Assessment of Nursing Educators' Opinions, Knowledge and Teaching Methods regarding Encouragement Student's Critical Thinking

Discussion

Ongoing changes in science and technology have contributed to revolutionary changes in every sector of the health care system. In nursing, critical thinking has been identified as a valuable educational goal in meeting the challenges of science and technology in the twenty-first century and beyond. Learning and thinking are interrelated lifelong processes (Chaffee, 2011). To add depth and substance to knowledge, one must learn to refine and adjust one’s thinking. With practice and time, one can get better at making more thoughtful observations and judgments and can recognize how values are reflected in thinking and behaving (Yıldırım, & Özkahraman 2011).

The current study showed, regarding the personal data of nurse educators, about two thirds were aged from (30-39 years old); and for the gender the majority of nursing educators were females; concerning to years of experience about one third of nursing educators had (6-10) experience years. As regard to position and qualification, nearly half of the sample were assistant lecturers and with master degree. About department, the highest percent as one third (32.5%) of them were in Medical Surgical Nursing Department.

The study findings revealed that there were no statistically significant difference between nurse educators' opinions and general knowledge about CT at different departments. That may be regarded as all nursing educators of any specialty value critical thinking in nursing because they believe it can improve professional standards of practice, stimulate inquiry, encourage sound reasoning in practice, and contribute to personal and professional development.

Also, educator's knowledge of critical thinking and use of critical thinking methods for didactic nursing courses help students to face and deal with issues facing them in clinical practice. Another possibility is that nurse educators' opinions are more positive today than in years past due to new trends applied in medical and nursing education fields.

This was supported by Van-Graan & Williams, (2017) who revealed in their study that there were no statistically significant differences in the opinion and knowledge mean scores of nurse educators of critical thinking based on specialty or educational setting.

The study findings illustrated that the most method used to promote critical thinking in clinical teaching at nursing administration and mental health nursing departments is ''Pre-clinical written assignments'' as mean scores (3.00+1.24&2.73+1.27) respectively.

As in these departments a part of student clinical activity depend on student preparation of assignment which give students the opportunity to thoroughly explore a particular topic, and to develop and stimulate critical thinking skills independently. These written assignments also give educator the opportunity to evaluate each student’s critical thinking ability, independent of the group. Written assignment involves highly complex cognitive processes and can be used not only to communicate with others. It also, engages students in generating and converting knowledge. In addition to facilitating essential inquiry, writing situates individuals in roles of “self-active” learners who are motivated to assume responsibility for their own learning.

 This supported by Ferreria & Schulze, (2014) who asserted that writing assignment is an important strategy to develop critical thinking because it inspires students to think in the abstract domain, to conceptualize, to interpret and to reason. Writing and rewriting with thoughtful and ongoing feedback allows for student and educator to become active participants in the practice of dialogue and thus learning effectively.

This also, supported by Chan, (2017) who believed that by having students “write assignment continuously, we can help create the quality of mind needed for professional and critical thinking expertise in nursing.

The study findings illustrated that the most method used in clinical teaching to promote critical thinking in woman health and obstetric nursing department, community health nursing and pediatric nursing department in favor to use the method of ''Written Nursing Care Plan'' as mean scores (4,00+0,0, 3.40+0.84&3.33+0.70) respectively. This regarded as the clinical activity in these departments involve hospital rotations which involve dealing with patients of various health status and diagnoses in a real life situation.

Student in these departments deal with patients with complex nursing problems through which they coming up with nursing diagnosis, nursing intervention, and using clinical judgment to decide upon the best way to approach how to direct care for patient. Written nursing care plan also is a systematic approach that used by students to gather data, critically examine and analyze this data, identify patient response, design outcomes, take appropriate action, then evaluate the effectiveness of action and each of the previous steps require that the student use his critical thinking skills.

This supported by Papathanasiou, et. al, (2015) who encouraged using written nursing care plan in clinical teaching. This method help students see complex nursing problems from multiple perspectives. Students may be tempted to base their actions on logic using his critical thinking abilities. They also, stressed that using nursing care plan steps help student to use critical thinking abilities to prioritize patients' daily needs.

The study findings illustrated that the most method used in clinical teaching to promote critical thinking at medical surgical nursing department is ''Small Group Discussion and Clarification of Values'' as mean scores (3.12+0.58&3.12+0.76) respectively. As when practicing clinical skills in medical surgical department labs, educators use small group activities which used to get all students involved and give each one of them the opportunity to practice skills taught, and to offer and receive feedback, which help to improve their self -awareness about their thinking.

Educators in these departments also, socialize students through using group discussion into the values, standards, and methods of discipline. This also contribute to students' personal growth, self -confidence, improve their listening, self- control, and collaborative skills and broaden their perspectives on interpreting and applying the skills taught. This method help to wake students out of their passivity. When using small group discussion it help educators to determine if students understand the material taught.

Also, when students are engaged in participating through meaningful contributions to a small-group discussion, they are more actively involved in thinking and learning. Small-group discussions promote inquiry, higher-order thinking, cooperation, and student responsibility, all of which have been shown to increase student achievement. The small-group setting and structured discussion format calls on students to think deeply, contribute their thinking to the conversation, listen attentively, and respond thoughtfully to one another.

 These findings supported by Vander and Schneider, (2014), who mentioned that the use of small-group discussion is a collaborative and constructivist teaching method widely recognized as a high-yield, best-practice instructional strategy. Small-group discussions engage students in critical thinking, working collaboratively, and communicating effectively, all of which are hallmarks of deeper learning. The small-group discussion protocols are designed to engage students in critical thinking by applying, analyzing, synthesizing, and/or evaluating information and ideas.

The study findings revealed that the most method used in clinical didactic teaching at nursing administration department, mental health nursing department and medical –surgical department is small group discussion as mean scores(3.36+0.84,3.36+1.02&3.19+0.69) respectively. This may be related to these departments use different small group discussion activities according to content of each to improve quality of teaching process. During data collection the researcher asked each of these department educators about group discussion activities that are appropriate to their contents material.

At administration and mental health nursing department they were in favor to use it during "Seminar overview" as this activity type is suitable to larger classes, during which the educator have outer circle students who stay silent, observe and take notes and inner circle students those who participate in the discussion and view their subject matter. During this activity the educator evaluate the critical thinking ability for all student group, by observing the manner of showing and explaining information by inner student circle and asking questions for outer circle students.

For medical- surgical nursing department, in which they use "Video tutorials'' which created by educator or students for content related clinical practice. In which the educator present a video for content matter or procedure explained, ask students to take notes for what they see and then ask questions which promote critical thinking abilities for students.

This come in the same line with (Morrall and Goodman, 2013) who reported that proper preparation of group discussion activities by educators increases the student ability to think effectively and critically.

The study findings revealed that the most method used in clinical didactic teaching at woman health and obstetric nursing department in favor to use the method of classroom case simulation as mean score (4,00+0,0). As the educators at this department create a real clinical area through practice laboratories and computer aided nursing situations may be one way to teach critical thinking in a simulated, safe, clinical environment. Nursing students can take the time they need for reflection and practicing without endangering patients in the clinical labs.

This supported by (Gambrill, 2012) who indicated that classroom case simulation is attractive for students and help promoting critical thinking abilities.

The study findings revealed that the most method used in clinical didactic teaching at community health nursing department and pediatric nursing department the most methods used (written assignments) as mean scores (3.30+0.67&3.44+0.52respectively). As in these departments educators choose some elements or subjects of course to be prepared by students through writing assignment. Students use their critical thinking abilities to design a unique and relevant assignment. Then those educators carefully analyze students work, grading it and may sometimes discuss and ask for rewriting some parts of it using constructive and critical thinking.

 This supported by (Macpherson and Owen, 2017) Who  found in results of his study that about 75% of  educators have demonstrated that they favor focused written assignments and readings for improving the concept of critical thinking.

The study findings illustrated that the most method constructs of the concept CT used in nursing administration department is deductive reasoning as mean scores (2.79+0.42), this as deductive reasoning is considered a mental process of making inferences that are logical. Deductive reasoning move from general premise to specific conclusion. So, when teaching a theoretical content as which related to nursing administration as applying change process, leadership style, resolving a conflict and  achieving quality and so on. When educators discuss these topics with their students they explain the desired outcome they want to reach in each subject matter then explain steps to reach this conclusion, in each step of this process the educator and student use critical thinking skills.

This supported by (Jenkins, 2011 and Kaya, et. al. 2011) who indicated in their studies that deductive reasoning and critical thinking are working in the same line with each other.

The study findings illustrated that the most method constructs of the concept CT used in woman health and obstetrics nursing and mental health nursing departments are Identify Assumptions for both as mean scores (2.90+1.16& 92.54+0.64), and Decision Making in woman health and obstetrics nursing department  (2.90+0.31). As educators in this departments consider that analyzing assumption is considered a main characteristic of critical thinking. As analysis of assumption means for them reflecting the nature and origin and consequences of what being taught.

Thus, for them analysis of assumption includes where they come from, what they mean and where they lead. They consider that helping students to analysis of assumptions lead students to critically think about exploring new ideas to revise or change the old assumption.

This supported by (Yancher, et. Al, 2008) who reported that analyzing and identifying assumption is considered as a main direction for critical thinking.

Regarding decision making, at woman health and obstetrics nursing department they teach their students when become a nurse or have hospital rotations they should use decision making process to reach appropriate action to fulfill the desired objectives through critical thinking. This requires that the student should be both decision maker and critical thinker. As when facing patient with multiple needs, they should set priorities and decide the order in which they help the patient.  They teach their students to examine the advantages and disadvantages of options, prioritize needs, assess priority actions and implement it and finally reach evaluation of results. Each of above mentioned steps need to apply critical thinking.

These findings came in the same line with (Chan, 2017) who reported that determining if critical thinking has occurred came after a decision has been made and the consequences of that decision are known. Learning to become a critical thinker requires being a decision maker.

The study findings illustrated that the most method constructs of the concept CT used in community health nursing and medical surgical nursing in favor to believe analyzing arguments as mean scores(2.80+0.42&2.54+0.64 respectively), as educators in these departments deal with health problems, each of these problems always have more than possible solutions. Through their explanation of details of these problems and its possible, feasible and multiple solutions. During this discussion they use analyzing arguments, claims, point of views and opinions with students and the reasons for this opinions through analytical critical thinking skills.

This supported by (Mathews& Lowe, 2011) who mentioned that argument analysis and critical thinking are closely linked skills and concepts. Argument analysis allows one to utilize and apply critical thinking.

The study findings illustrated that the most method constructs of the concept CT used in pediatric nursing department is the productive thinking as mean scores (2.89+0.86). As educators in this department may encourage and motivate student to use mental operation regarding information taught in their classroom content to reach creative and critical thinking. When educating student specific theory, experimental technique or known observation, they encourage combining this known knowledge to critical thinking reaching logical and productive results in any situation.

Also, students in this department are taught specific diseases, deal with patients with various and complicated health status. Through their hospital rotations the educators encourage students to use their cognitive abilities to reach etiology of this health status, determining the etiology of it and complications may occur to produce an action using productive and critical thinking. Educators also, encourage and prepare students through reading and research preparation from wide variety of resources which in return enhance the ability of productive thinking of students.

This supported by (Krupat, et, al. 2011) who reported that the process of thinking using motivation and memorization is skillfully combine creative and critical thinking is called productive thinking.

Conclusions It can be concluded from the current study that:

• The majority of the sample had moderate level of knowledge about CT at faculty departments. The highest mean scores of nurse educators' regarding use each method in clinical teaching at faculty departments was "written nursing care plans".
• The highest mean scores of nurse educators' regarding use each method in clinical didactic and methods that enhance student ability to think critically at faculty departments was "small group discussions" , and the highest mean scores of nurse educators' believe regarding constructs of the concept CT at faculty departments was "productive thinking"                                                                                       

Recommendations

On the light of the results of this study the following recommendations will be suggested:

Recommendations for Nurse Educators

• Nurse educators need to scrutinize curriculum plans, course structures, course assignments, and teaching strategies to ascertain how critical thinking is defined, how it is operationalized, and how its progression as part of these structures is nourished or obstructed.
• Nurse educators need to identify, measure, and motivate thoughtful, fair-minded engagement in problem-solving, decision-making, and professional judgment. There is a need to prepare graduates who are able and willing to think.
• Nurse educators need to create assessment portfolios which comprise a collection of multiple (reliable and valid) measures of thinking that may be used to observe the progress, strengths and areas of weakness of nursing students.
• Number of clinical instructors and nursing educators should be increased to meet needs of student nurse to improve CT.
• Study the personal and environmental factors that impact nurse educators’ decisions to participate or decline participation in nursing education research.

Recommendations for Practice

• Develop and implement workshops and learning activities to support faculty development focused on critical thinking, role modeling, and questioning specific for nurse educators who are working with students in clinical settings.
• Enhance nurse educators’ practice through the use of reflection and engagement in ways that support their own critical thinking skills and dispositions and how these can be role modeled in the clinical setting.

Recommendations for future research studies

• A similar study should be replicated in others universities (nursing faculties) in Egypt to validate these findings.
• Longitudinal studies including the same cohort of baccalaureate students from Year 1 through Year 4 should be carried out to ascertain whether there is a change in the students’ CTS and CTD upon completion o f a baccalaureate nursing program.