By D Hayes, RN, BEd(Hons)

The concept of critical thinking (CT), in spite of best efforts, remains perplexing. As an examiner for undergraduate student nurses’ assignment scripts, I discovered through reflection (Johns, 1995) that students were not gaining high marks in written assignments for critical thinking. In order to critically evaluate this issue, I conducted a literature search, and reviewed articles on the definition of CT, its policy, and the ethical and philosophical aspects that determine its degree. The conclusion on this issue is that CT is complex and needs further investigation.

In one occasion, I encountered several students who expressed their disappointment over getting low marks for descriptive, rather than critically analytical, work. Similarly, a colleague was dismayed over a same experience that was also illustrated in an article authored by Gopee (2002) on critical thinking. The situations concerned and prompted me to critically evaluate the issue, initially through a literature review , which aims to facilitate students to gain higher marks. I developed a basic level research question using the PIO model: P=persons (student nurses); I=intervention (learning CT); and O=outcome (identifying best practice) in order to gauge ‘the best practice for the learning of critical thinking by student nurses’. Using a data base, the key words used for the literature search were ‘critical thinking’ and ‘nurse education’. The inclusion criteria were articles written in the English language, scholarly discussions or research reports from peer reviewed journals, resulting in 36 articles being retrieved. Some articles involved non-western participants, of particular interest in my work setting in Malaysia. As the subject of CT generally is well established, the year of publication was not made an issue; in the event, the articles spanned 18 years – from 1991 to 2009.

All articles except those by Schommer-Aikins and Easter (2009) discuss in varying detail the problems of defining CT. Exceptionally, Schommer-Aikins and Easter (2009) refer to higher order thinking, though they do not venture to define it. Girot (2000) points out to CT as a process needing higher order thinking. Most other articles rely on the results of the research reported by Jones and Brown (1991) carried out on behalf of the National League for Nursing. The resulting definition is a complex one, and has cognitive, behavioural,moral, ethical and personality dimensions. This gives rise to discussions about the suitability of the scientific method for investigating the issue (Ku ,2009).

CT as a Gender Issue

Although a positivistic, scientific philosophy is generally highly valued, its use for investigating complex human behaviours is questionable (Hill, 2008). Schommer-Aikins and Easter (2009) use questionnaires using multiple choice questions and Likert scaled statements to investigate the complex human behaviour of willingness to argue. With the relationship between context, response and experience in the critical thinker’s worldview, feminism may be a more appropriate philosophy (Cohen , et. Al., 2007), especially as CT skills appear to need the critical thinker to be outside the limits of control and conformity (Ip, et. al., 2000).

Indeed, CT as a gender issue is mentioned as a side issue by some researchers, in the context for example of distance learning materials they reviewed being mostly written by men (Bethune and Jackling ,1997). However, the literature is accepting of the progress so far in measuring CT using scientific methods such as questionnaires (Mitchell and Batorski, 2009; Staib, 2005; Kyung, 1998), though there are reservations (Ku, 2009; Girot, 2000). Daly (1998), whilst also quoting the definition reported in Jones and Brown (1991), discusses several others, again reflecting the complex nature of CT. Even with such problems of definition, nursing has embraced the concept of CT and has incorporated it into policy.

CT as a Major Policy in Nursing

Many articles refer to a major policy by the nursing profession to demand increased critical thinking ability in nurses (Anderson and Tredway, 2009; Fero, et. al., 2009; Duchscher,1999). This was perhaps reinforced by the studies of Benner and her colleagues into the nature of nursing expertise starting in the early 1980s (Benner, et. al., 1996). The interest in CT is described as starting in earnest in the 1980s (Duchscher ,1999), rather later than most academic disciplines.\

The rationale for CT comes from a perception that with increased change in clinical practice, increased aptitude in CT among nurses is necessary to respond effectively to health care challenges (Simpson and Courtney ,2002). This is based on the concept that CT is a preparation for higher order thinking, and deemed necessary for better clinical decision making in the face of new diseases, new treatments and new expectations of care, which are all part of the scenario of change (Girot, 2000). The transfer of CT to clinical decision making is however not necessarily linear and cannot be assumed (Greenwood, 2000) though Simpson and Courtney (2002) argue that the clinical decision making process needs CT. This was researched by others using high fidelity human patient simulation, but with equivocal results (Horan, 2009; Ravert, 2008; Rush, et. al., 2008). The relationship between CT and clinical decision making therefore is still to be explicated fully.

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