i UNIVERSITY OF CAPE COAST GHANAIAN NURSING FACULTY’S PERCEPTION OF CRITICAL THINKING BY CHRISTIAN MAKAFUI BOSO THESIS SUBMITTED TO THE SCHOOL OF NURSING OF THE COLLEGE OF HEALTH AND ALLIED SCIENCES, UNIVERSITY OF CAPE COAST IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF MASTER OF NURSING DEGREE IN NURSING EDUCATION JUNE 2014 University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library ii DECLARATION Candidate’s Declaration I hereby declare that this thesis is the result of my own original work and that no part of it has been presented for another degree in this university or elsewhere. Candidate’s Name: Christian Makafui Boso Signature: …………………………………… Date: …………………… Supervisors’ Declaration We hereby declare that the preparation and presentation of the thesis were supervised in accordance with the guidelines on supervision of thesis laid down by the University of Cape Coast. Principal Supervisor’s Name: Dr Mate Siakwa Signature: ……………………………… Date: …………………….. Co-Supervisor’s Name: Prof. Janet Louise Gross Signature: ………………………………. Date: ……………………... University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library iii ABSTRACT The ability to critically evaluate information for the purpose of rendering healthcare is a prerequisite for modern nurses in this complex and changing healthcare environment. The nursing faculty’s perception influences the utilization of critical thinking strategies. The purpose of this study was to assess nursing faculty’s perception of critical thinking. A cross sectional descriptive study with cluster sampling technique was used to assess the perception of 106 nurse educators from diploma and degree nursing programs in Ghana. Self-reporting questionnaire was used as the tool for data collection. The results revealed that majority (95.3%) of nurse educators could not provide a complete definition of critical thinking. However, the majority of nurse educators had positive perceptions of critical thinking. Nurse educators in universities had more positive perception of critical thinking than those in the Nurses’ Training Colleges (p=0.007). Course structure and materials, lack of institutional framework, students’ characteristics, time limitations, faculty limitations, and desire for grades were identified as barriers to the promotion of critical thinking. The results suggested that the current nursing programs are not preparing nurses for necessary skills for the complex health care environment. Curriculum review with focus on course content and design as related to critical thinking is required. University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library iv ACKNOWLEDGEMENTS It has been through the support of many friends and family members that I have reached this point in life. The support and sacrifices of my family have been immeasurable. Many thanks go to my wife, Aggie, who inspires me every day. Thank you to my lovely daughters and son, Kristin, Dzifa, and Kekeli, who have endured my absence just for me to pursue this program. I would like to express my appreciation to Prof. Janet Gross, my co- supervisor and Dr. Peter Mate Siakwa, my principal supervisor, whose insights and guidance have been invaluable. I also express my appreciation to the nurse educators who participated in the study. Without them it would not have been possible to progress with this work. I thank all my colleagues, and lecturers who contributed to the success of this work. My thanks also go to Mr. Emmanuel Armoh who proofread my work. University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library v DEDICATION To my wife, children, and mother. University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library vi TABLE OF CONTENTS Pages DECLARATION ii ABSTRACT iii ACKNOWLEDGEMENTS iv DEDICATION v LIST OF TABLES vi LIST OF FIGURES vii LIST OF ACRONYMS xii CHAPTER ONE: INTRODUCTION 1 Background to the Study 1 Statement of the Problem 6 Purpose of the Study 8 Specific Objectives 8 Research Questions 8 Significance of the Study 9 Assumptions 10 Delimitation 10 Limitations 11 Definition of Terms 12 Organization of the Report 13 Summary 13 University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library vii CHAPTER TWO: LITERATURE REVIEW 15 Nursing Education in Ghana 15 Historical Background of Critical Thinking 18 Theoretical Background 20 The Philosophical Approach 20 The Cognitive Psychological Approach 23 The Educational Approach 24 Dispositions 26 Critical Thinking: Discipline Specific or Neutral 27 Critical Thinking in Nursing 28 Teaching Strategies that Promote Critical Thinking Development 39 Barriers to the Promotion of Critical Thinking Development 53 Simpson and Courtney’s (2007) Conceptual Framework to Guide Teaching and Evaluation of Critical Thinking Skills 59 Conceptual Framework for the study 62 Summary of Literature Review 65 [ CHAPTER THREE: METHODOLOGY 69 Research Design 69 Study Setting 70 Study Population 71 Sample and Sampling Technique 72 Instrumentation 76 Data Collection Procedure 78 University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library viii Ethical Considerations 79 Data Analysis 80 Summary 81 CHAPTER FOUR: RESULTS AND DISCUSSION 82 Results 82 Further Comments (Optional) from Participants 113 Discussion 113 Perception of Critical Thinking 114 Teaching Methods Used to Promote Critical Thinking 119 Teaching Methods Often Used by Faculty 121 Barriers to Critical Thinking 122 Comparison of Perception of Faculty in NTCs and Universities 126 Summary 127 CHAPTER FIVE: SUMMARY, CONCLUSIONS AND RECOMMENDATIONS 128 Summary 128 Key Findings 129 Conclusions 130 Recommendations 131 Implication for Further Research 131 REFERENCES 134 University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library ix APPENDICIES A A Sample of Introductory/Permission Letter 146 B Nursing Faculty’s Perception of Critical Thinking Questionnaire 147 C Cronbach’s Alpha Reliability Coefficient Test 152 D Ethical Clearance 155 E Informed Consent Form 156 University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library x LIST OF TABLES Page 1 Distribution of Respondents to the Study 74 2 Demographic Characteristics of Respondents (n=106) 83 3 Definition and Attributes of Critical Thinking 86 4 Nursing Faculty’s Perception of Critical Thinking 88 5 Teaching Strategies that Promote Critical Thinking 92 6 Teaching Methods Used by Faculty 93 7 Teaching Methods Often Used by Faculty 94 8 Faculty-related Barriers to Critical Thinking 95 9 Student-related Barriers to Critical Thinking 97 10 Course-related Barriers to Critical Thinking 98 11 Other Barriers to Critical Thinking 99 12 Kaiser-Meyer-Olkin Measure of Sampling Adequacy and Bartlett's Test 102 13 Variance Explained by Eight Factors on the Critical Thinking Barriers (n=106) 103 14 Factor Loadings and Factor Structure of Critical Thinking Barrier 105 15 Comparison of Perception of Nursing Faculty in Universities and NTCs 109 16 Comparison of Perception of Nursing Faculty in Universities and NTCs Using Independent t-test 112 University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library xi LIST OF FIGURES Page 1 Simpson and Courtney’s Conceptual Framework of Critical Thinking Skills 59 2 Eclectic Conceptual Framework of Critical Thinking Skills 62 3 Scree Plot 104 University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library xii LIST OF ACRONYMS CCTDI California Critical Thinking Disposition Inventory CCTST California Critical Thinking Skills Test CT Critical Thinking LEP Learning Environment Preferences NLN National League for Nursing NMC Nursing and Midwifery Council of Ghana NTC Nurses’ Training Colleges QRN Qualified Registered Nursing SRN State Registered Nurses University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 1 CHAPTER ONE INTRODUCTION The chapter covered the introduction to the research report. The chapter was organized into eleven sections. These include background to the study, statement of the problem, purpose of the study, research questions, and significance of the study. Other sections include assumptions, delimitation, limitation, definition of terms, and organization of the report. Background to the Study The ability to critically evaluate information for the purpose of rendering healthcare is a prerequisite for modern nursing in this complex and changing healthcare environment (Toofany, 2008). National League for Nursing (NLN, 2006) in United State of America recognized critical thinking as a vital skill for practicing nurses. Nurses employ critical thinking in their practice every day. A high level of critical thinking disposition and critical thinking skills are required to care for patients/clients with similar health care needs. Patients react to needs in different ways. Therefore nurses are expected to draw on holistic nursing knowledge base to consider each incident in order to render personalized and efficient nursing care rather than merely complying with tradition. The responsibility of the faculty in helping foster critical thinking is vital (Twibell, Ryan, & Hermiz, 2005). As a student progresses through a program, it is the responsibility of the nurse faculty to assist in fostering critical thinking skills University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 2 in the student (Billings & Halstead, 2009). Carlson-Catalano (1992) asserted that traditional curricula do not empower nurses. She recommended an empowering strategy of professional nursing practice through the acknowledgement of students as important members of the profession. She suggested the use of nursing analysis, change actions, cordiality, and funding support as tools for nurses’ empowerment. Additionally, she contended that the only way to accomplish empowerment is for nurse educators to implement the philosophy of critical thinking as the basis for practice. Faculty needs to reconsider their philosophy of teaching in order to develop critical thinking disposition and skills in students. The National League for Nursing (NLN, 2003) of United State of America recommended that nursing institutions should implement a learner-centered philosophy in teaching for optimal student learning. If nurse educators believed that learner-centered teaching philosophy was beneficial, they would readily implement changes to reflect their belief (Colley, 2012). Learner-centered approaches lead to accountability and active learning which result in the demonstration of significant levels of achievement than students instructed with traditional educational strategies (Doyle, 2008). However, studies show that most nurse educators persist in using traditional approaches in teaching (Brown, Kirkpatrick, Greer, Matthias, & Swanson, 2009). They are usually comfortable with the traditional lecture method and find it challenging adjusting to alternative instructional formats (Candela, Dalley, & Benzel-Lindley, 2006). Many educators do not have time to acquire skill regarding new approaches to teaching and preparing materials for University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 3 use in learner-centered classes (Colley, 2012). In addition, student resistance to learner-centered approaches to teaching may be apparent (Colley, 2012). These factors may hinder the introduction of a learner-centered philosophy into nursing programs. The educators’ role must be to facilitate purposeful and optimal learning experiences (Freeman, Wright, & Lindqvist, 2010) rather than merely giving information. Communicating only facts to students is no more a desired option because with time, many facts become unfounded (Jones & Brown, 1991). A faculty dominated classroom does not create the suitable learning environment to develop critical thinking. The teacher and students must share in the responsibility of creating a learning environment conducive for students’ empowerment (DeYoung, 2009). The teacher is responsible for creating an environment that promotes critical thinking (DeYoung, 2009). Creedy, Horsfall, and Hand (1992) suggested that students can be empowered if their contributions are recognized, opinions are encouraged, mistakes are corrected objectively without humiliating them, and risk taking is permitted. To implement the principles of critical thinking, the learning environment must be altered. Active learning may provide a frightening situation to students. The teacher must create a nonthreatening environment that permits students to explore the learning materials, commit errors, probe the content, relate with past experiences, and convert the content into personal knowledge (McCabe, 1992). To create a conducive learning environment, the following strategies are suggested: faculty should share with the students their philosophy of teaching to University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 4 enhance critical thinking (Billings & Halstead, 2009); establish a sense of connection between faculty and students (Billings & Halstead, 2009); make students aware that there are conflicting ideas of concepts; and modify physical characteristics of classroom to ensure eye contact (Billings & Halstead, 2009). MacIntosh (1995) suggested the rearrangement of chairs in small or large circles. Transmitting information through rote lecture does not guarantee learning. In order to guarantee that educators are fostering critical thinking skills among students, some specific teaching methods have been suggested. These include reflective analysis, concept mapping, problem-based learning, Socratic questioning, role play, simulation, and seminar. These strategies promote active learning in the teaching and learning process and highlight the concepts of critical thinking and adult learning (Billings & Halstead, 2009). The Concept of critical thinking has been highlighted so much in educational literature (Graffam, 2007). However, many educators have not embraced it as a vital value, and may not comprehend the concept as constructed overtime by authors persuaded of its substance (Billings & Halstead, 2009). For example, Barnes (1983, as cited in Billings & Halstead, 2009) reported that faculty posed questions that were at the lowest level of cognitive skills. She discovered that faculty used lecturing most often with questions that are at low level of cognitive skills; and they followed with more lecturing. Similarly, Braxton and Nordvall (1985, as cited in Billings & Halstead, 2009) scrutinized examination questions in 83 colleges. They discovered that less than 0.5% of University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 5 questions may be categorized as requiring the evaluation skills to answers –– showing a deficiency in a very vital critical thinking skill. Several reasons may account for the inability of educators to make critical thinking an essential ethic in education. One reason is that many educators themselves did not witness the critical thinking strategies as they progress through their own educational program. Rather, they were modeled after lecturers who were dispensers of contents. Therefore, they teach what they are familiar with. Another reason is that most faculty members have not been educated specifically in critical thinking skills. This leads to lack of confidence in making a change in their teaching methods. Other reasons include performance evaluation that reward students who memorized contents; educators not committed in reading critical thinking literature; lack of consensus on what critical thinking mean; too much workload, and class sizes that are large; textbooks that do not encourage critical thinking but are designed for content coverage; and reward system for faculty that does not emphasis critical thinking. In Ghana, there have been reports of poor work ethics that are exhibited by nurses. Some of these poor work ethics included nurses shouting at patients, talking on the cell phone, and browsing the internet (Adjatey, 2013). The complaints of poor attitudes and work ethics exhibited by nurses in Ghana calls into question the kind of education being offered by nursing programs. This clearly indicates that there is something wrong with nursing education in Ghana. Nurses who possess critical thinking skills appreciate the consequences of their actions and inaction. Ghanaian nursing faculty’s perception of critical thinking is University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 6 not known. Therefore, this study assessed the nursing faculty’s perception of critical thinking. Statement of the Problem Rapid developments and changes are occurring in the information age in which we live. Consequently, the accumulation of knowledge is rapidly increasing. Nurses need to utilize their intellectual ability, and theoretical and experiential knowledge in applying critical thinking to appropriate healthcare situations (Jarvis, 2008). Critical thinking is crucial to nursing care. Most graduates of nursing programs are unable to meet entry-level requirements for making clinical decisions (del Bueno, 2005). Nurse educators have implemented a variety of teaching methods to foster critical thinking with varied outcomes (Adams, 1999). Programs have typically focused on mastering content instead of relating critical thinking to circumstances (del Bueno, 2005; Fero, Witsberger, Wesmiller, Zullo, & Hoffman, 2009; Walsh & Seldomridge, 2006). Nurse educators need to utilize educational strategies that foster the development of critical thinking to address students’ learning needs. Nurse educators are required to assist students in addressing current and future health care challenges. Contemporary nursing programs tend to give guidelines that highlight critical thinking as necessary to address the expectations and needs of a diversified society (Walsh & Seldomridge, 2006). Competent and safe nursing practice results from nursing faculty creating learning environments where students are active participants (Rothgeb, 2008). University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 7 In Ghana, some indicators that have been identified point to the fact that critical thinking is not being exhibited by nurses in caring for their patients. The public complains of negligence, poor work ethics, and violence by nurses (Adjatey, 2013; Adofo, 2010). The emphasis of nursing on tasks is partly blamed for this state of affair. Students are still taught to follow the functional model of nursing care. This model supports a situation in which nursing service is still task- oriented. This is a major obstacle to the development of critical thinking skills in students. The Nursing and Midwifery Council of Ghana (NMC, 2007) has incorporated critical thinking into its curricula with one of the program outcomes being to foster critical thinking skills in nurses in Ghana. However, challenges in the nursing educational system may erode the attempt to develop critical thinking skills of nursing students in Ghana. Some of these challenges include: limited educational resources; lack of access of faculty members to online information; under-stocked libraries; too few and outdated textbooks; few journals; poorly resourced clinical laboratories; and unavailability of disposable nursing supplies for teaching (Talley, 2006). These challenges could potentially serve as obstacles to the promotion of critical thinking skills. Also, there is no specific educational program on critical thinking for nurse educators. Yet, the educator is the critical element for critical thinking development. Meanwhile, the literature reveals that educators have challenges teaching critical thinking skills (Shell, 2001). Additionally, objective data on how the critical thinking is perceived and fostered by faculty is lacking in the field of nursing in Ghana. University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 8 This identified gap in the literature indicated a need for the assessment of the nursing faculty’s perception of critical thinking and identification of instructional strategies that have been adopted to foster critical thinking. Purpose of the Study The purpose of this study was to assess the nursing faculty’s perception of critical thinking. Specific Objectives The specific objectives of this study were: 1. To assess the perception of nursing faculty about critical thinking. 2. To identify the instructional strategies used by nursing faculty to develop critical thinking in their students. 3. To identify barriers that hinder nursing faculty from fostering critical thinking in students. 4. To compare perceptions of critical thinking between nurse faculty of Nurses’ Training Colleges (NTCs) and public universities. Research Questions To accomplish the objectives of this study the following research questions were addressed: 1. What is the perception of nursing faculty about critical thinking? 2. What instructional strategies do nursing faculty use to promote the development of critical thinking in their students? 3. What are the barriers that hinder nursing faculty from fostering critical thinking in students? University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 9 4. Is there a significant difference in perceptions of critical thinking between nursing faculty of NTCs and public universities? Significance of the Study Studying about the perception of educators will help to comprehend how critical thinking can be fostered in the classroom. Studies have revealed that thoughts and beliefs of educators impact practices in the classroom. The need to study educators’ perception in the view of promoting critical thinking is therefore apparent. This study sought to find out the nurse educators’ perception of critical thinking. Studying nurse educators’ perceptions of critical thinking is worthwhile from a variety of viewpoints. First, it may have implications for Nursing and Midwifery Council of Ghana (NMC) and nursing educational institutions in terms of policy making regarding curriculum decisions, and textbook selections. Second, the study may provide recommendations for universities and other nursing educational institutions in terms of professional development offered for nurse educators prior to employment. Third, it may have implication for in-service training, monitoring, and evaluation in order to improve the quality of teaching and learning, and standards setting. Furthermore, it may contribute to the limited literature especially in Ghana on nurse faculty’s perceptions of critical thinking. It will also contribute in identifying the barriers to critical thinking and teaching strategies employed by nurse educators to foster critical thinking development in students. Additionally, the findings from the study may assist superiors, curriculum University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 10 designers, policy makers, and educators by providing insight into the subject of nurse educators’ perceptions of critical thinking. Nursing faculty who play a central role in nursing education will find the basis to examine their own instructional strategies. Finally, it may inspire researchers to undertake further research by providing insight from a different context. Assumptions For the purpose of this study, it is assumed: 1. Critical thinking is essential for nursing education and nursing practice. 2. Nursing faculty’s educational philosophy guides their perception of teaching strategies that will effectively develop critical thinking. 3. Critical thinking enables novice nurses to enter clinical practice with ability to make decisions in patient care situations that promote positive outcomes. 4. Nursing faculty’s teaching strategies are related to the development of critical thinking. 5. Nursing faculty create learning environments that promote critical thinking. 6. Critical thinking is appreciated more by nursing faculty in universities than those in NTCs. Delimitation For the purpose of this study, the following delimitation was applied: University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 11 The participants constituted of only current faculty with full-time appointment to universities and NTCs in seven southern regions of Ghana at the time of the study. Limitations For the purpose of this study, the study had some limitations. The following limitations were identified: 1. The data collection was from one point in time (cross-sectional survey design). The cross-sectional design produced data about nurse educators at a specific time in their teaching career. A cross-sectional design can be generalized to other population but is not as strong as longitudinal in showing the entire process as nurse educators develop their educational philosophy. 2. The instrument employed in collecting data was self-reported perceptions of nurse educators. Therefore, the tool did not directly measure the actual critical thinking skills in implementing critical thinking strategies in the teaching. Additional limitation of self-reporting is that participants might not be knowledgeable on the subject. Therefore, they may choose not to answer questions because they do not understand a question or for other reasons. 3. Only nursing training schools offering general nursing programs at both diploma and undergraduate programs from southern part of Ghana were included in this study. Accordingly, the findings can only be generalized to this population. University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 12 4. The response rate of 65% limits the generalization of this research. This stems from the fact that nonrespondents could possess perceptions that contrast those who responded to the survey. Definitions of Terms Critical thinking: For the purpose of this study, Scheffer and Rubenfeld’s (2000) definition was used. Their definition was as a result of a Delphi study they conducted. A team of nursing experts around the globe was assembled to brainstorm on critical thinking and nursing. The findings of the study classified as “habits of mind” (affective) skill and cognitive skill with their associated characterizations to explain critical thinking. The definitions of the “habits of mind” for critical thinking in nursing consisted: “confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection” (Scheffer & Rubenfeld, 2000, p. 357). While the requisites definitions for the cognitive aspect included: “analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting, and transforming knowledge” (Scheffer & Rubenfeld, 2000, p. 357). For the purpose of this study, nurse educators’ definition should contain attributes that recognizes the two aspects of critical thinking (affective and cognitive). Nursing faculty refers to individuals who have current teaching appointments with nursing educational institutions. The term nursing faculty is used interchangeably with nurse educator. University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 13 Teaching strategy is an instructional method used by nursing faculty based on their perception that it effectively develops the learning outcome. The terms instructional strategies, best practices of instruction, and teaching strategies are used interchangeably. Perception is an individual’s viewpoint or opinion of belief of something. In this study, it is the faculty’s opinion or viewpoint of belief of critical thinking. Barriers to critical thinking are factors that hinder the promotion of the development of critical thinking. In this study, barriers are factors that hinder the promotion of the development of critical thinking in nursing students in Ghanaian nursing educational institutions. Organization of the Report This report was organized into five main chapters. The first chapter focussed on the introduction of the study. The second chapter dealt with the review of relevant literature. Chapter three addressed the methodology of the study. Chapter four concentrated on the analysis of the data and finding. The last chapter looked at summary, conclusion of the study and recommendations. Summary The introductory section of this report established the widespread recognition of critical thinking as a vital component of educating professional nurses. Furthermore, the role of the nurse faculty in critical thinking development was established. This role is largely affected by the faculty’s perception of critical thinking. Therefore, the purpose of this study was to assess the nursing faculty’s perception of critical thinking. Four research questions were stated, indicating the University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 14 purpose of assessing the perception of critical thinking, teaching strategies that enhance critical thinking, barriers to critical thinking, and differences of perception of critical thinking between faculty in Nurses’ Training Colleges and universities. Additionally, this introductory chapter identified limitations and delimitations of the study. Also, definitions of important terms used in this study were presented. The next chapter reviewed relevant literature for the study. Theoretical background of critical thinking, teaching methods that foster critical thinking, barriers to the promotion of critical thinking, and other relevant issues were discussed. University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 15 CHAPTER TWO LITERATURE REVIEW The literature review looked at quite a number of pertinent areas of critical thinking inquiries. The chapter is separated into the following segments: nursing education in Ghana; historical overview of critical thinking; definitions of critical thinking; theoretical background of critical thinking; critical thinking disposition; critical thinking: discipline specific or neutral; critical thinking in nursing; teaching strategies and methods used to promote critical thinking; barriers to the promotion of critical thinking; Simpson and Courtney’s conceptual framework; conceptual framework used for the study; and summary of the literature. This review also included current empirical studies on teaching strategies that enhance critical thinking skills in nursing as well as the barriers to the promotion of critical thinking development in students. Nursing Education in Ghana Nursing education in Ghana has undergone various transformations. It has moved from the training of male orderlies during pre-independent era to the current preparation of post-graduate nurses to take up leadership positions in education, administration, and research. In reviewing the evolution of nursing education in Ghana from1957 to1970, Opare and Mill (2000) contended that the transformations took place in a socio-economic and political environment with their associated challenges. Ghana was a pacesetter in nursing education having University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 16 been the first country in Sub-Saharan Africa to gain independence (Opare & Mill, 2000). In 1963, University of Ghana was the first university in tropical Africa to introduce diploma nursing program to prepare nursing tutors (Opare & Mill, 2000). During the pre-independent era, the health care system was fashioned to provide health care to the colonial masters, civil servants, and African soldiers. Later, the medical doctors trained male orderlies to assist them expand their services to the indigenous people. Only males were trained to render nursing care because the existing tradition at that time did not allow young women to provide nursing care to nonrelatives. The establishment of nursing school in Kumasi in 1945 by Isobel Hutton for State Registered Nurses (SRN) saw a shift from recruiting males (Boahene, 1985, as cited in Opare & Mill, 2000; Osei-Boateng, 1992, as cited in Opare & Mill, 2000). Only females were eligible for admission to the nursing program. Qualified Registered Nursing (QRN) was concurrently introduced (Opare & Mill, 2000). The British nursing education system continued to dominate until the policy of Africanization was introduced after independence. The policy encouraged Ghanaian nurses to progress to positions of decision-making. This is because the White sisters who occupied senior positions in education did not renew their appointment due to the Africanization policy. The British system had a heavy influence on the nursing educational system in Ghana. However, the British influence on nursing education in Ghana received harsh criticism. For example, Chittick (1965, as cited in Opare & Mill, 2000) argued that the kind of University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 17 relation that existed between the British system and Ghanaian nursing education accounted for the lack of flexibility, scope, and impetus that would lead to a system of nursing service and education to meet the unique health needs of Ghana. Additionally, the British system encouraged rote learning (Chittick, 1965, as cited in Opare & Mill, 2000). These assertions suggested some of the weaknesses that have existed in our nursing educational system to date. Similarly, nursing education and services lacked the internal dynamic required for the necessary transformation. Currently, there are several public funded and private nursing programs in Ghana offering undergraduate programs. However, the emphasis of nursing on tasks has not changed. Students are still taught to follow the functional model of nursing care. This model supports a situation in which nursing service is still task- oriented. This is a major obstacle to the development of critical thinking skills in students. In addition, undergraduate nursing programs are not encouraged. Talley (2006) asserted that the hospital-based diploma model is the most frequently used in nursing education in Ghana. Similarly, postgraduate nursing programs are limited. Another challenge identified in nursing education in Ghana is lack of resources. Some of these challenges include lack of infrastructure, large class sizes, and shortage of nurse educators (Bell, Rominski, Bam, Donkor, & Lori, 2013; Talley, 2006). University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 18 Historical Background of Critical Thinking Critical thinking theory originated from ancient Greek philosophers who sought to approach truism through the avenue of critical discussion (Yildirim & Özkahraman, 2011). Historically, the concept of critical thinking has been attributed to the ancient scholars such as Socrates, Plato and Aristotle as far back as 500 BC. It was first traced to the teaching and practice of Socrates who formulated a method of questioning that probed issues and knowledge held by people. Socrates asserted that one cannot rely on facts emphasized by people in positions of influence to develop knowledge that is sound and insightful. He established that people might be confused and highly irrational even though they might hold high positions and wield power. The fundamental philosophy was simply through critical discussion and criticism that the truth could be discovered (Norris & Phillips, 1987, as cited in Yildirim & Özkahraman, 2011). Socrates established the significance of accepting ideas as worthy of belief only after examining and questioning the ideas profoundly. Socratic Method of inquiry is what is commonly called “the Socratic questioning” which is said to be the most effective critical thinking educational method (Foundation for Critical Thinking, 2013). The persistent widespread use of Socratic questioning in academia from pre-schools to tertiary institutions attests to the influence of Socrates (Foundation for Critical Thinking (2013). Plato, Aristotle, and other thinkers followed the philosophy of Socrates. They stressed the fact that people could isolate and decipher the realism from the misrepresentation only if their minds were trained University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 19 and that the human mind was competent and completely willing to distort received stimuli. Most successive great thinkers were influenced by the way the Greek searched for in-depth meanings, associations, and realisms based on orderly thought processes (Foundation for Critical Thinking, 2013). There was no evidence of the influence of critical thinkers until the middle age when persons like Thomas Aquinas surfaced. The rubric of critical thinking was justified by Aquinas. His thinking was regularly and systematically examined by anticipating, considering, and answering every probable criticism of his thoughts that he might envision. In going through this process, he instituted the acknowledgment of evidence-based practice in learning as well as for self-corrected and self-regulated thoughts through an orderly cross-examination (Foundation for Critical Thinking, 2013). The Englishman, Francis Bacon, in the sixteenth century also held that people misapply their minds. He was a strong advocate for evidence and intense observation through experience on which reasoning must be based. The foundation for modern science with emphasis on the critical part of verification is generally attributed to him (Foundation for Critical Thinking, 2013). Other great thinkers played various roles in expanding the concept of critical thinking. Some of these thinkers include Rene Descartes (1596-1650), Sir Thomas Moore (proponent of new social Utopia), Robert Boyle (17th Century), and Sir Isaac Newton. Other contributors who emerged in the 19th century were University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 20 Karl Marx, Charles Darwin, and Sigmund Freud. Others were William Graham Sumner, John Dewey, and Ludwig Wittgenstein (20th century). The search for knowledge on the working of the mind is expected to continue perpetually. However, some familiar and vital trademarks run throughout from the time of Socrates till now. These include probing questions, demonstrable evidence-based reasoning, and the mind is not automatically in the position of regulating or correcting itself (Foundation for Critical Thinking, 2013). In addition, effective thinking depends on structures and processes that routinely undergo evaluation to ensure that reasoning has not been compromised. These processes go through constant analysis (Foundation for Critical Thinking, 2013). Theoretical Background The theory of critical thinking has two main approaches namely philosophy and psychology (Lewis & Smith, 1993); and a more recently recognized approach within the education field (Sternberg, 1986). The definitions of critical thinking that relate to these distinct academic disciplines mirror their individual concern. The different perspectives of critical thinking are further expounded in the subsequent paragraphs. The philosophical approach Some of the definitions of critical thinking that originate from the philosophical approach include 1. “critical thinking is reflective and reasonable thinking that is focused on deciding what to believe or do” (Ennis, 1985, p. 45); University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 21 2. “…..the skills and propensity and skill to engage in an activity with reflective skepticism……” (McPeck, 1981, p. 8); 3. “critical thinking is skillful, responsible thinking that facilitates good judgment because it 1) relies upon criteria, 2) is self-correcting, and 3) is sensitive to context” (Lipman, 1988, p. 39); 4. “purposeful, self-regulatory judgment which results in interpretation, analysis, evaluation, and inference, as well as explanation of the evidential, conceptual, methodological, criteriological, or conceptual considerations upon which that judgment is based” (Facione, 1990, p. 3); 5. “disciplined, self-directed thinking that exemplifies the perfections of thinking appropriate to a particular mode or domain of thought” (Paul, 1992, p. 9); 6. thinking that is goal-directed and purposive, “thinking aimed at forming a judgment,” where the thinking itself meets standards of adequacy and accuracy (Bailin, Case, Coombs, & Daniels, 1999, p. 287); and 7. “judging in a reflective way what to do or what to believe” (Facione, 2000, p. 61). The works of Socrates, Aristotle, Plato, and more recently, Matthew Lipman and Richard Paul have manifested the philosophical perspective to critical thinking (Lai, 2011). Unlike the cognitive psychological approach where critical thinking is looked at as actions and behaviors the critical thinker performs, the philosophical approach centers on the hypothetical person who thinks critically in relation to characteristics and qualities (Lewis & Smith, 1993; Thayer-Bacon, University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 22 2000). Sternberg (1986) asserted that the philosophical approach sees the critical thinker as a perfect kind, focusing on what a person could do in the ideal situations. Therefore, Paul (1992) postulated for critical thinking from the viewpoint of “perfections of thought” (p. 9). In addition, the perspective of an ideal critical thinker is evident in the American Philosophical Association’s Delphi study which described the critical thinker as someone who habitually probes, fair-minded, open-minded, flexible, information-seeking, values other perspectives, and is ready to reconsider his/her own judgment based on other viewpoints (Facione, 1990). The philosophical perspective also emphasizes criteria for thinking critically. For example, Bailin (2002) defined critical thinking according to a set of standards of thinking. Further, this perspective encouraged the application of rules of reasoning which are formal (Lewis & Smith, 1993; Sternberg, 1986). The philosophical approach to defining critical thinking is not always consistent with reality and that is one of its significant limitations (Sternberg, 1986). As noted by Lai (2011), this school of thought on critical thinking might have less impact on the debate regarding real thought processes of individuals because of the doggedness of this approach of the ideal critical thinker and what individuals are capable of performing. Meanwhile, according to Raymond-Seniuk and Profetto- McGrath (2011), the philosophical definitions most often referred to that are non- nursing are that of Facione (1990), and Paul (1992). University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 23 The cognitive psychological approach Some common definitions of critical thinking that have reflected cognitive psychological perspective consist of: 1. “the mental processes, strategies, and representations people use to solve problems, make decisions, and learn new concepts” (Sternberg, 1986, p. 3); 2. “the use of those cognitive skills or strategies that increase the probability of a desirable outcome” (Halpern, 1998, p. 450); and 3. “seeing both sides of an issue, being open to new evidence that disconfirms your ideas, reasoning dispassionately, demanding that claims be backed by evidence, deducing and inferring conclusions from available facts, solving problems, and so forth” (Willingham, 2007, p. 8). There are two main aspects that distinguish cognitive psychological perspective of critical thinking from that of the philosophical approach (Lai, 2011). These are reflected in the view that (1) psychological perspective focuses on how people actually think against how they should think under normal circumstances (Sternberg, 1986); and (2) psychological perspective’s definition looks at critical thinking according to the kinds of acts or conducts critical thinkers are able to perform (Lai, 2011). Lai argued that cognitive psychologists dwell on outcome of thought (behaviors or overt skills) such as scrutiny, judgment, and fine question formation because thought processes could not be observed. This contrasts the philosophical view that defines critical thinking according to the characteristics of the ideal critical thinker. Classically, the University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 24 cognitive psychologists approach to describing critical thinking involved a listing of the critical thinkers’ skills (Lewis & Smith, 1993). Critics of the cognitive psychological perspective, mainly from the philosophers, have often challenged the cognitive psychologists’ view of critical thinking as reductionist. That is limiting complicated issue of critical thinking involving combination of knowledge and abilities to a collection of distinct steps (Sternberg, 1986). Bailin (2002), a philosopher saw the attempt to reduce critical thinking to distinct steps or abilities as fallacy, and the behaviorist’s attempt to define constructs in a manner that are straightforward apparent emanate from this elementary misconception . Proponents of the philosophical perspective argued that critical thinking’s activities should not be confused with its component skills (Facione, 1990). Thus, critical thinking should not be looked at as merely the summation of its components (Van Gelder, 2005). In fact one could go through the steps or the procedures of critical thinking without really employing thoughts that are critical (Bailin, 2002). The educational approach Brookfield’s (1987, as cited in Raymond-Seniuk & Profetto-McGrath, 2011) definition is referred to often in the educational field. Brookfield defined critical thinking as first, involving recognizing and challenging assumptions; second, challenging the significance of context; third imagining and exploring alternatives; and fourth employing reflective skepticism. These elements in Brookfield’s definition of critical thinking demonstrated his view of critical as a process with emotive and rational perspectives. Likewise, Dewey (1933, as cited University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 25 in Raymond-Seniuk & Profetto-McGrath, 2011) postulated that some disbelief in thought would cause people to reflect. The conflict in thought subsequently generates a cautious consideration of person’s beliefs which results into re- establishment of beliefs supported on knowledge (Raymond-Seniuk & Profetto- McGrath, 2011). Other renowned authors in the education field who have engaged in the critical thinking discussions include Benjamin Bloom and his associates. For educational instruction and evaluation of higher-order thinking, instructors commonly refer to the taxonomy they developed in 1956 for information processing skills (Lai, 2011). Kennedy, Fisher, and Ennis (1991) asserted that analysis, synthesis, and evaluation which are the three top stages of the taxonomy are often referred to as signifying critical thinking. Unlike philosophical and the psychological traditions, Sternberg (1986) asserted that the strength of the educational perspective is that it is founded on long period of student learning observation and classroom experience. Nonetheless, some authors have criticized the vagueness of the educational perspective as a limitation. Compared to philosophy and psychology approaches, the education approach has not undergone vigorous testing (Sternberg, 1986). Additionally, challenges in using the taxonomy to help in teaching and evaluation exist because concepts in the taxonomy are deficient in clarity (Ennis, 1985; Sternberg). There are aspects of critical thinking that the three approaches have consensus on when it comes to the definition of critical thinking. These areas of University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 26 agreement include the exact abilities that classically go with the definition of critical thinking. These abilities consist of generalizing based on deductive or inductive reasoning (Facione, 1990; Paul, 1992; Willingham, 2007); assertions examination, proof, or arguments (Ennis, 1985; Facione, 1990; Halpern, 1998; Paul, 1992); evaluating (Case, 2005; Facione, 1990; Lipman, 1988); and problem solving or deciding on issues (Ennis, 1985; Halpern, 1998; Willingham, 2007). Some other vital skills recognized as important to critical thinking comprise seeking clarity through posing and responding to queries (Ennis, 1985); defining terms (Ennis, 1985); recognitions of postulations (Ennis, 1985; Paul, 1992); explanation and interpretation (Facione, 1990); ability to reason verbally (Halpern, 1998); ability to predict (Tindal & Nolet, 1995); and recognizing the fact that there are different sides to a matter (Willingham, 2007). Dispositions According to Lai (2011) dispositions have been defined by different authors as “attitudes or habits of mind” (p. 10). For example, critical thinking dispositions have been defined as “consistent internal motivations to act toward or respond to persons, events, or circumstances in habitual, yet potentially malleable ways” (Facione, 2000, p. 64). The majority of authors of critical thinking support the fact that critical thinking also involves disposition in addition to the abilities the critical thinker must possess (Facione, 1990). Some early authors such as Ennis (1985) researching into critical thinking acknowledged the fact that the ability to think critically is separated from the disposition. Facione (2000) asserted that the view that skills of critical thinking are different entities from critical University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 27 thinking dispositions seems to be supported by research. Pertinent dispositions essential to critical thinking identified by authors include: fair-mindedness (Facione, 1990); flexibility (Facione, 1990; Halpern, 1998); open-mindedness (Facione 1990, 2000; Halpern, 1998); seeking reason (Paul, 1992); being inquisitive (Facione, 1990, 2000); information seeking (Facione, 1990); and readiness to consider others’ viewpoints (Facione, 1990). Critical thinking: discipline specific or neutral There are some other issues that concerns critical thinking. One of such issue is whether critical thinking is discipline specific or discipline general. Some authors who supported the discipline specific argument asserted that critical thinking must not be taught as separate course but rather embedded into all courses (Ennis, 1997). On the other hand, those who support critical thinking as general asserted that it should be taught as a separate course. Solon (2001, as cited in Thompson, 2011) asserted that when students are taught critical thinking as a separate course, their critical thinking skills improves better than when it is embedded. Ennis (1997) argued that there is a third approach for the teaching of critical thinking where it is taught as a separate course and also incorporated into other courses. Another issue of critical thinking is that it is believed to be natural and that it does not need to be taught. Paul and Elder (2007) identified one of the problems of fostering critical thinking is that it is considered as natural and that everybody thinks. They argued that if individual thoughts are not challenged, they are “biased, partial, distorted, uninformed, or down-right prejudiced” (Paul & Elder, 2007, p. 2). University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 28 Critical Thinking in Nursing Critical thinking that leads to clinical judgment is vital to nursing care (American Association of Colleges of Nursing, 2008; Hoffman, 2008; Vacek, 2009). How nurse educators think about the definition of critical thinking will affect how they assess students and implement strategies to foster critical thinking (DeYoung, 2009). In the past, learners have been helped to develop their critical thinking skills through clinical experiences and the use of classroom experiences (Anderson & Tredway, 2009; Hoffman, 2008). Just as in many disciplines, critical thinking in nursing also lacks consensus. Allen, Rubenfeld and Scheffer (2004) asserted that the challenge in the promotion of critical thinking development in the clinical settings is as result of contradictory positions on a definition of critical thinking. Turner (2005) carried out a concept analysis of critical thinking in nursing literature to determine changes in the concept of critical thinking overtime. She reviewed relevant literature from 1981 to 2002 using three databases namely Cumulative Index of Nursing and Allied Health (CINAHL), MEDLINE, and EBSCO. The author stratified the references into two 11-years period (that is 1981-1991 and 1992- 2002). Turner (2005) used a randomized sampling technique of references from each period to code for definitions, referents, attributes, antecedents, consequences of critical thinking, and surrogate terms. The search yielded 646 distinctive literature references including books, journal articles, dissertations, and editorials. Dissertations were deleted because some of them had been published in journals. Therefore including them would have led to overrepresentation. University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 29 Commentaries, editorials, opinions, tips articles, and notes that lacked depth were also eliminated. Likewise, articles that could not be translated were deleted. A 10% sample (4 from first stratum and 45 from second stratum) was selected from the refined population of 492. Turner (2005) asserted that in the first stratum most often used definitions were that of Matthews and Gaul (1979, as cited in Turner, 2005) or Watson and Glaser (1964, 1980, as cited in Turner, 2005). While many of those in second stratum (1992-2002) cited the American Philosophical Association’s definition of critical thinking as reported in the consensus paper led by Facione (1990). Attributes of critical thinking yielded many characteristics. The first stratum recorded 36 unique attributes of critical thinking. The attribute, judgment was the only attribute cited in three separate sources (7.5% of occurrence). Analysis and skepticism were cited in two separate sources (5% of occurrences). The fact that attributes have not appeared consistently during this period indicated in the literature suggested lack of maturity of critical thinking. In the second period or stratum 162 separate attributes of critical thinking were cited (401 occurrences). Attributes that were most frequently cited included analysis (23 occurrences); reasoning (15 occurrences); inference (14 occurrences); interpretation (11 occurrences); knowledge (10 occurrences); and open- mindedness, (10 occurrences). Majority of these attributes were also connected with Facione (1990) and Paul (1992) which were the most frequently cited definitions of critical thinking (Turner, 2005). University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 30 Analysis was a stable attribute in the nursing literature. This is because it appeared in both stratum one and two (Turner, 2005). Meanwhile, reasoning was the second most frequently cited element in the second stratum and also appeared in the first stratum in 2.5 percent of occurrences. This made it a fairly stable element of critical thinking. The attributes interpretation, inference, open- mindedness, and knowledge were stable over both periods. Twenty-seven surrogate terms were identified which directly related to critical thinking. The following were most frequently used: decision making, diagnostic reasoning, nursing process, clinical judgment, clinical decision making, and problem solving. Three terms–decision making, problem solving, and nursing process were the only surrogate terms that appeared in the first stratum. The author therefore concluded that the concept of critical thinking had matured, and reflected in clearer definitions in the nursing literature. Nevertheless, antecedents and consequences are not well defined, and many consequences were similar to attributes and surrogate terms. She suggested further attention to boundary delineation within definitions of critical thinking. Scheffer and Rubenfeld (2000) tried through a Delphi study to come out with consensus position on the definition of critical thinking in nursing. They classified the results into two categories–habits of mind (affective) and cognitive skills with their associated definitions to expound the process of critical thinking. The report identified the elements that constitute habits of mind as “confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection” (Scheffer & Rubenfeld, University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 31 2000, p. 357). On the other hand, the cognitive skills elements were identified as “analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting, and transforming knowledge” (Scheffer & Rubenfeld, 2000, p. 357). The authors highlighted that context and prior experiences with a situation was crucial when one is using critical thinking. Scheffer and Rubenfeld’s (2000) definition positioned critical thinking as a fundamental aspect of nursing service and recognized that dispositions and skills are needed by the nurse to think critically. The highlighting of intuition, contextual perspective, and creativity as elements of critical thinking in nursing was the noticeable variation in this definition (Raymond-Seniuk & Profetto-McGrath, 2011). These elements which are considered more feminine concepts underscored the distinction between definitions formulated from inside nursing and those formulated outside nursing (Raymond-Seniuk & Profetto-McGrath, 2011). Alfaro-Lefevre’s (1999, as cited in DeYoung, 2009) definition is another definition of critical thinking that is often referred to in nursing. According to her, critical thinking and clinical judgment in nursing is “purposeful, informed, outcome-directed (results oriented) thinking … [that] requires knowledge, skills, and experience …. [and helps one] constantly reevaluating, self-correcting …, and striv[e] to improve” (p. 9). The above definition of critical thinking provides a complete description of the elements encompassing critical thinking from a nursing standpoint (Raymond-Seniuk & Profetto-McGrath, 2011). Raymond- Seniuk and Profetto-McGrath (2011) asserted that there was a powerful University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 32 association between critical thinking and clinical judgment in Alfaro-Lefevre’s definition which was not apparent in other definitions. Meanwhile, studies on nurse educators on the definition of critical thinking yielded several themes. For example, a study by Walthew (2004) on the perception held by faculty on critical thinking was descriptive, interpretive approach. The purpose of the study was to explore the perceptions of critical thinking by nurse educators in a large nursing school in New Zealand. Individualized semi-structured interview was used as the data collection tool from a sample of 12 nurse faculty out of a potential 18 respondents. All the respondents had at least 10 years teaching experiences. After analyzing the data, the author identified four themes of critical thinking. The ability to seek information, relating theory to practice, and problem solving was the first theme. One of the interviewees discussed the ability to link theory to practice as a process that develops as students’ knowledge increases with increased experience. Many of the nurse educators regarded the nursing process to be closely associated with critical thinking. However, some disagreed with this position and considered the nursing process to inhibit critical thinking by stifling creativity due to the linear-type thinking it encourages (Walthew, 2004). Disposition and attitude of the students was the second theme recognized by the nurse educators. The learner must have a natural character trait to think critically instead of a skill that developed over a period (Walthew, 2004). The third theme that emerged was hunch and subjective knowledge component of critical thinking (Walthew, 2004). According to Walthew (2004), this viewpoint University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 33 contradicted the conventional view of critical thinking that realism can only be truthfully represented by being unbiased, regular, and not capricious. The fourth theme reported by the nurse educators was context and thinking based on relations. One could be said to be a critical thinker only if he/she has considered other viewpoints and based on that take a decision. Complexity of critical thinking was strengthened through this study despite the fact that some clarity of the concept was offered (DeYoung, 2009). Chabeli and Muller (2004) conducted a qualitative study in South Africa to explore and describe the perceptions of nurse faculty with regard to how reflective thinking can be fostered in clinical teaching. Twelve nurse faculty with a minimum of 10 years’ experience in teaching in the clinical setting took part in the study using a focused group discussion. The key theme that emerged from the study was “empowering learners to use reflective thinking skills” (Chabeli & Muller, 2004, p. 62). Twibell et al. (2005) also looked at nurse faculty’s perception of critical thinking in clinical settings. The aim of this descriptive case study was to explore the perceptions of nurse educators teaching critical thinking skills to undergraduate nursing student in clinical settings. The researchers interviewed 6 clinical nursing instructors individually thrice at two weekly intervals. Using a modified version of the developmental research sequence (DRS) devised by Spradley, five themes emerged. These included putting it all together; strategies to promote critical thinking; role of clinical instructors; beneficial characteristics of instructors; and rewards for critical thinking. University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 34 Themes that had the greatest consensus among respondents were putting it all together and strategies to promote critical thinking. The theme, putting it all together was understood to mean combining different parts into one piece. Participants used phrases such as information seeking, reflecting on experiences, assigning meaning, problem solving, predicting, planning, and application to novel contexts. The strategies to promote critical thinking domain saw respondents acknowledging the instructor as a central element in influential learners’ ability to think critically. The questioning, written products, clinical conferences, and student journals were noted by the participants as the four definite strategies to foster critical thinking in students, though questioning was the most used (Twibell et al., 2005).The researchers concluded that critical thinking in nursing may be different from other disciplines because of affective dimension of nursing practice, clinical processes, and the nature of nursing knowledge. Twibell et al. (2005) recommended the use of different teaching strategies to promote the development of critical thinking in nursing practice as being the best approach for faculty. Zygmont and Schaefer (2006) tested nurse faculty with California Critical Thinking Skills Test (CCTST). The purpose of the study was to determine the critical thinking skills of nurse faculty. A sample of 300 full-time nurse faculty from all types of nursing education programs (except doctorate) from the National League for Nursing member schools was randomly selected. Five packets containing the California Critical Thinking Skills Test (CCTST), the Learning Environment Preferences (LEP), and a demographic questionnaire were sent to University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 35 the directors or chairs of the 60 schools of nursing selected. Only thirty-seven faculty completed and returned the packets. The study revealed that the majority (78.4%) of the nurse faculty responding noted that they had not attended any formal or informal training in critical thinking. About one fifth (18.9%) reported having some training in critical thinking. When two categories of college students’ scores on the California Critical Thinking Skills Test were contrasted against the faculty scores, it was revealed that most faculty members are significantly more skilled at critical thinking than the classic fourth year student. Faculty and students had a related mean score. This led the researchers to conclude that there might be a link between critical thinking skills promotion in students and the capacity of the nurse educator to employ critical thinking. Accordingly, a nurse educator who is not skilled in critical thinking may disadvantage his/her students in promoting critical thinking skills needed for practice. The researchers also noted critical thinking skills may be associated with time, experience, and education. Additionally, the nurse educators noted that promoting critical thinking in students seen as going further than information sharing but rather helping them through guidance. The relationship between the student and teacher where an atmosphere is created for the student to question or challenge an idea is a key part in fostering critical thinking. Zygmont and Schaefer (2006) finally recommended that the faculty should emphasize how the student comprehends and considers content (and not just covering the content), brainstorming on experiences in the clinical settings, and integrating active learning methods into the classroom settings. The major University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 36 weakness of this study was the small sample size used and therefore cannot be generalized. Riddell’s (2007) study on nurse educators was aimed at developing an understanding of nurse educators’ perceptions of critical thinking and how it can be assessed. The nurse educators the University of Western Ontario, in London, Ontario, Canada were selected and interviewed. The nurse faculty noted that critical thinking was more than problem solving. Teaching strategies that encouraged critical thinking included how students were questioned, case studies, role playing, journaling, or Socratic questioning. The researcher concluded that even though nursing is not a linear process, it was often taught as if it were a linear process. More recently, Al Hadid (2012) studied the perception of nurse educators in Jordan. The purpose of this explorative research was to examine the critical thinking experiences of nursing faculty in six universities in Jordan. The sample for the study included 100 Masters and PhD nurse educators from 4 public and 2 private universities with a return rate of 73%. The tools used to collect data were a questionnaire with three sections–the experience survey, California Critical Thinking Skill Test, and the California Critical Thinking Disposition Inventory. The results showed that nurse faculty exhibited positive dispositions of critical thinking on the California Critical Thinking Disposition Inventory and high anticipations of practicing critical thinking. However, an overall mean score of 12.37 was lower than the average 16.8 found among 4-year graduates in the United State of America on the skill test. The results further showed that nurse University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 37 educators needed additional professional training in critical thinking to help develop the critical thinking skills of students. Additionally, the results were influenced by age, gender, degree and experience in education. Those with PhD degrees scored significantly higher on all scales then those with Masters degrees. Similarly, participants with an age greater than 55 years recorded significantly higher than the other age groups. Female respondents attained significantly higher on the analysis and induction sections, and overall item, while the males achieved significantly higher on deduction section. The study indicated that nurse faculty did not reveal critical thinking in the test; they possessed positive disposition and elevated perceived application of critical thinking. The researcher therefore recommended that measure should be adopted to translate the perception of the nurse educators regarding critical thinking into practices. The organizations where the educators work must take the responsibility to improve professional knowledge on critical thinking. Critical thinking is pertinent to evidence-based practice. Evidence-based practice helps in achieving nursing care that takes into account the preferences of patients and their relatives through clinical judgments that are more useful, rationalized, and vibrant (Ireland, 2008; Youngblut & Brooten, 2001). Profetto- McGrath (2005) looked at critical thinking in evidence-based practice. The purpose of the study was to explore the importance of critical thinking as a vital skill required to support evidence-based practice and to describe some of the teaching strategies and processes that are considered key to the ongoing development of critical thinking. This was a systematic review that looked at University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 38 several issues in relation to evidence-based practice. It was revealed that critical thinking skills and dispositions are required for evidence-based practice and indeed, critical thinking and disposition are consistent with evidence-based practice. Critical thinking and disposition, and evidence-based practice could be promoted in students both in the classroom and clinical settings. A number of teaching strategies were noted as fostering both critical thinking skills and evidence-based practice. These strategies which are grouped included writing strategies (reflective journaling, scholarly writing, and critiques), questioning and role modeling, verbal strategies (clinical rounds, simulations, and planned controversies and debates), problem-based learning, concept maps, and computer- assisted instruction. The author concluded that nurses and nursing student who think critically are able to effectively ensure the implementation of evidence- based practice. In light of this, critical thinking skills as well as evidence-based practice must be taught explicitly and implicitly at the beginning of nursing programs, constantly taught during the programs, and promoted as a lifelong characteristic of the practicing nurses. The study did not describe the method used for this systematic review and therefore could be a weakness in this study. Nursing students are described as self-directed adults who decide to enter nursing programs (Mangena & Chabeli, 2005). Nursing students enter nursing programs for personal and professional development, social, economic, or political reasons. Personal reasons may be to establish careers that will sustain themselves and their families. Professionally, nursing students may assess their career goals and enter nursing programs for career advancement. University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 39 They enter undergraduate and graduate nursing programs at different levels of maturity and with obligations such as families and jobs. Nursing students enter nursing programs with their educational goals and objectives intact seeking specific information to reach those goals and objectives. Additionally, nursing students understand the responsibility needed for learning. Nursing faculty who understand the principles of adult learning create learning environments with the understanding that nursing students have individual characteristics; enter nursing programs with enormous life experiences to share and expand learning; require flexibility in learning because of differences in learning styles; and have internal enthusiasm as the most likely reason for entering the nursing programs (Knowles, 1984). Nursing students need an awareness of their ability to critically think about nursing subject content and gain confidence in their ability to analyze, integrate, and evaluate subject content (Mangena & Chabeli, 2005; Riddell, 2007; Zygmont & Schafer, 2006). Teaching Strategies that Promote Critical Thinking Development In contemporary times, many nursing programs emphasized the promotion of critical thinking skills owing to its substance and significance to professional nursing practice. Yet, studies on critical thinking are usually weak or the findings contrast, resulting in limitation in its utilization in the educational field (Adams, 1999; Staib, 2003; Walsh & Seldomridge, 2006). As a result, many nurse educators continue to teach learners in the same manner they were taught with much importance attached to content coverage (National League for Nursing, 2003). Lecture becomes the obvious choice as the instructional method because University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 40 lecture could cover large amount of content within a limited time (DeYoung, 2009). Even if the teacher allows question and answer time, the lecture format is passive which restricts assumptions. It does not allow curious questions. Additionally, faculty makes every effort to include all vital information into their lectures because of the large amount of content that needs to be covered at the neglect of focusing on synthesizing knowledge through critical thinking for desired outcomes and clinical judgment (Fitzpatrick, 2005). The result is the production of graduates who cannot think critically but rather reproduce facts (McMullen & McMullen, 2009; Neuman & Fawcett, 2002). To ensure the promotion of critical thinking in students, faculty needs to re- examine their own philosophy of teaching. The learner-centered philosophy must be at the center of teaching in order to maximize student learning (National League for Nurses, 2003). The traditional lecture format is preferred because of the perceived challenges in opting for unconventional instructional formats (Candela et al., 2006). Time limitations and student resistance account for the choice of lecturing method (Colley, 2012). These factors may hinder the introduction of a learner-centered philosophy into nursing programs. In order to guarantee that the educators are fostering critical thinking skills among students, some specific teaching methods have been suggested. These included concept mapping, role play, reflective analysis, simulation, Socratic questioning, seminar, and problem-based learning. These strategies promote active learner participation in the learning process and emphasize adult learning and critical thinking concepts (Billings & Halstead, 2009). University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 41 Strategies to foster critical thinking are a shared responsibility between the learner and the teacher. However, it is the duty of the educator to create the atmosphere that encourages this concept (DeYoung, 2009). Mentorship and facilitation of learning is the teacher’s role. Strategies to foster critical thinking include discussion (DeYoung, 2009), asking effective questions (Socratic questioning) (Brown, Bannigan & Gill, 2009), problem based learning (DeYoung, 2009), concept mapping (Clayton, 2006), narrative pedagogy (DeYoung, 2009) as well as case study (Billings & Halstead, 2009; DeYoung, 2009). Other strategies include one minute papers (DeYoung, 2009), microthemes (Paul, 1994), focused reflection through journaling and other means (Murphy, 2004), and self-assessment evaluation (DeYoung, 2009). Studies investigating particular teaching strategies that promote critical thinking skill development in students like case study, journaling, simulation, concept mapping, and questioning, are few and have not been repeated (Ellermann, Kataoka-Yahiro, & Wong, 2006; Fonteyn, 2007; Hoffman, 2008; Lasater, & Nielsen, 2009; Ravert, 2008). Adams (1999) in his integrated review on critical thinking revealed several deficiencies. The deficiencies in the literature included lack of random sampling, lack of comparison groups, and small sample sizes (Adams, 1999). In addition, although critical thinking assessment tools are available, most of them are general in their application to population and therefore do not measure critical thinking in the clinical reasoning approach (Ravert, 2008). Vacek (2009) asserted that current curricula used in nursing programs do not University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 42 empower learners. She argued that instead of students becoming autonomous in their thinking and in evaluating a state of affairs, they actually become more reliant and subservient. Chabeli and Muller’s (2004) study described above also revealed that the nurse educators noted strategies for promoting reflective thinking skills in students. These were noted in the second phase of the study that included encouraging students to ask questions, lecture demonstration (giving lecture and demonstrating simultaneously), observations (through simulation, field trips, demonstration, and audio-visuals), and narrative (storytelling). Other teaching strategies noted by the nurse educators to encourage skills included reflective journal writing, nursing process/case studies, peer tutoring, and concept mapping. The use of poster presentations, workbook, and observations of performance with checklist and rating scales enabled students’ comprehension and response evaluation (Chabeli & Muller, 2004). Other teaching strategies reported by nurse educators to promote skills in students included clinical conference, values clarification, research/community outreach projects as well as self-directed learning contracts. To evaluate the learning of this skill, research presentations, rounding on students on units, and comprehensive task performance assessments were strategies used by this group of educators (Chabeli & Muller, 20004). Chabeli and Muller (2004) concluded that clinical teaching provides a dynamic, continually varying, real-life situations where students are able to link theory with practice. University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 43 Murphy’s (2004) study on teaching methods looked at the effects of focused reflection and articulation through the use of post-clinical conferences and journal writing to promote clinical reasoning. The aim of the study was to determine the effectiveness of the use of focused reflection and articulation on the development of clinical reasoning. The author defined clinical reasoning as the health care provider’s ability to appraise clients’ health needs and analyze information gathered to acknowledge and frame problems in the viewpoints of the individualized clients’ setting. Four cohorts of clinical students and instructors in a community college nursing program were selected to participate in the study. Two student cohorts and the instructors were trained in the use of focused reflection and articulation. The training did not benefit the other groups. The clinical teachers used Assessment and Analysis Instrument (AAI) to evaluate the students’ written patient assessment. The AAI instrument was used to appraise students’ assessment and their ability to analyze both at the middle of the term and at the end of the semester. A 5-point Likert-type tool was used to verify the domain-specific knowledge by using a single examination test. Murphy (2004) used the Focused Reflection and Articulation Inventory (ARI) to assess the learner’s self-report of occurrence and perceived effectiveness in the clinical situation. The findings of the study indicated that there were no significant differences between the groups on the composite scores of clinical reasoning. However a significant difference was found between the two groups on the University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 44 practice measure of clinical reasoning. Those with lower level clinical reasoning were more task and skill oriented. However, those that had higher level of clinical reasoning revealed that reflection was self-initiated and they were passionate and inherently motivated to think about the problem and give explanation. Therefore, the author’s conclusion (Murphy, 2004) was that the strategies of having the educator employ knowledge to focus, point, and instruct learners to concentrate on significant points in the clinical setting positively influenced learning outcomes. The nursing care plan has been used to determine learners’ capacity to evaluate and prioritize patients’ needs but some assert that critical thinking has been hampered by many standardized care plan being available (Billings & Halstead, 2009). Concepts maps are diagrammatic forms of ideas (Irvine, 1995, as cited in Toofany, 2008) “usually consisting of nodes or cells that contain linked concepts, items or questions” (Toofany, 2008, p. 28). Concept mapping is considered an effective strategy that improves critical thinking and clinical decision-making skills in students. Concept mapping can be utilized in other teaching methods including lectures, group work, discussion in the classroom setting, clinical practice settings as well as skills laboratories (All, Huycke, & Fisher, 2003). Post clinical experience, learners were supposed to integrate all the relevant patient information into a concept map. Both objective and subjective data on the patient were included into concept map. Concept maps give a visual illustration of a patient’s disease process, condition, and treatments (Ellermann, University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 45 Kataoka-Yahiro, & Wong, 2006). Learners use graphical representation of material and identified associations among patient factors. Because students’ critical thinking skills were considered to have improved if they could better develop concept maps within a semester. Similarly, Abel and Freeze (2006) asserted that concept maps improved the critical thinking skills of students. Wilgis and McConnell (2008) conducted a study on concept mapping and the development of critical thinking. The purpose of this study was to determine whether concept mapping fostered critical thinking skills in graduate nurses during a hospital orientation. Benners’ (1984, as cited in Wilgis & McConnell (2008) Novice to Expert Theory was used as the framework of the study to aid in identifying and incorporating appropriate critical thinking elements from orientation objectives. Fourteen graduate nurses present in an orientation program in a Northeastern Florida hospital participated in the study. The participants were required to map a key health problem, main assessment findings, suitable nursing diagnoses, and interventions of a patient at the commencement and then at the closing stage of an orientation course. Only 1 of the 14 had graduated from a baccalaureate nursing program. A tool constructed by Schuster was used to evaluate the concept maps. The tool was congruent with the six American Nurses Association (ANA) standards of nursing care practice which is used for collection of data, analysis of data to formulate nursing diagnosis, identification of expected patient outcomes, development of a plan of care, implementation of nursing measures, and patient’s evaluation. University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 46 The results revealed a significant increase in the composite score during post orientation evaluation (Wilgis & McConnell, 2008). The global scores for criteria associated with linkages of data with interventions indicated considerable improvement in graduate nurses’ skills. The graduates were able to identify the main health needs and come out with specific and appropriate interventions on the concept maps during post orientation program evaluation. Post orientation program concept maps were more reasonable, more composite and placed in a suitable hierarchical order. The graduate nurses’ post orientation evaluation comments were assessed and classified. The findings revealed that 71% of participants believed that concept mapping assisted them in making a link between knowledge, improved prioritization, helped in the organization of care plan and fostered critical thinking. However, 14% of participants perceived that concept mapping did not assist them or was too baffling. Wilgis and McConnell (2008) concluded that concept mapping facilitated linkages in knowledge, improved the ability to prioritize, assisted in the organization of care plan, and improved the development of critical thinking. They recommended that instructing in the fundamental idea of concept mapping in orientation and preceptor courses could prepare both new graduates and preceptors for using this alternative way of promoting critical thinking. However, a major limitation of this study was the small sample size and therefore cannot be generalized. Similarly, Atay and Karabacak (2012) conducted a study on nursing care plan and concept mapping. The purpose of the study was to analyze the effects of care plans prepared using concept maps on the critical thinking dispositions of University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 47 students. A pre-test post-test control group design was used with a sample size comprising 80 freshmen and sophomore students from the nursing department of a health educational institution in Turkey. Three sessions of training on concept mapping nursing care plan were given to the experimental group while the control group prepared nursing care plans using the column format. Both groups’ critical thinking dispositions were evaluated with California Critical Thinking Disposition Inventory (CCTDI) during the pre-test and post-test. Those in the experimental group were also evaluated with the criteria for evaluating care plans with concept maps developed by Schuster in 2000. The results were then compared using t-test. The findings revealed that though both the experimental and control groups did not have significant differences in the total and sub-scale pre-test scores on the CCTDI, there were significant differences in the total and sub-scale post-test scores among the experimental and control groups. Additionally, the experimental group had significant differences in the mean core on the concept map care plan evaluation criteria. The findings suggested that if concept mapping strategy was used to instruct students in nursing care plan, their critical thinking skills would be fostered. Though the study provided support for concept mapping in nursing care plan, concept mapping was also structured and therefore may not encourage creativity. Reflective journaling has been reported as an effective teaching method that promotes the development of critical thinking skills in student. It helps students contemplate and reflect on life or learning experiences which enhanced self-awareness (Billings & Halstead, 2009). Journal entry development leads to University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 48 active learning engagement through expressed thoughts in a form of writing (Billings & Halstead, 2009). The active learning nature of journaling makes it a good tool for fostering the critical thinking skills of learners. Ruthman et al. (2004) reported on the outcomes of guidelines developed for clinical journaling. The purpose of the guidelines was to provide a reliable structure for student learning and evaluation in a range of clinical practice settings. The author revised practices of the nursing program following which a draft of proposed clinical log project was developed. The proposal was reviewed by two English department faculty members who helped to clarify the design and limits of the guidelines. The draft was presented to the entire faculty for their input. After some minor changes were made, the guidelines were tried in at three practicum levels. Students also reviewed the guidelines and recommended setting specific guidelines. Subsequently, further revision was done and the guidelines piloted throughout the program for a year. Weekly logs were kept by students for each clinical practice rotation. They identified learning goals, analyzed incidences and related them to nursing practice, related theory and practice through the utilization of critical thinking, and reflected on the experiences. A pattern of achievements and a cumulative integration of skills provided reliable standards for student evaluation as the students journeyed through the program. After reviewing the project for a year, project was found to be favorable and adopted as a reliable method of communication during the 2001/2002 academic year. Students and faculty were asked to evaluate the clinical log activity two semesters after the department had adopted the activity. Eighty-eight out of one University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 49 hundred ten students were involved in the evaluation. Students identified several benefits which were congruent with the objectives of the log activities. These benefits included helping them reflect, think, determine strengths and weaknesses, enhanced personal improvement, and setting of goals (Ruthman et al., 2004). Similarly, faculty found that the log improve reflection; provided the avenue to track progression of students; helped students organize thoughts better; engaged students active learning as a result of weekly goals setting; enhanced students’ ability in communicating thoughts, fears, and skills; helped students think critically by relating theory to practice; and created the opportunity to identify experiences that were desired (Ruthman et al., 2004). Despite challenges of repetitiveness and time consuming nature of journaling (Ruthman et al., 2004), timely feedbacks to students and constant review of the log activities potential enhance critical thinking skills of students. Additionally, Walsh and Seldomridge (2006) looked at how critical thinking is being implemented in classroom settings and clinical practice settings. The objective of the study was to explore the role and place of critical thinking in an undergraduate nursing program and examined whether critical thinking was being strengthened or diminished in the clinical and classroom settings. The researchers identified a variety of issues in reinforcing the significance of critical thinking in nursing education. The study revealed that nurse educators acknowledged their role in developing critical thinking skills in learners. However, educators faced the obstacle of pressure to cover content within the available time. Students are said to benefit more if they are taught to analyze University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 50 issues. Accordingly, educators must move away from using only lecture format in their instructions. Dewey (1948) pioneered reflection on one’s action as a way to strengthen knowledge. Reflection on one’s nursing action has been identified as important to the development of clinical judgment (Tanner, 2006; Vacek, 2009). Learners, if provided with a template or guide for appraising clinical judgment can develop those skills. Dillard et al. (2009) examining the journals of 25 nursing students for evidence of clinical judgment with the Lasater Clinical Judgment Rubric. The Rubric provided a format to evaluate students’ skills. The findings revealed that students had the tendency of focusing on more task-oriented duties than the clinical reasoning process. The students also employed Lasater Clinical Judgment Rubric to monitor the level of their progress (Lasater & Nielsen, 2009). A strong questioning skill is the most essential strategy of accomplishing the goal of dealing with the complexities of the current health-care environment (Brown et al., 2009). According to Paul and Elder, (2006, as cited in Brown et al., 2009), Socratic questioning is the most effective teaching strategy for the nurturing of critical thinking because it stresses on reflection and logic. The Socratic questioning method suggests that when people query critically they generate more knowledge than focusing on finding a right answer (Brown et al., 2009). However, Socratic questioning is a difficult skill to develop, and for it to succeed faculty needs support and guidance (Brown et al., 2009). Problem-based learning has been cited in improving the development of critical thinking in students. In problem-based learning, students are provided a University of Cape Coast https://ir.ucc.edu.gh/xmlui Digitized by Sam Jonah Library 51 patient and con