STRATEGIES FOR PROMOTING

CRITICAL THINKING IN NURSING EDUCATION

1 Introduction

Nursing education has changed dramatically since Florence Nightingale asserted the

importance of education and moral standards to fulfill the nurse’s role. Based on these

criteria, selected candidates were trained under a formalized training program of nurses

(Russel, 2000). In the years of Nightingale’s system, nursing education was taken at hospital-

based. However, it has been transferred into the higher education sector in the late of 20 th

century (Russel, 2000; Sutton, 1996). According to Hart (1985), this transfer was influenced

by the increase of expectation of high quality nursing care, the changes role of women in

society followed by economic efficiency, political reasons and the needs of trained staff.

Regarding the purposes of higher education, Quinn (2000) outlines two aims of

education for undergraduate program. Firstly, the specific aims related to particular subjects

like nurse and midwifery. Secondly, general aims for all undergraduate programs such as

“development in communication skill, problem-solving, critical thinking and evaluation”. For

postgraduate level, students are directed to asses and evaluate their professional practice. p.

79. Furthermore, Adams (1999) states that nursing education has to develop students’ ability

to make decisions and solve problems which are necessary in providing high quality nursing

care which is safe and promotes wellness. Again, according to Adams (1999) these skills are

rooted from critical thinking which builds skills in making decisions and solving problems.

Therefore, within the transfer of nursing education into university, nurse educators

have to create appropriate curriculum and develop innovative teaching strategies to facilitate

student’s critical thinking skills in learning process (Bell, et.al 2002). Requirement to

integrate critical thinking in nursing education was asserted since the National League for

Nursing Accreditation Commission and The Commission on Collegiate Nursing Education in

US has asked nursing schools to develop student’s critical thinking ability (Billings and

Hastead, 2005).

There are various meaning of critical thinking that has been formulated by experts

over the years (Myrick, 2002). Watson and Glaser (1980) define critical thinking as elements

of attitudes, knowledge and skill which involve inference; acknowledge the assumptions,

deduction, interpretation and evaluation of arguments. Meanwhile, Girot ( as quoted in

Banning, 2006) state that critical thinking is “a complex cognitive process requiring higher

order thinking and application to decision-making in practice”. Alfaro-LeFevre (1995)

describes that critical thinking in nursing field including outcome-directed, purposeful

thinking; promote nurses to not focus on assumption but make a decision based on evidence,

built on scientific approaches and principles; and needs methods to maximize potentiality of

human and compensate for difficulties that come from human nature. Moreover, Edwards

(2007) identify five concepts that include in critical thinking that are critical, analysis,

thinking, synthesis and creative.

In addition, based on American Philosophical Association Delphi report on critical

thinking in 1990, it was concluded that dispositional characteristics of critical thinking

(affective) is needed to develop this skill. It includes inquisitiveness, open-mindedness,

systematicity, analicity, truth seeking, self-confidence and maturity (Walker, 2003).

Even though the definition of critical thinking is diverse, there is no doubt that this

skill is essential in nursing education. (Profetto-McGrath, 2005; Koch and Speers,1997).

However, the implementation of teaching method to enhance critical thinking has several

challenges and difficulties that have to be encountered.

In order to explore the challenges and useful strategies to promote critical thinking, in

the following essay, the challenges in developing critical thinking would be presented

followed by several strategies to promote critical thinking in nursing education.

2 The challenges in developing critical thinking

The application of critical thinking in nursing education has been introduced in the

past few years which mean this concept is new in nursing education. Therefore; it is not easy

to shift the former teaching-learning methods into a new curriculum. Nurse educators have

experienced several challenges and difficulties in developing and assessing students’ critical

thinking skills (King and Shell, 2002).

Edwards (2007) identifies several problems that hamper development of critical

thinking skill. The first problem is there are numerous of literature of critical thinking which

is too theoretical and using complex language or jargon in the articles. It results in an

ambiguity to understand and to apply critical thinking concept into clinical practice.

Secondly, the various definition of critical thinking that caused by different perspective of

authors in viewing critical thinking creates some doubtful among nurse educators. Further,

Edwards (2007) assumes that the one cause of why critical thinking process is not employed

in clinical practice is the confusion of the term critical thinking, reflective practice and

decision-making.

The other difficulties in promoting critical thinking skill are found by Girot (1995).

Girot’s study reveal two problems. First, the student’s abilities to encourage cognitive skills

are more emphasized in academic field rather than clinical practice. Second, in actual

practice, student’s critical thinking ability are assessed mostly by practitioners who do not

indicate expand this skill by themselves. Moreover, Billings and Halstead (1995)

acknowledge that mostly, faculty use traditional model in teaching which mainly dominate by

teacher. They claim that this model is not contributed to encourage critical thinking. The use

of teacher-centered in learning has produced students who are passive in learning process,

whereas, the ability to think critically will be growth when students engaged actively in

learning process (DeMarco, Hayward and Lynch, 2002). It is one of challenges for nurse

educators to create strategies that bring students into active learning style.

In addition, based on my own experience in Indonesia, the use of one-way

communication in teaching process is still common. May be, it is because the influence of

culture where students hesitate to communicate with teachers who is considered have to be

respected. It still influences attitude of students and relationship with teacher either in

classroom or in clinical practice.

On the other hand, nurse educators ‘attitude have an important role in learning

process. Mostly, teachers act in an authoritarian manner which is not conducive in learning

environment, while to develop critical thinking, disclosure relationship and consider students

as colleague are necessary.

3 Strategies for Promoting Critical Thinking

An integrative review that was conducted by Adams (1999) revealed that no consistent

indication that nursing education play a role to develop student’s ability to think critically.

This finding shows that the results of critical thinking development do not come yet. In order

to achieve the goals to develop students’ critical thinking ability, nurse educators have to

review their curriculum and lesson plans continuously. Faculty also needs to shift their

philosophy of teaching to support this process, while environment which free from risk to

support students to become active learners should be constructed as well. (Billings and

Halstead, 2005). Furthermore, some strategies in teaching-learning process have to be

expanded by finding reliable resources and employing relevant strategies to empower

students. Another way to discover new strategies is by conducting some research in nursing

education.

The following are some innovative strategies to promote critical thinking based on a lot

of research findings.

3.1 Active learning strategies.

Walker (2003) emphasizes that in critical thinking, an individual have to get involve in

thinking process actively. Abilities to analyze and evaluate information and inferences

indicate the engagement in critical thinking process. To develop these abilities certain

characteristics and self awareness are needed. Moreover, Walker (2003) discusses several

active learning strategies such as questioning, discussion, and written exercises.

3.1.1 Questioning

Nurse educators can use various questioning methods that enhance students to analyze

and synthesize the facts and concepts. Walker (2003) identify several words or sentence to

start the questions including the use of word “explain, compare, why, what is the best and

why, which is the best solution, do you agree or disagree”. Another type to encourage

students’ thoughts is by asking students who do not raise their hand. Further, he suggests to

not using questions which have only one point of view. Similarly, an ethnographic study

conducted by Twibell, Ryan and Hermiz (2005) reveals that in clinical instructor use multiple

questioning to encourage critical thinking. The use of series of simple question is considered

more useful rather than a general question. Skill to create high-level questions to stimulate

critical thinking needs to be learned either by educators or students.

Further, Profetto-McGrath, et.al (2004) undertook a study of the type of questions asking

by nurse educators and students a baccalaureate nursing program in Canada during first three

years of program. In this study they found that the type of questions was form low-level

questions including knowledge, comprehension and application). They suggested that nurse

educators and students should learn to formulate high-level questions that call for analysis,

synthesis and evaluation.

3.1.2 Classroom discussion and debate

Another strategy to enhance active learning according to Walker (2003) is classroom

discussion and debate. The controversial issues in debate can develop critical thinking.

Students are stimulated to perform strong arguments to defend their opinion. Galotti (as cited

in Walker ,2003) discusses strategy to observe student’s reasoning skill that. In this method,

students are instructed to work in pair and are given 4 reasoning tasks. Student who get the

tasks have to talk a lot while another student have to observe and write the key words.

3.1.3 Writing: assignments/informal journals

Written assignments give students opportunity to think critically. Oermann (as cited in

Walker 2003) state that the general rule for assignments which is used to promote critical

thinking is assignments should not too long paper. In clinical practice, written assignments

are also useful to develop critical thinking skill. For example: “review of nursing care plans, a

milieu assessment, clinical case study and management problems analysis” (Twibell, Ryan

and Hermiz , 2005).

Billings and Halstead (2005) identify several steps in evaluating writing tasks, they are:

arrange the assignment with the final grading in mind, review the whole paper rather than

focus on grammar and style. Then, peer review of drafts, specifies criteria of grading, identify

students’ learning needs by giving the flexibility of the topic. Finally, review of students’

draft as the beginning assessment is important, it also assists teacher to recognize if any

problems emerges.

3.1.4 Case Study/Case-Based Instruction/Case Problem/Case Scenario

Case study is one of active learning strategies. According to Billings and Halstead

(2005), definition of case study is “in-depth analysis of a real-life situation as a way to

illustrate class content; applies didactic content and theory to real life, simulate life or

both”(p. 296). By using this method, nurse educators have to create well-designed scenarios

to provide opportunities for students to overcome the problems and relate it to their clinical

practice. Moreover, explain that nurse educators have to analyze the scenario to determine the

possibilities of student’s response in analyzing the scenario. Then, in class session nurse

educators have to give relevant questions and motivate students who prefer passive learning.

Giving corrections to misconceptions and provide a conclusion of the important parts.

In addition, state that case-based instruction can be focused either on student individually

or a group of students. Students can work together to find solutions of the complex cases.

Nurse educators play a role as facilitator and encourage students to analyze, do active

research, solve the problems and critiques other students their group.

From the result of their study of case-based instruction, DeMarco, Hayward and Lynch

(2002) found that this learning strategy enable students to solve the problems similar to the

real world situation. It is considered stimulate students to think critically, solve the problems,

make prioritize, work in team and value the task of nurse manager. Further, they conclude

that case-based instruction raise students ‘confidence about their lessons and expand

student’s knowledge from clinical field to the classroom.

3.2 Mind Mapping/Concept Mapping

Billings and Halstead (2005) define mind mapping or concept mapping as “learning

complex phenomenon by diagramming the concepts and sub concepts. Similarly, Gul and

Boman (2006) present that concept map is a general approach to elucidate the opinion about

an issue into a visual form.

Further, King and Shell (2002) state that concept mapping is a useful teaching approach

to develop critical thinking and the main goal of concept mapping is to synthesize pertinent

data. Then, they illustrate the process of mind mapping. For example, in clinical practice the

reason for “seeking help” is arranged as the center of map. Then other important data such as

nursing diagnoses, sign and symptoms, nursing intervention and other patient’s needs are

clustered and linked to the center. With the identification of concept and diagram, students

start to analyze the case and try to find other information and relationships between

components in the diagram and concept. By filling the gaps in diagram, students begin to

prepare a decision.

Hicks-Moore (2005) reports that students showed that the use of concept maps were

useful in preparing their clinical practice and it enhanced them to think critically. In the same

way, faculty recognized that this strategy was valuable because it allowed faculty to insight

the level of student understands and assisted faculty in assessing student’s performance.

On the other hand, the process in constructing concept mapping is assumed time

consuming, particularly when students have to prepare it for more than one patient. Yet, it

become easier when this method is practiced continuously (Hicks-Moore, 2005).

3.3 Problem-Based Learning (PBL)

According to Billings and Halstead (2005), problem-based learning is a method that

applied to the whole curriculum. In addition, Wilkie (2000) defines PBL as “an instructional

method in which students work in small groups to gain knowledge and acquire problem-

solving skills.” (p.11)

In PBL, students work in a small group and share the information with their friends.

During the interaction, students should perform openness and honesty (Baptiste, 2003). Frost

(1996) describes that an issue in PBL is delivered before learning session by using videos,

audio-tapes, a scenario or case notes.

Tiwari et, al (2006) reports that students who were taught used PBL method had higher

level of critical thinking disposition compared to students who attended lecture group.

Moreover, students in PBL class felt that this method enhanced them to analyze problems,

gain a critical methods to investigate data related to the issue and taught them work

systematically. In addition, Quinn (2000) explains that PBL is more useful in computer-

assisted learning. Within the use of simulation and case method, students are motivated to

formulate a set of care plan based on a basic data of patient in the computer.

However, the implementation of PBL spends amount of time for creating problem

situation, the exchanges roles between lecturer and students and students need clear

explanation about the roles (Billings and Halstead, 2005).

4 Conclusion

Indeed, the ability to think critically is essential in nursing education and many efforts

have been under taken by experts and scholars to develop it. Various strategies to promote

critical thinking have been discovered by a number of researchers.

However, there are a lot of constraints and challenges that requires our attention. The

process to implement strategies to facilitate critical thinking needs time and hard works. The

insight of concept of critical thinking is important and faculty which has the main role in

developing critical thinking should provide relevant training for the nurse educators, create

conducive learning environment and expand the curriculum that stimulate critical thinking for

students.

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