To Improve the Academy: A Journal of
Educational Development
Professional and Organizational Development
Network in Higher Education
1995
Improving Students' Critical Thinking Outcomes: An Process-Improving Students' Critical Thinking Outcomes: An Process-
S. Kay A. Thornhill
Melissa Wafer
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Thornhill, S. Kay A. and Wafer, Melissa, "Improving Students' Critical Thinking Outcomes: An Process-
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To Improve the Academy: A Journal of Educational
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Improving Students' Critical
Thinking Outcomes:
An
Process-Learning Strategy in
Eight
Steps
S.
Kay
A.
Thornhill
Southeastern Louisiana University
Melissa
Wafer
Our Lady
of
the
Lam
College
This article describes an eight-step strategy through which stu-
dents learn to critically analyze situations that they have encountered
in their clinical practice. The method was derived from
Stephen
Brookfield's four components
of
critical thinking
and
his suggestions
for
themes that relate to nursing culturalization. The approach used
to develop this model
has
implications
for
educators in all fields
because it illustrates a method
for
integrating the learning
of
critical
thinking processes with their real-world applications.
Although
educators in all disciplines share a general interest in
developing students' ability to
think critically, nurse educators are
especially challenged because they must prepare their students to
perform technical; interpersonal, and critical thinking skills simulta-
neously. They must
learn to function as safe, competent, and skillful
clinical nurse practitioners in a complex health care environment in
which new information and new clinical situations continually emerge
(del Bueno, 1990; Miller & Malcolm,1990).
To Improve the Academy, Vol. 14, 1995
251
To Improve the Academy
In
1988, the U. S. Department
of
Education issued a mandate that
required accrediting agencies to consider evidence
of
educational
outcomes when conducting program reviews (U. S. Department
of
Education, 1988).
As
a result, nursing education's accrediting agency,
the National League for Nursing
(NLN), changed its accreditation
criteria
to include five required outcomes, including critical thinking,
in
Baccalaureate
and
Higher Degree Programs (National League for
Nursing, 1991).
As defmed
by
the NLN, critical thinking should
reflect student skills
in
reasoning, analysis, research,
or
decision
making relevant to the discipline
of
nursing (National League for
Nursing, 1992).
In
addition to these developments, the U.S. Depart-
ment
of
Health
and
Human Services published a list
of
national health
promotion and disease prevention objectives that supported the need
to balance nursing education's program content and learning strategies
(U.S. Department
of
Health and
Human
Services, 1992).
These factors provided the impetus for the authors' development
of
a process-focused critical thinking strategy. The authors' employ-
ment
setting is a baccalaureate nursing program with
over
500
nursing
student majors, located
in
an
urban area
of
the Southeastern region
of
the country. Students participating
in
the critical thinking activity
selected acute cardiology nursing for their clinical learning setting
in
a nursing synthesis course. The cardiology nursing unit is located
in
a large urban regional medical center complex.
Conceptual Framework
In
his 1987
book
on
developing critical thinkers, Stephen Brook-
field posited four components
of
critical thinking: (1) identifying and
challenging assumptions; (2) challenging the importance
of
context;
(3) imagining and exploring alternatives; (4) reflective skepticism.
More
recently, Brookfield (1993) also suggested a ''phenomenogra-
phy
of
nurses as critical thinkers" to account for
how
nurses learn and
experience critical thinking.
Each
of
these culturalization themes
has
important implications for anyone
who
practices critical thinking
in
the field
of
nursing (and, potentially,
many
other professional fields):
impostership, cultural suicide, lost innocence, roadrunning, and com-
munity.
Because these themes are less widely known than Brookfield's
252
Improving Students' Critical Thinking Outcomes
components
of
critical thinking, they require some elaboration. A
complete exploration
of
these themes is beyond the scope
of
this
article, but brief
definitions, based on Brookfield (1993), follows.
"Impostorship," common to many professionals, is a feeling
of
underlying incompetence that often does not diminish with years
of
practice. Imposters must always appear to know what they are doing
and they live in fear that they will be
"exposed" for the hopeless
incompetents that really are.
"Cultural suicide" refers to a kind
of
cultural alienation that can result when critically aware nurses question
their colleagues who are less critically aware:
...
nurses who expect
their efforts to ignite a
flre
of
enthusiasm for critical reflection and
democratic experimentation may be sorely disappointed when they
fmd themselves regarded as uncooperative subversives (and) whistle-
blowers
...
(p. 201). The theme
of
"lost innocence" relates to the
often sad discovery that there are no perfect, unchanging models
of
clinical practice, but only "the contextual ambiguity
of
practice" (p.
203). "Roadrunning" (inspired by the Warner Brothers cartoon) de-
scribes the state
of
limbo that occurs in the process
of
critical thinking
when ''we realize that the old ways
of
thinking and acting no longer
make sense, but
...
new ones have not yet formed to take their place"
(p.
204). Brookfield explores this theme in the context
of
the rhythm
and pace
of
the epistimologic, transformational process
of
critical
thinking.
''Community" is a more positive and hopeful theme that
relates to the development
of
"emotionally sustaining peer groups"
that may consist
of
just four or flve good friends who "know that
experiencing dissonance, challenging assumptions, taking new per-
spectives, and falling foul
of
conservative administrators are generic
aspects
of
the critical process, not idiosyncratic events" (p. 205).
Brookfield's four components
of
critical thinking and his cul-
turalization themes provided the conceptual framework for the
authors' eight-step learning strategy for critical thinking. The process
is initiated in Step One by the examination
of
a critical incident (a
real-life situation) in nursing care. Steps Three, Four, Five, and Six
incorporate Brookfield's four components
of
critical thinking, and his
culturalization themes involve Steps Two and Seven.
In
Step Eight
students explore the usefulness
of
critical incidents as a means
of
achieving their' learning outcomes.
253
To
Improve
·the
Academy
The Eight-Step Process: Critical Thinking in Clinical
Practice
Step One: Identify a Critical Incident
In
Step One students first identify critical incidents they encoun-
tered during clinical practice.
As Brookfield (1993) advises, students
are instructed to think about episodes in which they experienced
••good"
or
•1>ad"
fonns
of
clinical practice. A critical incident cited by
a student
in
the class is described below and used as
an
example in the
remaining steps
of
the process:
The
40
year old cardiac patient was experiencing chest pain,
nausea, vomiting, and headache.
He
was unable to take his oral
medications for the heart condition and other problems. The student
nurse
notified the staff nurse assigned to the patient. The nurse told
her not to
·-oother" the patient's physician because they had talked
with
him earlier and he was aware
of
the patient's present condition
and had not given any additional orders to treat the patient. The nurse
refused to call the physician for the student nurse.
Step Two: Note Personal Experience
In
Step Two, the student describes why the incident should be
defmed as .. critical.
••
The student thinks about what happened during
the incident and writes responses to four questions (Brookfield,1993):
What
triggered your engagement in critical thinking and was there a
clear cause?
As you moved through the situation, what resources were
most helpful
to you? What were the high and low points
of
the process?
What happened because
of
the critical thinking process? The student•s
answers to these questions for the incident in Step One are given
below:
254
An
inability to relieve the patient
of
symptoms prompted the
student
to engage in critical thinking. The most helpful resource
was the patient's understanding
of
the
students desire to care him
and the faculty serving as a resource when the staff nurse differed
in
the student's decision to call the physician. The helplessness
experienced by the student nurse after the staff nurse refused
to
call the physician was the low point
of
the episode.
Improving Students' Critical Thinking Outcomes
Step Three: Identify & Challenge Assumptions
In
Step Three, the critical incidents provide the basis for exploring
the values, beliefs, rationales, and appropriateness
of
ideas that influ-
ence their individual actions. Ideas are often based
on
cultural norms,
ethnic values, influential teachers
or
mentors,
or
policies and proce-
dures learned in discipline-specific programs, and these perspectives
frame group discussions
of
each clinical practice incident.
In
the final
exercise
in
Step Three, students identify assumptions and propose
challenges on a group worksheet.
In
the incident in the example,
students identified the following points:
1.
Nurses rely on the medical doctor and
or
medications for relieving
patient's symptoms.
2.
Staff nurse showed more compassion and caring for the physician
than for the patient.
3.
Staff nurse feared physician actions more than patient as a con-
sumer
of
health care.
4.
Student nurse had more compassion and caring for the patient than
did the primary nurse assigned to his care.
5.
The patient was passive in his ability to treat himself and required
the care
of
his admitting physician.
6.
The staff nurse and student nurse were in conflict with the method
of
treatment.
Step
Four:
Challenge the
Importance
of
Context
In
Step Four, students examine the importance
of
the circum-
stances surrounding their critical incidents. Students must struggle
with the difficulty
of
interpreting any action without considering the
context within which the action occurred. This discussion includes
an
examination
of
the group worksheets from Step Three and how
differing perspectives on the incidents help shape their interpretation.
Developmental context issues identified by the student nurse
included the patient's loss
of
role functions: i.e. head
of
household,
family provider, faced with serious debilitating heart disease at
an
early age.
255
To
Improve the Academy
Professional context issues included student nurse-staff nurse
relationships, student nurse-physician relationships. Students
were concerned with care
of
this
patient only and their perspective
on
the situation concerned only the patient, as opposed to staff
nurses who were concerned with a myriad
of
other issues such as
the physician's actions, the days unit staffmg, and previous expe-
riences in caring for the patient.
Step Five: Imagine
and
Explore Alternatives
Step Five is essentially a brainstorming session in which students
explore alternatives to the way each critical incident occurred and
speculate
on
ways to resolve each one. Students are encouraged to
express their opinions about the outcomes
of
each situation.
In
the
example, students suggested the following alternatives:
1.
Student nurse could state she was caring for the patient also and
would call the physician without the staff nurse's permission.
2.
The student nurse could confer with a faculty member and request
the faculty member call the physician.
3.
The student nurse could present the situation to the nurse respon-
sible for all patients care on the unit.
4.
The student could explain to the patient the staff nurse's decision
to not call the physician and perhaps the patient could call the
physician from his room telephone.
5. The staff nurse could reassess the patient's chest pain and other
symptoms, and call the physician to report the changes with
additional orders to treat the patient's current status.
6. The student could reevaluate the situation from a more holistic
viewpoint
of
the patient.
7. The student could provide nursing comfort measures for the
symptoms noted for the patient without relying totally on the
medical regimen.
Step Six: Reflective Skepticism
Following step five's brainstorming session, students begin to
focus
on
possible outcomes
of
the critical incidents and to question
the scenarios for their resolution. Students are urged to
questi~n
ideas
256
Improving Students' Critical Thinking Outcomes
suggested as the answer for the critical incident as well as general
assumptions about the explanation
of
human behavior. Students re-
cord these questions on their individual worksheets. Students gener-
ated the following questions in the example case:
1.
Are the decisions made by the unit nurses regarding assigned
patients made with an awareness that the decisions have an impact
on all members
of
the health care team?
2.
Are nurses a part
of
a collaborative effort to assure that quality
care standards are maintained?
3.
Are unit nurses accepting the accountability and responsibility for
providing nursing care to all patients according to the hospitals
established standards
of
care?
4. Is the patient allowed to participate in decisions related to his/her
plan
of
care?
5.
Are the patient's rights a factor in this situation?
Step Seven: Consequences
of
Critical Thinking Experience
Step Seven turns the focus
of
the discussion away from the critical
thinking process itself and toward an exploration
of
the professional
consequences that may result from their engagement in the critical
thinking process. Using Brookfield's definitions
of
impostership,
cultural suicide, lost innocence, roadrunning, and community, stu-
dents discuss the implications
of
engaging in critical thinking in the
specific context
of
their critical incidents.
In
their discussion
of
this
theme, it becomes clear to students that there may be a variety
of
implications, some
of
which are very unpleasant, for practicing the
critical thinking skills they have been working on in the course. In the
example, students suggested the following consequences:
1.
Calling the physician without the nurse's permission would be
cultural suicide for the student. The student with less experience
and nursing knowledge has questioned the nursing care practices
of
a "real" nurse.
2.
Impostership may be a consequence also. The student nurse may
agree with the staff nurse's decision to not call the physician but
the
"correct" decision is to be a patient advocate.
3.
The situation is jolting to a student nurse who envisions nursing
practice as nursing education has shaped the student's image
of
257
To
Improve the Academy
nursing. practice.
The
student's way
of
interpreting nursing prac-
tice and the way nursing is practiced differs.
This jolting, halting,
and fluctuating rhythm is .. roadrunning.
••
4.
The
student nurse realizes that nursing care practices and deci-
sions involving patient care are complex and there are
no
set rules
to serve as a rigid guide. Hence, another consequence
may
be
..
lost
innocence."
Step Eight: Impact
of
Thinking Critically
on
Learning
Outcomes
In
the final step
of
the process, students identify concepts, themes,
and issues that may have
an
impact
on
clinical practice and affect
student learning outcomes. Students organize the critical incidents by
focus areas, analyzing the impact
of
each area, and assess the impact
of
the learning activity
on
their learning outcomes.
In
this stage
of
the
example case, students made these points:
1.
Patient care decisions learned in education programs may differ
in nursing practice since many variables are considered in actual
nursing practice situations.
2. Nurses standards
of
care may differ from student nurses, from
ones ascribed to, and from ones reflected
in
actual nursing prac-
tice.
3. Nurses practice nursing from a medical model
of
care more than
from an interdisciplinary patient care framework.
Conclusions
and
Recommendations
Students were pleased with their critical thinking experience in
this class, citing the use
of
real clinical situations as a basis for learning
and how the process assisted them in clarifying course objectives,
understanding the management theory
of
the course, and validating
clinical outcome behaviors. The richness
of
the critical incidents they
chose helped make the method a success. They explored situations
relating to issues
of
management, patients and families, nurse-physi-
cian relationships, and clinical nursing practice. Students also partici-
pated freely in discussions and they differed widely in their individual
responses during each step
of
the process.
258
Improving Students' Critical Thinking Outcomes
The
eight-step critical thinking process encourages students to
engage
in
critical thinking, to view situations from broad perspectives,
and to
seek
solutions to problems and situations experienced
in
clinical
practice settings. This learning strategy incorporates the realities
of
nursing practice, merges nursing education with practice, and involves
students
in
affective, cognitive, and psychomotor domains
of
learning.
It
provides students with enhanced skills
in
critical thinking
and
prepares them to function
in
a dynamic and complex health care
system. Baccalaureate nursing education programs seeking accredita-
tion could document their graduates' critical thinking abilities using
this strategy at all levels
of
the curriculum. Completing the eight-step
critical thinking learning strategy could also serve as
an
alternative
clinical learning method for Registered Nurse students and students
absent from clinical practice.
Brookfield's culturalization themes for nursing and their relation-
ship to critical thinking clearly have parallels in other professional
fields. Educators in these fields might fmd
it
useful to study the extent
to which the themes apply
in
other fields and possibly identify addi-
tional themes that could
be
used to teach the application and conse-
quences
of
critical thinking in the real world. Critical incidents for
use
in
the program could
be
suggested
by
recent graduates
or
developed
by
teachers, based
on
their
own
real-life experiences. Using Brook-
field's model
of
the four components
of
critical thinking as a basis for
analyizing these incidents, multi-step processes
such
as the
one
de-
scribed
in
this article could
be
established in many other fields.
References
Allen, D., Bowers, B. & Diekelrnann, N. (1989). Writing to learn: A reconceptualization
of
thinking and writing in the nursing curriculum. Journal
of
Nursing Education,
28(1),
6-10.
Brookfield, S., (1987). Developing critical thinkers: Challenging adults to explore alter-
native ways
of
thinking
and
acting. San Francisco: Jossey-Bass Publishers.
Brookfield,
S. (1993). On impostership, cultural suicide, and other dangers: How nurses
learn critical thinking. Journal
of
Continuing Education in Nursing, 5(24), 197-205.
del Bueno, D.J.
(1990). Experience, education, and nurses' ability to make clinical
judgments. Nursing
and
Health Care, 11(6), 290-293.
Foster, P.J. Larson,
D.
& Loveless, E.M. (1993). Helping students learn
to
make ethical
decisions. Holistic Nursing Practice, 7(3), 28-35.
259
To Improve the Academy
Kramer, M. K. (1993). Concept clarification and critical thinking: Integrated processes.
Journal
of
Nursing Education, 32(9), 406-414.
Lewis, J. B. ( 1992). The AIDS care dilemma:
An
exercise in critical thinking.
The
Journal
of
Nursing Education, 31(3), 136-137.
Miller, M.A., Malcolm,
N.S. (1990). Critical thinking in the nursing curriculum. Nursing
and Health Care, 11(2),
67-73.
National League for Nursing, (1989).
Curriculum revolution: &conceptualizing nursing
education.
New
York: National League for Nursing Press.
National League for Nursing, (1991 ). National League
for
Nursing Accreditation Criteria:
1991.
New York: National League for Nursing Press.
National League for Nursing, (1992).
Perspective
in
Nursing-1991-1993.
New
York:
National League for Nursing Press.
U. S. Department
of
Education ( 1988). Secretary's procedures and criteria for recognition
of
accrediting agencies. Federal Register, 53(127),25088-25099.
U.S.
Department
of
Health and Human Services Public Health Service. (1992). Healthy
people 2000 national health promotion and disease prevention objectives.
Bos-
ton:Jones and Bartlett Publishers.
260
