1. Follman, John PhD

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There has been a surge of research in nursing since 1983 on the construct of critical thinking, a construct that has been studied in the social and behavioral sciences as far back as 1925. Incorporation of evaluation of critical thinking into the National League for Nursing's accreditation criteria for both baccalaureate and also higher degree programs illustrates its importance. 1


Contemporary nursing critical thinking research can be categorized into two central foci. One focus is the relationship between nurses' critical thinking and their clinical judgment. The other focus is the efficacy of nurses' education on their critical thinking. Both foci are examined in this article.


Nurses' Critical Thinking and Clinical Judgment Research Relationship

In two studies of nursing undergraduate students and one of nursing graduate students, Tanner 2 reported no significant relationship between nurses' critical thinking and their clinical judgment. In her review of four studies, Kintgen-Andrews 3 reported no relationship between nurses' critical thinking and their clinical judgment, which was tested by seven different measures. Hickman 4 reviewed 10 studies of the relationship between nurses' critical thinking and their clinical judgment and concluded that these 10 studies presented "mixed and contradictory results."


Perciful and Nester 5 studied 83 senior baccalaureate students of nursing (BSNs) and found correlations between the Watson-Glaser Critical Thinking Appraisal (WGCTA), the National League for Nursing Psychiatric Nursing Exam, Part 2:Assessment, Analyzing and Evaluation (.36), and Part 3: Planning and Implementation (.19). These correlations were higher than most other studies, and higher than most other nursing tests of "critical thinking."


Beeken's 6 review reported that no relationships had been found between critical thinking and ability to generate nursing hypotheses, between critical thinking and clinical skill level, or between critical thinking and problem-solving ability. Duchscher's 7 review concluded that the "research studies have not demonstrated a consistently significant relationship between clinical nursing judgment and critical thinking." She suggested that this might have resulted from inadequate refinement in design and instruments, rather than from the lack of an intrinsic relationship between critical thinking and clinical judgment.


Finally, Hicks 8 reviewed the reviews of the 20 years of research on critical thinking in nursing and concluded that the gold standard of critical thinking tests, the WGCTA, showed inconsistent relationships with measures of clinical judgment and decision making. Hicks called for a reexamination of critical thinking in nursing education including a redefinition of critical thinking, followed by a more context-based, reflective entity.


Efficacy of Nursing Education on Nurses' Critical Thinking

What is the effect of nursing education on nurses' critical thinking? Adams 9 reviewed 20 studies, from 1977 to 1995, regarding change in professional nursing students' critical thinking ability and concluded that the results were mixed and contradictory. Adams et al 10 reviewed seven studies of the efficacy of baccalaureate nursing education on BSN students' critical thinking tested by the WGCTA and found inconsistent results over time. In their own experiment, Adams and colleagues found no increase in critical thinking from their 203 students' sophomore to senior years. Investigating the efficacy of a baccalaureate nursing education program on 32 students' critical thinking ability as measured by the California Critical Thinking Skills Test, Turner obtained no significant differences 11. In England, Girot 12 reported similar findings.


A productive research direction was suggested by Hartley and Aukamp. 13 They recommended that an instrument be developed to measure critical thinking ability in situations specific to nursing. I heartily embrace this recommendation based on the problems demonstrated above using tests of critical thinking adopted from the social and behavioral sciences. Several "critical thinking" evaluations developed within the context of nursing include:


* Critical Thinking Vignettes 14


* Model Care Planning (problem solving) 15


* NCLEX 16


* Nursing Performance Simulation Instrument 17


* Reflection for Professional Practice. 18



I recommend that when these nursing/medical based instruments are validated, the validation criteria should not be traditional tests of critical thinking developed in the social and behavioral sciences, but rather, criteria developed within the context of nursing education. I also recommend that at least one of these criteria be a psychometrically sound test of nursing/medical vocabulary.


Efficacy of Nonnursing Critical Thinking Treatments

At the college (ie, adult) level, the most tuitional finding is in McMillan's review of 27 critical thinking treatment studies. 19 McMillan concluded that few treatment effects were found for any approaches, except for the overall college experience.


At the subcollege level, the most representative and tuitional findings are in the Bangert-Drowns and Bankert 20 meta-analysis. It is striking that the critical thinking treatment effect size declined dramatically with the ages of the subjects, from .50 standard deviation for middle and elementary school subjects, to .21 standard deviation for high school and college subjects. These findings are considered tuitional.


The basic reason that nursing education workshops, courses, and programs lack success in enhancing nurses' critical thinking is that nurses and nursing students are adults. Critical thinking correlates .50 to .60 with IQ in adults 21; workshops, courses, and programs in the social and behavioral sciences had little success in enhancing the IQ of adults. Therefore, nurse educators should not expect the IQ, and correlatively the critical thinking, of nurses to increase from nursing education any more than that of adults in any other discipline.


One explanation for the unproductive, low relationship between nurses' critical thinking and their clinical judgment is that it is a psychometric problem; mainstream critical thinking tests developed in the social and behavioral sciences do not measure nursing outcomes. As Hicks 8 and Hartley and Aukamp 13 suggested, a promising approach is to employ nursing context developed tests such as those cited previously. I suggest that these tests employ nursing/medical vocabulary in nursing problem-solving situations. This approach exploits the two-fold advantage of using nursing/medical vocabulary. Initially, using nursing/medical vocabulary increases the precision of the nurses' knowledge of nursing/medicine. Second, increasing nurses' nursing/medical vocabulary while probably not increasing their IQ and corollary critical thinking certainly will not decrease it! Even if there is no increase in nurses' IQ and/or critical thinking, there will be an increase in their nursing/medical vocabulary, an admirable achievement in itself. What a parlay!




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