The development of a critical thinking conceptual model to enhance ...

SCHOLARLY PAPER
The development of a critical thinking conceptual
model to enhance critical thinking skills in
middle‑eastern nurses: a middle‑eastern experience
AUTHORS
ABSTRACT
Elaine Simpson
Objective
PhD, RN
This paper aims to describe the development of
Manager, Regis, Corinya Aged Care Facility,
a critical thinking conceptual model which was
Queensland, Australia.
constructed to guide the teaching and evaluation of
Elaine_phd@yahoo.com
critical thinking skills to Middle‑Eastern nurses.
Mary Courtney
Setting
PhD, RN
A large tertiary hospital situated in the Middle‑East,
Professor of Nursing and Assistant Dean (Research),
which adopted North American standards of
Queensland University of Technology, Queensland,
healthcare.
Australia.
Subjects
Twenty Middle‑Eastern female nurses who graduated
from a nursing college in the Middle‑East, wherein
KEY WORDS
basic nursing subjects were taught, but critical thinking
conceptual model; critical thinking; critical thinking
was not included in the curriculum of the nursing
strategies
content.
Primary Argument
Critical thinking is an essential element for nurses
who function in today’s complex healthcare domain.
Nursing organisations worldwide have recognised
the need to develop and stimulate higher‑order
critical thinking by using innovative strategies to
stimulate critical thinking abilities. This Middle‑Eastern
hospital sought to promote critical thinking skills
in Middle‑Eastern nurses, and a Professional
Development Nursing Program was established. An
education component to promote critical thinking was
developed and integrated into the curriculum of this
program.
Conclusion
Nurses and nurse educators favoured a model that
supported critical thinking. Reasons given refer
to improving professional standards of practice,
stimulating inquiry and promoting sound reasoning
in practice, as well as contributing to personal and
professional development.
The model was effective for this nursing educational
program and could be duplicated by other programs to
create a learning environment for developing critical
thinking, as well as promoting professionalism in
nursing.
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INTRODUCTION
Nursing Program was of twelve months duration.
A large tertiary Middle‑Eastern hospital recognised
Nurses had to score at least 120 on the Oxford
the need to upgrade Middle‑Eastern nurses’
English test to enter the program because English was
knowledge and skills to meet North American
the medium of instruction and documentation. The
registered nurse standards, where the National
program consisted of twenty nurses, an administrator,
League of Nursing (1987) mandated the necessity
a senior nurse educator and three nurse educators.
to measure critical thinking skil s in nurses. To
One of the nurse educators was of Middle‑Eastern
meet these standards, the hospital established
origin who supported the nurses with translation
a Professional Development Nursing Program
issues as required.
to develop nurses to practice competently and
An extensive review of the literature was undertaken
demonstrate critical thinking skil s. An education
and a conceptual framework was constructed. The
component to promote critical thinking abilities in
conceptual framework is adapted from Arangie
Middle‑Eastern nurses was introduced and integrated
(1997); Colucciel o (1997); Dexter et al (1997);
into the curriculum. The Professional Development
Paul (1993; 1990); King (1995) and Whiteside
Figure 1: A conceptual framework to guide teaching and evaluation of critical thinking skills
CRITICAL THINKING (CT)
Dimensions
Cognitive
CT
Skills
DispositionSkills
CT
Strategies
Criteria
Clarity
Analysis
Open‑minded
Precision
Interpretation
Inquisitive
Truth‑seeking
Questioning
Relevance
Variables
Inference
Small Group
Depth
Explanation
Analytical
Role‑play
Fairness
Evaluation
Systematic
Debate
Accuracy
Self‑regulation
Self-confident
In Reasoning
Logicalness
Completeness
Nurse Educators Observations by senior educator

Interviews with senior educator

Feedback by senior educator

Focus group interview with senior nurse educator

Peer evaluations

Combined focus group interview
Evaluation
Students
Observations by senior nurse educator to assess their co‑operative

learning. For example, class interaction and participation;

presentations of group work, case studies, debates, homework

assignments.

Interviews with senior nurse educator.

Focus group interview with senior nurse educator and peers.

Generating critical thinking questions.

Combined focus group interview.
The conceptual model is adapted from Paul (1993, 1990); Facione et al (1998); King (1995); Arangie (1997);
Colucciello (1997); Dexter et al (1997) and Whiteside (1997), and reflects the dimensions, variables and evaluation
of critical thinking.
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(1997) and comprises the dimensions, variables
inference, judgement, explanation, interpretation
and evaluation of critical thinking, which forms the
and evaluation.
basis for this program. This conceptual framework
On the whole, questioning, smal group activities,
appears as figure 1.
role‑play and debate are wel supported by many
LITERATURE REVIEW
authors (such as: Jones and Sheridan 1999; Daly
1998; Sel appah et al 1998; Fowler 1998; Bil ings
As a concept, critical thinking has been expressed in
and Halstead 1998; Abegglen and O’Neil Conger
several ways. Critical thinking is an essential element
and Mezza 1996; Morin 1997; Oermann 1997;
for nurses who function in today’s complex health
Whiteside 1997; Lipman and Dietrick 1997; Lenburg
environment, in which they are required to deal
1997; Walsh 1997; El iott 1996; Brookfield 1987;
with issues such as advanced technology, greater
Malek 1986).
acuity of clients in hospital settings, the ageing
population and complex disease processes. Facione
DISCUSSION
et al (1994) state that critical thinking is both a skill
In the Professional Development Nursing Program, a
and a habit of mind and one must be disposed to
senior nurse educator wel versed in critical thinking
think critical y as wel as have the skil s to do so. At
provided guidance and support to nurse educators
the core of critical thinking are the cognitive skil s
in this concept by providing them with literature on
of analysis, interpretation, inference, evaluation,
critical thinking and discussions on the subject. The
explanation and self‑regulation. The dispositions
classroom was arranged in a ‘U’ shape, to al ow
toward critical thinking can be understood in terms
participants to have eye contact and the ability
of open‑mindedness, inquisitiveness, cognitive
to question and interact with each other. It also
maturity, truth‑seeking, analyticity, systematicity and
permitted facilitators the opportunity to interact
self confidence (Facione et al 1994) (the cognitive
openly with the nurses. The senior nurse educator
and disposition skil s are explained later on). For the
observed nurse educators in the classroom to support
purpose of this article, critical thinking is identified as
and guide them in using the dimensions and variables
‘purposeful, self‑regulatory judgement which results
of the model effectively, to promote critical thinking
in interpretation, analysis, evaluation and inference
skil s in nurses. The observer listened, and noted
as wel as explanation of the evidential, conceptual,
nurses’ behaviours. The critical thinking conceptual
methodological, criteriological or contextual
model is reflected in figure 1 and explained below.
considerations upon which that judgements is based’
(Facione 1990 p.4).
The critical thinking conceptual model
A conceptual model/framework development
In nursing literature, various methods are discussed
was based on the relevant literature to guide
that could be employed to enhance critical thinking
the development of critical thinking skills in
skil s. The literature suggests the importance of using
Middle‑Eastern nurses. This model is divided into
critical thinking strategies. For example, Mil er and
three components consisting of:
Malcolm (1990) advocated instructional strategies
such as written assignments, problem solving and so
• dimensions
forth to foster critical thinking that can be integrated
• variables
into al levels of nursing curriculum. King (1995)
• evaluation
recommends the use of questioning to stimulate
higher order thinking processes. Stringfield (1995)
Dimensions and variables
suggests video presentations, while Whiteside
The dimensions and variables of critical thinking
(1997) advises the use of debate and case studies
wil be explained simultaneously as they are closely
to enhance core critical thinking skil s of analysis,
inter‑related. The term ‘dimensions’ relates to
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cognitive and dispositions which are crucial to
• Self‑Regulation: constantly monitoring one’s
becoming an effective critical thinker (Colucciel o
own thinking using critical thinking criteria and
1997) and other interacting elements such as, critical
correcting oneself (Facione et al 1998).
thinking strategies and critical thinking criteria (also
Facione et al (1998) and Chenworth (1998) stress the
known as intel ectual criteria), required to promote
importance of developing and changing dispositions
critical thinking skil s (Paul 1993). The dimensions
or attitudes, such as being open‑minded, inquisitive,
of critical thinking are explained as fol ows:
truth seeking and so forth. These authors also
• Cognitive skil s: analysis, interpretation, inference,
advocate that while content knowledge and cognitive
explanation, evaluation and self‑regulation
skills (for example, analysis and so forth) are
(Facione et al 1998, 1994);
necessary, they emphasise that without stimulation
• Disposition skil s: open‑mindedness, inquisitive,
of dispositions, engagement of critical thinking will
truth‑seeking, being analytical, systematic and
not occur. The variables associated with disposition
self-confident in reasoning (Facione et al 1998,
skil s are explained as fol ows.
1994);
Disposition Skills
• Critical thinking strategies: questioning, small
• 0pen‑mindedness: appreciating alternative
group activity, role‑play and debate; and
perspectives and values of others who hold
different opinions; understanding other cultural
• Critical thinking criteria (intel ectual criteria):
traditions in order to gain perspectives on self
clarity, precision, specificity, relevance, depth,
and others;
fairness, accuracy, logicalness and completeness
(Paul 1993, 1990).
• Inquisitiveness: curious and enthusiastic in
wanting to acquire knowledge and to know how
The variables associated with each of the dimensions
things work, even when the applications are not
as used in this program wil be described. The
immediately apparent;
variables related to cognitive skil s are as fol ows:
• Truth seeking: courageous about asking critical
• Analysis: examining ideas/arguments in
thinking type questions to obtain the best
problems, objective and subjective data and
knowledge;
possible courses of action;
• Analytical: thinking analytically and using
• Interpretation: accurately interpreting problems
verifiable information; demanding the application
as wel as objective and subjective data from
of reason and evidence;
common information sources;
• Systematic: focused and diligent in approaching
• Inference: querying claims, assessing arguments
complex problems; and
(recognising faulty reasoning) and reaching
conclusions, which are appropriate;
• Self-confidence: trusting one’s own reasoning
and using critical thinking skills in order to
• Explanation: clearly explaining and defending
respond to problems and decisions based on
the reasoning by which an individual arrives at
scientific evidence and facts (Facione et al
specific decisions in the context of the health
1998).
care of the patient.
Bittner and Tobin (1998) indicated that facilitators
• Evaluation: evaluating information to ascertain
should be wil ing to expand their teaching repertoires
its probable trustworthiness as well as its
to include instructional methods such as critical
relevance; and
thinking strategies, to open nurses’ minds, broaden
and augment their ways of thinking to assist growth
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and develop cognitive skil s in order to make a change
• Debate: The process of debate entails analysing,
in dispositions. The fol owing variables (questioning,
critiquing and constructing arguments, al of
smal group activity, role‑play and debate) used in
which are vital elements of critical thinking and
this model relating to critical thinking strategies are
“higher level skil s” required to participate in this
now described.
activity (Bell 1991 p.6). Doyle (1996) supported
Critical Thinking Strategies
Bel and indicated that debate is an effective
• Questioning: Case (1994) and King (1995)
teaching method that develops the skill of
considered that the hallmark of a critical thinker
argumentation. Its environment of open inquiry
is an inquiring mind. These authors assert that
and debate provides opportunities for students
good thinkers are good questioners in that
to investigate their own feelings, notions and
they question whatever they see, read, hear or
opinions. This results in the student becoming
experience. Good thinkers also frame questions
more involved with the topic, challenging
in a manner such as ‘what is the nature of this?’;
ideas, as well as refuting them, and enhancing
‘what does this mean?’; ‘why is it happening?’;
listening and communication skil s. Questioning,
‘what if?’ (King 1995). Walsh (1997) commented
wondering, thinking aloud and taking intel ectual
that in nursing, ‘rounds’ are frequently used as
risks are encountered in a debate. Garrett et al
a technique of observation, inquiry and close
(1996) further stated that educational debate
scrutiny of decisions for nursing diagnosis
has been recognised in the educational literature
or treatment. During these rounds nurses
as a useful instructional strategy for promoting
are expected to problem solve their patients’
critical thinking and verbal communication
conditions and plan their daily care. Therefore,
abilities. Debate provides a comprehensive and
thinking and framing critical thinking questions
innovative learning mode when integrated as an
can assist participants to predict outcomes
essential aspect of the curriculum.
and create alternatives to deal with problems
• Role‑play: Chubinski (1996) stated that through
confronting them.
the power of role‑play, people can be put into
• Small group activity: Small group activity
circumstances that conflict with their ‘normal’
encourages participant interaction and enables
life style and choices, hence providing perfect
them to share their ideas and examine individual
opportunity to appreciate alternative views
assumptions. Small groups are less threatening
and opinions on a first hand basis in a non
and promote comfort to formulate questions for
threatening environment. Fuszard (1989)
which participants may not have the answers.
described role‑play as an effective means for
This technique promotes collaboration with
developing decision‑making and problem‑solving
peers. Students have the opportunity to compare
abilities. The problem‑solving process can
points of view and interpretations and to
be analysed within the context of role‑play.
“contrast their critical thinking styles with their
The post‑play discussion gives teachers an
peers” (Neill et al 1997 p.31).
opportunity to provide analysis and formation
Table 1: Guided/stem questions adapted from King (1995 p.14)
Generic questions
Specific thinking skills induced
What would happen if?
Prediction/hypothesis
What are the strengths and weaknesses of…?
Analysis/inferencing
What is the difference between… and…?
Comparison/contrast
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of new ideas and strategies in patients’ care.
• Fairness: ensures no participant(s) dominates;
Tools or devices were used to support critical
gives positive feedback and praise; randomly
thinking strategies such as guided/stem
selects participants to respond;
questions, videotapes, pre‑reading homework,
• Accuracy: thorough; particular in following
presentations as teaching aids to increase
teaching plan;
effectiveness of techniques (Robinson 1994).
Guided questions act as a device to stimulate
• Logicalness: information is presented in a logical
students to formulate their own questions based
and sequential format;
on their reading material and clinical experience
• Completeness: before closing, asks if participants
(King 1995), and are illustrated in table 1.
have further questions; allocates time for
Robinson distinguishes between techniques
students to generate critical thinking questions;
and devices and explains that techniques
allows for further discussions to occur.
are the ways in which a facilitator establishes
Evaluation
relationships between the learner and the
Evaluation for nurse educators consisted of the
learning task, and they may be designed to assist
senior nurse educator observing nurse educators
the learner obtain information, acquire a skill,
to ascertain if they were using the dimensions and
apply knowledge, develop creativity or achieve
variables effectively to promote critical thinking skil s.
a change in attitude.
For example, were the appropriate critical thinking
By contrast, devices are the instructional materials
strategies and devices selected to enhance core
or teaching aids that increase effectiveness
critical thinking skil s of analysis, interpretation,
of techniques or strategies, “but which cannot
inference and so forth, to open nurses’ minds
themselves instruct” (Robinson 1994, p.101). They
and augment their way of thinking? Did they use
range from books to simulations, from films to
overhead materials to demonstrate and engage in
working models, from chalk‑boards to video tapes.
thought‑provoking questions? Were the educators
The variables associated with critical thinking criteria
adhering to critical thinking criteria such as being
are explained.
clear, precise relevant and the like; were the
Critical Thinking Criteria
stem/guided questions used to facilitate nurses in
In reviewing Paul’s (1993, 1990) work on critical
generating critical thinking questions; did nurses
thinking criteria, no explanations are provided by the
interact and participate?
author to describe each of the criteria. Appropriate
The nurse educators were provided timely
explanations were extrapolated from the literature
constructive feedback, advice and guided as
to ‘fit’ each of Paul’s criteria from authors such as
necessary. As they became confident, peer
Fuszard (1989); King (1995); Arangie (1997) and
evaluations were conducted and mutual feedback
Whiteside (1997) and described as fol ows:
was encouraged. They were also invited to
• Clarity: communication - clear, not muffled; gets
participate in a focus group interview with their peers
to the point; using a tone of voice to suggest
approximately four weeks fol owing implementation,
openness;
to voice their feelings toward the use of critical
thinking strategies and observations from the senior
• Precision: thorough with explanations; uses
nurse educator and peers. A combined focus group
critical thinking‑type questions;
(senior nurse educator, nurse educators and nurses)
• Relevance: asks pertinent questions on the
was conducted a further four weeks later.
content;
Evaluations for nurses entailed observations by the
• Depth: encourages participants to generate
senior nurse educator to assess their co‑operative
critical thinking questions;
learning (for example, class interaction, participation
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and so forth); the ability to generate critical thinking
program and could be duplicated by other programs
questions, initial y using King’s (1995) stem/guided
to create a learning environment and facilitate the
questions, interviews and feedback. Likewise, they
development of critical thinking, as wel as enhancing
attended a focus group interview with their peers,
professionalism in nursing.
fol owed by a combined focus group interview (senior
If curriculums are going to become more educative
nurse educator and nurses).
and teach students to think and interact, then
The outcome from these evaluations was positive.
instructional methods must be designed to achieve
For example, anecdotal comments from nurses were
this outcome. The conceptual model provides a
as fol ows: “We like this type of teaching style”; “It’s
framework for nurse educators to develop curriculum
enjoyable, makes us think, argue constructively and
that used critical thinking. This mandates a change
interact with our peers”; “Also, our hands are not tired
in the classroom environment that can only be
from taking notes”; “We like the stem questions as a
achieved by a change in nurse educators’ behaviors
tool to help us construct critical thinking questions, to
and attitudes.
improve our critical thinking skil s.” Nurse educators
had similar feelings. They commented that: “Critical
RECOMMENDATIONS
thinking strategies provided variety and creativity in
1. Use a framework/model to provide structure and
the teaching and learning environment ‑ the nurses’
guidance.
interaction and participation was stimulating and
2. Integrate critical thinking strategies into the
rewarding, given their tradition on rote learning”.
curriculum to support the development of critical
CONCLUSIONS
thinking skills.
Faculty members of the education program were
3. Select appropriate critical thinking strategies and
acutely aware that for the program to have maximum
devices to promote critical thinking abilities.
success, it was essential to “consider individual
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