Gloudemans, Schalk and Reynaert (2013, p.276) state,
Nurses with a Bachelor's degree are believed to use higher levels of cognitive skills: in higher education nursing programmes students for example learn how to analyse situations, reflect on their performance, evaluate interventions and make clinical judgements. In other words, they learn how to develop meta-cognitive skills known as critical thinking skills. This helps them cope with difficult, more complex and unexpected situations. They show initiative in learning how to deal with these kinds of situations, and thereby increase their level of self- efficacy.
One of the key outcomes of graduate education is the development of critical thinking skills (Girot, 2000a; Kreber, 2014). The concept of critical thinking dates back to the Greek philosophers and indicates a capacity to inquire, explore and synthesise ideas (Burrell, 2014; Fero, Witsberger, Wesmiller, Zullo & Hoffman, 2009). Since the 1980’s critical thinking has been increasingly debated in relation to nursing and nurse education (Burrell, 2014; Profetto-McGrath, 2005; Raterink, 2008). Many authors agree that there is a lack of a universally acceptable definition for critical thinking. It is a complex phenomenon that involves analysis (Burrell, 2014; Chan, 2013a; Facione & Facione, 2007), described as ‘robust’ by Morrall and Goodman (2013) and ‘rational’ by Zuriguel Pérez et al. (2015), the gathering, seeking and interpretation of information (Chan, 2013a), thoughtful problem-solving (Facione & Facione, 2007), and the application of theory (Chan, 2013a). Facione, Facione and Sanchez (1994) describe critical thinking as ‘giving reasoned consideration’, and Profetto-McGrath (2005) suggests it is likely to require the suspension of judgements. In addition, critical thinking involves ‘self-regulation’ or ‘meta-cognition’; the ability to think critically about oneself (Facione et al., 1994; Facione & Facione, 2007;Gloudemans et al., 2013; Kim, Moon, Kim, Kim & Lee, 2014). There is an element of discipline-specific criteria to any definition of critical thinking (Pitt, Powis, Levett-Jones & Hunter, 2015; Zuriguel Pérez,
56 et al., 2015) with Raterink (2008) suggesting that critical thinking in nursing must also include creativity and intuition.
There is some, though inconsistent, evidence that critical thinking improves patient/service user outcomes (Burrell, 2014; Chan, 2013a; Fero et al., 2009; Fesler- Birch, 2005) and is therefore vital in nursing (Chan, 2013b; Lechasseur, Lazure & Guilbert, 2011). Critical thinking is a learned skill, not automatic (Martin, 2002), and should be included in any undergraduate and post-graduate nursing programme (Chan, 2013a; del Bueno, 2005). Just like competence (Benner, 1984), there is a ‘development’ of critical thinking from the novice to the expert, with experienced nurses demonstrating critical thinking and its links with clinical reasoning more clearly than students and more junior/novice nurses (Fero et al., 2009). Linked with this, there is some evidence to suggest that graduate-level nurses demonstrate more critical thinking than their non-graduate colleagues (Fero et al., 2009; Gloudemans et al., 2013) although this is not consistent (Martin, 2002). There is also evidence to show that levels of entry critical thinking determine academic performance and course completion (Pitt et al., 2015). According to Zurmehly (2008) critical thinking leads to better job satisfaction for RNs. There is mixed evidence of the effectiveness of educational programmes in developing critical thinking skills (Pitt et al., 2015), perhaps, it is argued, due to the way nursing is taught (del Bueno, 2005; Fesler-Birch, 2005) with an emphasis on developing the skilled practitioner (Morrall & Goodman, 2013), a carryover from the ‘knowledgeable doer’ of Project 2000 (UKCC, 1986), and the different influences that have led to what Shields, Morrall, Goodman, Purcell and Watson (2012) describe as the ‘dumbing down’ and de-intellectualization of academia in general and nursing more specifically.
In her study amongst RNs working in long-term care facilities in the USA, Raterink (2008) asked her focus group participants to discuss characteristics that enhanced their ability to use critical thinking. These were teamwork, and staffing arrangements that allowed some consistency with who they worked alongside and the patients they cared for. Three of the eleven participants indicated that the variety and acuity of patients allowed them opportunity to practice key skills. Barriers to utilizing critical thinking included too much paperwork, a feeling of being overworked leading to a lack
57 of sufficient time to complete the necessary ‘tasks’, and excessive criticism from colleagues, patients and their families (Raterink, 2008). Although this study focused on RNs, there are factors here that are significant for the student nurse working in clinical practice. The importance of working in a variety of clinical settings to enable the development of their critical thinking and clinical reasoning skills is clearly vital. Educators must work alongside colleagues in clinical practice to promote these ‘enhancers’ and limit the ‘barriers’. This also highlights the need to consider the ‘Ascent to Competence’ framework developed by Levett-Jones and Lathlean (2009) during their study on student nurses sense of ‘belongingness’ in their clinical placements. The framework highlights the importance for the student to feel accepted, appreciated, recognised and respected for making a valuable contribution to patient care – becoming a member of the ‘team’, not an outsider. Perhaps of more significance to the academic setting is Chan’s (2013a) reference to the work of Zygmont and Schaefer where they suggest that a barrier to the development of critical thinking was a lack of confidence. Students who lacked confidence did not express opinions or learn to think critically due to a fear of making mistakes. This can occur in the lecture room or simulation suite just as it can on the ward or in the patient’s/service user’s home. Chan (2013a) argues that educators undertake a pivotal role in teaching and assessing the application of nursing students’ critical thinking.