemphasised that the maturity of a creative idea depended on itsapplicability, while others were more concerned with the liberty ofcreativity rather than its ultimate achievement. The latter argument

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contrasts with Lau's (2011) idea of creativity. One of his principles ofcreativity was “selection of useful ideas”, which emphasises on rulingout unpractical ideas through applying and reviewing alternative op-tions. The difference between learners' and scholars' perspectives to-wards practical value should arouse the attention of nursingeducators. Regarding patients' safety, nurses should follow certainprocedures of healthcare provision. However, according to one partic-ipant, overemphasising on the practical value would prohibit theexploration of new ideas. It is hoped that future studies may providea clearer direction on balancing between creativity and applicabilityin nursing education.

Conclusions

The provision of critical thinking and creativity training is crucial inpreparing professional and ethical nurses. This study revealed nursingstudents' perspectives on critical thinking and creativity concepts, andshowed that while the participants shared similar ideas about criticalthinking (such as logical reasoning and multi-dimensional perspec-tives) and creativity (such as non-traditional thinking and happiness),they debated the influence of knowledge and experience on creativityand critical thinking, the practical value of creativity, and the differencesbetween critical thinking and criticising. Their debates shed some lighton nursing education, in particular to transferring learning process andco-construct healthcare knowledge, to encourage student-driven learn-ing, to eliminate Chinese cultural barrier of being “critical”, and to nur-ture students' creativity and critical thinking according to their needsand concerns (Lauder et al., 1999). It is hoped that future studies onlearners' perspectives would further clarify the fundamental conceptsof critical thinking and creativity, close the gap among teachers and stu-dents, and enhance the relevance between learners' expectation andplanning of nursing curriculum.

Acknowledgment

The author acknowledges the funding from Learning and TeachingCommittee of The Hong Kong Polytechnic University (Project Code:1.53.xx.465D).

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