Critical thinking is one of the most desired outcomes of nursing programmes worldwide. In Canada, all nursing regulatory bodies emphasise critical thinking as part of entry-level competencies for nursing programmes in Canada to practise safely and ethically once qualified in all settings (Canadian Nurses Association (CNA), 2015). This skill is salient for nurses to identify the use of evidence-informed knowledge, skills and judgement as a standard of practice for registered nurses (Nurses Association of New Brunswick, 2012. According to Scheffer and Rubenfeld (2000:352), critical thinkers in nursing are characterised by ‘confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection’. The terms ‘critical thinking’, ‘clinical judgment’ and ‘clinical reasoning’ are often used interchangeably to indicate ‘the process of searching, obtaining, evaluating, analyzing, synthesizing, and conceptualizing information as a guide for developing one's thinking with self-awareness, and the ability to use this information by adding creativity and taking risks’ (Yildirim et al, 2011:175). The significance of critical thinking in nursing is evident, and nursing education programmes are evaluated by nursing authorities based on the development of these skills (Khosravani et al, 2004).
Preparing nursing students to become qualified nurses includes developing their critical thinking abilities: students must learn how to identify a problem, collect, interpret and prioritise data, and plan to solve the problem (Menezes et al, 2015). The significance of critical thinking in nursing has been discussed throughout the literature. Papathanasiou et al (2014) discussed why it is crucial to the nursing profession:
- First, critical thinking is a significant component of the problem-solving process that enables nurses to make the best creative decisions to provide safe, competent and effective nursing interventions. In addition to knowledge and psychomotor skills, nurses use their cognitive and mental abilities to assess, analyse, synthesise, diagnose, plan, intervene and evaluate individuals, families and communities
- Second, this kind of thinking is vital for nurses to make meaningful connections between past and present history and assessments to determine the most appropriate nursing intervention, especially when they are working in settings where there are limited resources
- Third, critical thinking guides nurses' decisions when caring for ever-changing patient needs and when encountering complex situations
- Fourth, critical thinking enables nurses to think out of the box and to handle multifaceted contexts via learnt knowledge, experience and intuition when working with non-traditional cases.
Kabeel and Eisa (2016) emphasised that critical thinking in nursing reflects the scientific underpinnings of nursing science, where nurses take a logical approach to providing systematic care. Nurses use their logical thinking and goal-oriented attitudes to deliver evidence-based care, taking into account many factors: professional standards of care, ethics, procedures, rules, health policies and regulations, and applying their knowledge, skills and experience (Tajvidi et al, 2014). Critical thinking allows nurses to select the best nursing interventions and nursing care for their clients using their contextual clinical experience and educational backgrounds (Ignatavicius, 2001). Critical thinking is the foundation of nurses' thinking and is applied daily in practice. As such, it is an essential component of the curricula of nursing programmes. Finally, although critical thinking is a lifelong skill, the foundation for building this skill begins in undergraduate nurse education.
Many nurse education programmes struggle to integrate and teach critical thinking to their students. Shell (2001) reported that many factors hindered nursing faculty from teaching critical thinking skills. These included the unwillingness of some students to employ new learning techniques, the reluctance of some educators to foster critical thinking, the method of teaching used (ie traditional versus innovative teaching methods), lack of time to prepare and perform critical thinking activities, time constraints on faculty members and pressure to conduct research, short duration of classes and the physical educational environment.
Yildirim et al (2011) reported that nursing educators do not have sufficient time to develop the most appropriate teaching strategies to develop their students' critical thinking skills. In nursing education, it is not always effective to apply critical thinking strategies taken from the broader educational context because nursing requires the application of critical thinking in client-specific situations. Moreover, nursing educators struggle to balance course content with critical reflection. Yildirim et al (2011) suggested that students' attitudes toward learning often impaired educators from teaching critical thinking skills, namely, students focused on grades rather than learning and preferred more traditional didactic approaches to the learning process, rather than the novel approaches that have been found to enhance critical thinking.
Critical thinking among advanced standing programme students
The ‘advanced standing programme’ (ASP), the ‘accelerated track programme’ and the ‘2-year second-degree nursing programme’ are different terms used interchangeably in North America to describe a condensed Bachelor of Nursing (BN) programme, which has been designed in response to nursing shortages (Cormier and Whyte, 2016). This type of programme aims to produce graduate nurses with the same skills and knowledge as their counterparts undertaking a 4-year programme but in half the time (Cormier and Whyte, 2016). The ASP offers a condensed curriculum that enables students to meet requirements similar to those expected of students undertaking a traditional 4-year programme, thereby achieving the same standards and goals within a shortened time frame.
According to Cormier and Whyte (2016), the average age of ASP students tends to be higher than that of their counterparts in the traditional programme. They have higher self-motivation to learn and are more competitive; they also achieve higher grades and National Council Licensure Examination for Registered Nurses (NCLEX-RN) scores, and they prefer creative, challenging adult learning strategies that differ from students of traditional 4-year programmes, who tend to prefer structured didactic methods. (The NCLEX-RN is an assessment of nursing competence, without which is it not possible to practise in North America.) In a study undertaken more than 20 years ago, Youssef and Goodrich (1996) compared students undertaking an accelerated programme and those on a traditional 4-year programme. They did not find significant differences between the two groups in terms of characteristics such as age, race and stress levels between the second semester and the end of the programme, nor did the two groups' critical thinking skills differ significantly. However, students on the accelerated programme had a higher grade point average. The authors suggested that perhaps this was because these students' pre-existing critical thinking skills enabled them to perform better. A study by Korvick et al (2008) involving BSc (Nursing) (n=32) and Accelerated BSc (Nursing) (n=29) students reported similar results: students on accelerated programmes showed better performance in class test scores, nationally standardised examination scores, laboratory skills performance and final course grades compared with those on traditional courses. The study also found that age was not predictive of success in either group.
In 2017, Kaddoura et al conducted a study to explore whether the critical thinking scores of students on an accelerated programme were a valid predictor of first-attempt success with passing NCLEX-RN exams to practise in the USA. The authors used data from the records of a school of nursing in Northeastern USA to compare students' critical thinking skills at the beginning and the end of their nursing programme using a standardised critical thinking test developed by Health Education Systems Incorporated (HESI). The authors took these results and compared them with the students' NCLEX-RN first-time pass rates. They found a statistically significant relationship between critical thinking skills and first-time NCLEX-RN pass rates. Newton and Moore (2013), who measured critical thinking among nursing students using the Critical Thinking Assessment Entrance (CTAE) instrument, reported explicitly that critical thinking scores of accelerated programme students were higher than those of their traditional course counterparts.
Although many Canadian universities have adopted accelerated nursing programmes, no published Canadian studies could be found that measure critical thinking skills among ASP and traditional course students, and how the cohorts compare. Although the NCLEX-RN is now the standard entry to practise nursing that is used to assess the competency of nursing graduates in Canada, there is a dearth of knowledge about the critical thinking skills of nursing graduates. Furthermore, the authors were unable to find any Canadian studies comparing the critical thinking skills of students on a traditional 4-year BN course and students on an ASP. Therefore, this study aimed to evaluate the critical thinking skills of students at the University of New Brunswick, Canada: ASP students at Moncton campus and 4-year nursing students at the Fredericton and Saint John campuses.
Method
Design
A cross-sectional descriptive, comparative quantitative research design was used to collect data, using the valid and reliable California Critical Thinking Skills Test (CCTST) (Insight Assessment, 2016. Participants were nursing students at the University of New Brunswick and the study aimed to measure and compare the critical thinking skills of ASP students and their traditional 4-year course counterparts.
Inclusion criteria and sample size
A convenience sample of 100 nursing students (Moncton campus, n=30; Saint John campus, n=30; Fredericton campus, n=40) undertaking the Families in Populations course during the autumn/winter of 2018–2019 were invited to participate. The total number of students who were eligible to participate from the three campuses was 152: ASP, n=42; and BN, n=110.
Conceptual framework
The critical thinking conceptual model, which was developed by a panel of experts via the Delphi project (Colucciello, 1997), was used to guide the study. It consists of four dimensions of critical thinking and their variables, along with indicators of outcomes to measure each dimension. The four dimensions are: critical thinking dispositions, skills, elements, and criteria. In this study, only critical thinking skills and its variables subscales—analysis, evaluation, inference, deductive reasoning and inductive reasoning—were measured using the CCTST instrument.
Instrument reliability and validity
The Delphi project was the first to clearly define the meaning of critical thinking, a definition that guided the development of the CCTST, which is a valid, reliable and objectively scored standardised tool (Colucciello, 1997) used to assess critical care skills or subscales core reasoning skills. The CCTST consists of 34 multiple-choice items of short, discipline-neutral content, problem statements and scenarios that aim to measure variables within five specifically defined subscales: analysis, evaluation, inference, deductive reasoning and inductive reasoning. Each correct answer scores 1 point; the total score range is 0–34, with a higher score indicating stronger critical thinking skills. The tool takes 45-60 minutes to complete. For this study, the CCTST college-level paper and pencil form version of the tool was used. Demographic data on gender, age, programme location and type of nursing programme were collected.
The reliability of CCTST has been measured in previous studies using the Kuder Richardson-20 (KR-20) formula to estimate the tool's internal consistency, which ranged from 0.78 to 0.82. For an instrument with multidimensional scales such as the CCTST, a KR-20 score above 0.70 indicates a high level of internal consistency (Insight Assessment, 2016). The tool's validity was measured through content, construct and criterion validity tests. The results indicated that it is a highly valid instrument to measure critical thinking skills (Insight Assessment, 2016). A licence to use the CCTST instrument was granted by the author.
Data collection and analysis
After ethical approvals were received from the Faculty of Nursing Ethical Review Committee and the Research Ethics Board at the University of New Brunswick, a brief classroom presentation (15 minutes) was made to nursing students in their final year during one of their courses (with permission from course instructors) to recruit participants. The presentation included explanation of the study rationale, mode of participation (questionnaire) and that participation was voluntary; students had the right to withdraw at any point before submitting the questionnaire without penalty, not to answer any question on the tool and to ask the lead researcher questions related to the study.
There were no financial or academic incentives for participation in the study. Participants were assured of their confidentiality and anonymity, and were assured that their academic performance would not be affected whether they chose to participate or not. Participants were advised that completing and returning the questionnaire would be taken as implied consent. At the end of the classroom presentation, questionnaires were distributed and collected in sealed envelopes. The completed questionnaires were analysed using descriptive and inferential statistics. The significance level was set at (P<0.05) for all statistical tests.
Findings
Of 100 questionnaires distributed to the nursing students across the three campuses, 44 (44*) were returned. Thirty six participants were female (81.8*) and 8 (18.2*) were male, and average age was 22.8 years; 24 students (54.5*) were undertaking the 4-year nursing programme and 20 (45.5*) the ASP. The overall mean (M) critical thinking score for participants across both programmes was 20.1 (SD=4.2). The CCTST tool categorises the strength of participants' critical thinking as follows:
- Not manifested: 0-7
- Weak: 8-12
- Moderate: 13-18
- Strong: 19-23
- Superior: 24 or higher.
Table 1 presents the strength of students' critical thinking skills within each subscale. Table 2 shows that all participants had a moderate score for strength of critical thinking skills on the induction, deduction, inference and analysis skills subscales. As shown in Table 3, the ASP students had a higher overall mean score (M=21.6, SD=2.1) compared with those on the 4-year course. Students in both groups scored moderate strength for all critical thinking subscales, with the exception that the ASP students had a stronger score on their evaluation skills than their counterparts in the 4-year programme (7.6. versus 6.1 respectively).
Table 1. Scoring against each subscale of the California Critical Thinking Skills Test for students across both nursing programmes
| Not manifested | Moderate | Strong | |
|---|---|---|---|
| Analysis | 0 | 2 | 3–4 5 or more |
| Inference | 0–5 | 6-11 | 12 or more |
| Evaluation | 0–3 | 4–7 | 8 or more |
| Induction | 0–5 | 6-11 | 12 or more |
| Deduction | 0–5 | 6-11 | 12 or more |
Table 2. Strength of critical thinking dimensions of the California Critical Thinking Skills Test for students across both nursing programmes
| Skill/attribute name | n | Mean | Strength | SD |
|---|---|---|---|---|
| Overall | 44 | 20.1 | Strong | 4.26 |
| Analysis | 44 | 3.9 | Moderate | 1.2 |
| Inference | 44 | 9.4 | Moderate | 2.6 |
| Evaluation | 44 | 6.8 | Moderate | 2.1 |
| Induction | 44 | 10.3 | Moderate | 2.1 |
| Deduction | 44 | 9.8 | Moderate | 2.1 |
Table 3. Comparison of critical thinking skills between students on the advanced programme and students on the 4-year programme
| Skill/attribute name | Students: mean (SD) | |||
|---|---|---|---|---|
| ASP (n=20) | Strength | 4-year programme (n=24) | Strength | |
| Overall | 21.6 (2.1) | Strong | 18.9 (5) | Strong |
| Analysis | 4 (0.5) | Moderate | 3.9 (1.6) | Moderate |
| Inference | 10 (1.6) | Moderate | 8.9 (3.1) | Moderate |
| Evaluation | 7.6 (1.7) | Strong | 6.1 (2.3) | Moderate |
| Induction | 11 (1.7) | Moderate | 9.8 (2.4) | Moderate |
| Deduction | 10.6 (1.6) | Moderate | 9.1 (3.5) | Moderate |
The one-way ANOVA test (F) was used to refute the null hypothesis that two groups are the same (F=4.75, P=0.035). This result showed that the difference between the groups was statistically significant. Another way to check the importance of any differences is to examine the mean percentile scores for the groups (49th versus the 65th): the 4-year programme group had a mean of 18.9. This mean was similar to the overall mean of all health science undergraduate students across North America who were studied to measure their critical thinking using CCTST (Insight Assessment, 2020); the ASP group's overall mean score (M=21.6) was considered to be ‘high performing’ on the CCTST instrument.
Discussion
The results showed that participants on both nursing programmes had high scores for the strength of their critical thinking skills. However, the ASP students had significantly higher scores on their critical thinking skills than their 4-year programme counterparts (M=21.6 versus M=18.9, F=4.75, P=0.035). This result supports the research hypothesis and rejects the null hypothesis, namely that the students undertaking the ASP have stronger critical thinking skills than their counterparts in the 4-year course. Because of the study's small sample size, comparing these results with the findings of previous studies with larger sample sizes was a challenge to enable accurate comparison. However, in contrast to previous studies, these results found stronger critical thinking skills among participants than has previously been shown among their counterparts in other countries.
For example, using the same tool as this study, research undertaken in Iran by Azizi-Fini et al (2015) recorded mean critical thinking scores among first-year students and senior nursing students as 11.79 and 11.21 respectively. Among many studies conducted in Iran, 10 reported that critical thinking among nursing students as being below average (Sharifi et al, 2017).
The results of the study reported in this article also indicate that the average scores of critical thinking skills among participants were higher than previously recorded among other Canadian nursing students. For example, in Meherali et al's (2015) study, students achieved a weak overall mean score (M=243.70) on their critical thinking skills using the California Critical Thinking Disposition Inventory (CCTDI), which classifies those scoring below 280 as negatively disposed towards practising critical thinking, those with a score of 210–280 ambivalently disposed and those with a score of 280–420 positively disposed. The authors concluded that BN students might lack some of the attributes indicative of ideal critical thinkers. Similarly, Profetto-McGrath (2003) assessed critical thinking among Canadian BN course students in a Western Canadian university and found that only 38* of 228 nursing students had adequate levels of critical thinking skills (see Table 1 for the average CCTST scores).
A study conducted in India by Nirmala and Shakuntala (2011) found that nursing students had poor critical thinking skills. Nursing students in Hong Kong also failed to show adequate levels of critical thinking on the CCTDI (Tiwari et al, 2003). Kaya et al (2017) conducted a longitudinal study among students at Istanbul University, Turkey, to determine the strength of nursing students' critical thinking skills and emotional intelligence over the course of an academic year, and found low levels of critical thinking skills and intermediate levels of emotional intelligence both at the beginning and at end of the academic year.
By comparison with previous studies, therefore, participants in the study described in this article showed a higher level of and stronger critical thinking skills than their counterparts both in Canada and elsewhere.
There could be a number of reasons that the findings in this study were not congruent with previous studies. One possible interpretation is that previous studies were conducted in different countries which have different cultures, different nursing and general educational systems, different expectations and outcomes from nursing programmes, and also that different instruments were used to measure critical thinking skills among the study cohorts in other countries.
Enhancing critical thinking among nursing students at the University of New Brunswick is an essential requirement and an expected outcome within both nursing programmes. Enhancing students' critical thinking skills is one of five stated outcomes for every course within the undergraduate nursing curricula at Brunswick. Emphasising these outcomes has enhanced the critical thinking skills of students on both nursing programmes, leading them to have better critical thinking scores than nursing students in previous studies.
A study conducted in the Philippines by de Leon-Abao (2014)—to determine the influence of teachers' instructional competence on the intermediate students' reading comprehension skills profile and their critical thinking ability—concluded that it does play a significant role in enhancing students' critical thinking skills. At the University of Brunswick, the Center for Enhanced Teaching and Learning continually encourages university educators, including nursing educators, to attend teaching and learning workshops and conferences, and to take part in teaching kaleidoscope sessions. The latter are one day conferences that take place at the end of each semester where faculty members from different specialties meet to display and share the innovative teaching methods they used during the semester to teach different topics. In addition, the center invites faculty members to enhance their skills in certain teaching methods through a residency visiting scholar programme. This type of training has contributed positively to enhancing students' critical thinking skills. The staff in the department are also always ready for free consultations and mentorship for nursing faculty at the University of New Brunswick.
Therefore, within many nursing courses, non-traditional and evidence-based teaching methods are used to teach undergraduate nursing students. Examples of non-traditional strategies include: using art and drama, reflective journal writing, case studies, problem-solving teaching methods, integration of clinical and theory components, peer learning, group discussions, team project work, flipping the class format, and implementation of different assignment formats for theory and clinical components (eg concept maps, multiple-choice and essay exams, oral exams, computer-based exams, simulation, care-plans, etc). Moreover, admission to the nursing programmes at the University of New Brunswick is competitive. Students who are selected for the 4-year course or the ASP will have achieved the highest marks in their secondary or university education respectively. Therefore, higher scores in critical thinking are expected of all undergraduate nursing students at the University of New Brunswick.
The results of this study also support the hypothesis that students on the ASP have stronger thinking skills than their counterparts on the 4-year programme. The result is congruent with findings from studies cited earlier in this article (Youssef and Goodrich, 1996; Korvick et al, 2008; Newton and Moore, 2013; Cormier and Whyte, 2016; Kaddoura et al, 2017). However, although ASP students recorded higher overall mean scores on their critical thinking skills, students on both programmes recorded moderate scores on the critical thinking subscales for analysis, inference, evaluation, induction and deduction (Table 2 and Table 3). This may be because the data were collected from participants 6 months before they had completed their nursing degrees, and before they were to undertake their 12 weeks of preceptorship in clinical practice, as well as before they began to prepare intensively for their national entry exam (NCLEX-RN).
All of these contexts and experiences will contribute to enhancing the critical thinking skills of nursing students, even before they can be described as newly qualified nurses. In summary, the overall findings showing that nursing students have high scores for critical thinking skills indicate that these student cohorts are in an educational environment that adheres to high standards and promotes critical thinking skills, which is a required lifelong skill that enables nurses to provide optimum and safe care.
Limitations and recommendations
External validity and generalisability of the findings cannot be guaranteed because of the limitations of this study. The study cohort consisted of a small convenience sample of nursing students and the findings cannot therefore be generalised to all students undertaking nursing programmes in New Brunswick province, across Canada or more widely in universities across the world. Another limitation is that the study sample was selected from the English-speaking university campuses in New Brunswick, with no participants from French-speaking universities.
The data were collected using CCTST, a tool that was designed to measure general critical thinking skills not related specifically to nursing or any other specific discipline, which might not have accurately reflected participants' responses on critical thinking skills related to their future profession, which could be a limitation. Another limitation was that critical thinking was measured only 6 months before the students completed their programmes, rather than at the point of entry to the course, at the start of their learning.
Grade point averages and the results of HESI were not taken into consideration as indicators of critical thinking abilities among participants in this study, which provides an incomplete picture of the students' real critical thinking skills and how they were enhanced throughout their time of learning on the nursing programmes. For future studies, it is recommended that a larger random sample size involving students from both English- and French-speaking universities be engaged in a Canada-specific context, using a range of valid and reliable instruments designed explicitly to measure the critical thinking skills of nursing students or students in the health sciences, and that other critical thinking indicators such as grade point averages and HESI results are taken into consideration.
Longitudinal and qualitative studies are needed to understand the influence of nursing education on enhancing students' critical thinking skills. Based on the results of this study, it is recommended to enhance the current curriculum with a greater focus placed on promoting the dimensions of critical thinking using evidence-based teaching methods. Incorporating critical thinking courses earlier in the curriculum for different undergraduate nursing programmes is recommended too.
Assessing nursing students' critical thinking skills on a regular basis is also recommended to assess their level of preparedness for practice and to make prompt interventions if necessary. Despite these limitations, the results of the study are significant and provide a rationale for decision-makers in New Brunswick province to invest in expanding and adding more student places to the ASP in nursing to cover the shortage in nurses locally, nationally and internationally.
Conclusion
Nursing students in this study had high/strong overall mean scores for their critical thinking skills. However, students in the ASP group had significantly higher/stronger scores than their counterparts on the regular 4-year programme. Students undertaking both courses scored a moderate mean against the critical thinking subscales of analysis, inference, evaluation, induction, and deduction. Showing strong and higher critical thinking skill levels of ASP students is a promising sign to expand and support the ASP option as a fast and effective method to address the shortage of nurses nationally and internationally. However, further studies with larger sample sizes, with findings that support those reported in this study, are needed before making any final decision to expand the ASP option.
KEY POINTS
- Students undertaking both the 4-year course and the advanced standing programme (ASP) had moderate scores on the strength of their critical thinking skills across the dimensions that were assessed
- ASP students had a higher overall mean score for critical thinking compared with those on the 4-year course
- The stronger and higher level critical thinking skill levels of the ASP students is a promising indication for expanding and supporting the ASP option as a fast, effective method to address the nursing shortage
CPD reflective questions
- Consider other innovative teaching methods, other than those mentioned in the literature, that can be used to enhance critical thinking skills among nursing students
- How do you think online teaching and the use of technology affects the critical thinking skills of nursing students?
- If nursing students in a certain institution showed low scores in their critical thinking skills tests, what do you consider could be the possible reasons for this? What are the possible solutions to address the issue?