critical thinking disposition of nursing students a quantitative investigation

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Critical Thinking Disposition and Influencing Factors Among New Graduate Nurses

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In a rapidly changing health care environment, nurses are required to think critically to make accurate clinical judgments and deliver high-quality professional care ( Manetti, 2019 ; McCoy et al., 2020 ). Most novice nurses, however, lack critical thinking (CT) disposition ( Song & McCreary, 2020 ), resulting in inaccurate clinical judgments and an inability to identify the causes of problems ( Morisset, 2021 ; Sterner et al., 2021 ). Since 1984, the United States has standardized the nursing departments of universities, actively training nursing students in CT ( National League for Nursing, 1992 ). Subsequently, Taiwan's Nursing Accreditation Council proposed that nursing graduates must acquire CT abilities to ensure patient safety ( Cheng, 2021 ). Using CT is a high-order thought process and a foundational skill in the nursing profession ( Ali-Abadi et al., 2020 ; Chen et al., 2020 ; von Vogelsang et al., 2019 ). When faced with a clinical issue, nurses with CT disposition tend to show initiative in confirming the problem, identifying its cause, or seeking evidence related to the treatment by using CT skills such as interpreting, analyzing underlying causes, or reasoning about clinical problems. Conversely, when nurses do not have CT disposition, they often do not think comprehensively about the issues they face, leading to incorrect clinical judgments and jeopardizing patient safety ( Facione et al., 1995 ; McCoy et al., 2020 ). Thus, CT is directly related to patient safety and quality of care ( McCoy et al., 2020 ; Westerdahl et al., 2020 ).

Skill and disposition are two aspects of CT ( Ennis & Norris, 1989 ). Skill includes cognitive strategies, such as explanation, analysis, evaluation, inference, interpretation, and self-regulation, whereas disposition is an inclination to use such CT skills ( Facione, 1990 ). Attributes related to CT disposition include truth seeking, open-mindedness, analyticity, systematicity, inquisitiveness, self-confidence, and maturity ( Facione & Facione, 2001 ). Thus, people with CT disposition are likely to be proactive, curious, and keenly observant and to demonstrate a desire to discover the truth. Nursing students with these characteristics are also likely to be self-motivated learners, a characteristic that aids in the development of professional competence ( Mafumo et al., 2022 ). Nurses with CT skills can interpret and analyze clinical problems, evaluate evidence, make inferences, draw conclusions, and implement effective measures. During this process, they must consider the outcomes of their actions to ensure optimal decision making in clinical care ( Rababa & Al-Rawashdeh, 2021 ). However, nurses must have both CT disposition and CT skills to think critically ( Zia & Dar, 2019 ).

The factors that influence CT disposition are numerous and diverse ( Pu et al., 2019 ). According to research on basic personality attributes and CT disposition, gender ( Mawaddah et al., 2018 ), age ( Wang et al., 2019 ), and work experience ( Futami et al., 2020 ) influence CT disposition. Additionally, teaching strategies such as concept mapping, problem-based learning (PBL), and reflective training help with developing CT disposition ( Eisenmann, 2021 ; Kantek & Yıldırım, 2019 ; Pu et al., 2019 ). Among these strategies, PBL is the most commonly used to develop CT disposition for nurses ( Matlala, 2021 ; Ulger, 2018 ) and thus is crucial to the professional development of nurses ( Putri & Sumartini, 2021 ).

Since the concept was first discussed in 1977 ( Vygotsky, 1978 ), CT skills have been the main focus of most clinical care studies ( Boso et al., 2019 ; Shirazi & Heidari, 2019 ). However, studies related to CT disposition did not appear until the 1990s ( Facione et al., 1995 ), and only Wangensteen et al. ( 2010 ) focused on CT disposition and its associated factors among new graduate nurses (NGNs). To date, no other study has investigated these topics. This study explored the factors that affect the development of CT disposition among NGNs and the current level of CT disposition among NGNs to inform nursing education, practical training, and policy formulation.

Study Design

This study used a cross-sectional research method and a structured questionnaire to investigate CT attributes among NGNs and factors influencing them. The study was approved by the institutional review board of the study institution.

Participants

Participants were selected from one of two regional teaching hospitals located in central or southern Taiwan. The participants were NGNs who had obtained a nursing license and were at least 20 years old. We calculated the sample size with the method Hair et al. ( 2018 ) referred to as the sample-to-variable ratio, suggesting an observation-to-variable ratio of 15:1. A total of 120 participants were enrolled; 20 had incomplete data and were therefore excluded from analysis, yielding a final sample size of 100.

Data Collection

We collected quantitative data from September 2018 to August 2019. After written informed consent was provided, the records of basic characteristics and California Critical Thinking Disposition Inventory (CCTDI) scores ( Facione & Facione, 2001 ) of the participants were reviewed for the following information: gender, age, educational background, work-study experience, type of workplace, exposure to teaching strategies during education, PBL courses taken, length of study, and critical thinking disposition levels. This study used the Chinese translation of the CCTDI (Approval Code 089337) as the survey tool. The CCTDI consists of 75 questions evaluating seven attributes of CT: truth seeking, open-mindedness, analyticity, systematicity, inquisitiveness, self-confidence, and cognitive maturity. Scoring uses a 6-point Likert-type scale for self-assessment, and total scores range from 75 to 450 points. Generally, higher CCTDI scores indicate stronger CT disposition, and scores of less than 280 are considered to indicate weak CT disposition ( Pu et al., 2019 ). For the Chinese version of the CCTDI, subscale alphas ranged from 0.34 to 0.73, with an overall internal reliability of 0.71. The Chinese version of the CCTDI content validity index ranged from 0.50 to 0.80, with an overall content validity index of 0.85 ( Yeh, 2002 ). For the English version of the CCTDI, overall internal reliability was 0.90, scale reliability ranged from 0.72 to 0.80, and overall content validity index was 0.90 ( Facione, 1990 ; Yeh, 2002 ).

Data Analysis

We used SPSS Statistics for Windows, version 22 (IBM Corp.), to analyze the data. Descriptive statistics were used to determine frequency distributions and percentage for categorical variables, and mean and SD were used for continuous variables. Inferential statistics were analyzed with independent two-sample t tests, one-way analysis of variance, and multiple linear regression. Statistical significance was set at p < .05.

Table 1 shows the distribution of the nurses' personal characteristics. The age distribution of the participants was predominantly 22 years ( n = 86, 86.0%), and 90% ( n = 90) were female. In terms of education, 82 (82.0%) were from technical and vocational schools, making up the majority of the participants. Before graduation, only 12 nurses had no work experience (12.0%). Among those with work-study experience, the experience was mainly in the service industry ( n = 60, 60.0%). The NGNs mainly worked in medical or surgical wards ( n = 64, 64.0%). A total of 52 (52.0%) experienced mostly traditional teaching, whereas the other 48 (48.0%) had been exposed to PBL. Of those exposed to PBL, 36.0% learned PBL strategies while in professional nursing courses, and 27.0% had between 31 and 40 hours of exposure.

Table 2 shows the descriptive analysis of the nurses' CCTDI scores. The CCTDI scores ranged from 176 to 305, with a mean score of 244.11 and SD of 44.70. Table 2 shows that the inquisitiveness score was the highest ( M = 38.46, SD = 7.10), followed by cognitive maturity ( M = 36.52, SD = 9.11), analyticity ( M = 36.33, SD = 6.61), open-mindedness ( M = 35.98, SD = 5.36), systematicity ( M = 34.81, SD = 5.54), truth seeking ( M = 33.12, SD = 6.42), and self-confidence ( M = 29.26, SD = 6.90). Through univariate analysis of the effect of demographic characteristics on CT attributes ( Table 1 ), we found significant differences among teaching strategies during education ( t = −25.80, p < .0001), PBL courses ( F = 266.09, p < .0001), and time exposed to PBL ( F = 250.41, p < .0001). The Scheffé multiple comparisons test ( Table 1 ) showed that the significance value indicates that there are differences in the level of CT disposition between NGNs taught by PBL and with conventional methods. The Scheffé multiple comparisons test concluded that CT disposition levels using PBL strategies in basic medical courses, nursing professional courses, and general education courses were better than those with conventional learning. Further, CT disposition levels by length of exposure to PBL of 31 to 40 hours were better than those for no exposure, 1 to 20 hours of exposure, and 21 to 30 hours of exposure. Table 3 shows the factors affecting CT disposition among participants. The significant independent variables described earlier (teaching strategies during the educational period, PBL courses, and length of exposure to PBL) were further analyzed by multiple linear regression. Teaching strategies accounted for 88.9% ( p < .0001) of the total variance in the regression model. Table 3 shows statistically significant differences in CT disposition for participants who had used PBL strategies in professional nursing courses ( p < .0001) and general humanities courses ( p = .0003), with exposure to PBL reaching 1 to 20 hours and 21 to 30 hours ( p < .0001) in each respective course type.

This study explored CT disposition and its influencing factors among NGNs. The mean CCTDI score was less than 280 points, indicating generally weak CT disposition among the NGNs. Among the subscales, the inquisitiveness score was the highest score, and the self-confidence score was the lowest. The factors affecting the development of CT disposition were related to teaching strategies, PBL courses, and length of exposure to PBL.

The overall CT disposition scores obtained in this study are similar to the scores that were obtained by Turkish nurses and Hong Kong nursing students ( Mahmoud & Mohamed, 2017 ; Wong et al., 2020 ), but much lower than those obtained by nursing students in Norway and other countries ( Boso et al., 2021 ; Wangensteen et al., 2010 ). Researchers have postulated that teacher-centered instruction in Asia is incompatible with developing CT disposition. Possessing CT disposition means having the motivation to think and make decisions. The traditional teaching method emphasizes recitation and passive learning because of its clear teacher–student hierarchy ( Oh et al., 2021 ; Zhang et al., 2018 ). This style of learning discourages students from actively applying information gained through experience and reasoning ( Rababa & Al-Rawashdeh, 2021 ).

Among the inherent attributes of CT disposition, inquisitiveness was the strongest among the NGNs in this study, a result similar to that of Mahmoud and Mohamed ( 2017 ), who determined that people with this trait are curious and have strong interest in learning and developing professionally, thus learning effectively ( Chen et al., 2020 ; Futami et al., 2020 ). This result is also consistent with those of Huang et al. ( 2021 ) and Wangensteen et al. ( 2010 ).

The scores for systematicity, truth seeking, and self-confidence in this study were lower than those for the other CT disposition attributes. According to Benner's ( 1984 ) novice to clinical expert model, nursing graduates are in the advanced beginner stage. They can act according to the situation but cannot identify priorities. A novice must rely wholly on learned rules and principles ( Benner, 1984 ; Benner & Tanner, 1987 ). By contrast, those with strong CT disposition can systematically prioritize issues to prevent delays during emergencies. Therefore, training novice nurses to develop CT disposition can improve their ability to identify clinical problems and their clinical reasoning skills ( Benner & Tanner, 1987 ; Pu et al., 2019 ).

We suggest that the low scores for truth seeking are related to traditional teaching methods, which emphasize knowledge transfer and memorization and create a passive learning environment instead of one incentivizing proactive qualities and independent learning habits ( Zhang et al., 2018 ).

Nurses acquire self-confidence with age and experience ( Benner & Tanner, 1987 ; Pu et al., 2019 ). Both NGNs and nursing students need to build self-confidence in learning to deal with complex clinical situations. Bandura's social learning theory ( 1977 ) proposed that self-confidence emanates from performance of a task, observation of another person performing the task, emotional arousal, and verbal persuasion. In this study, the PBL course used played a critical role in developing self-confidence among nurses ( Komasawa et al., 2018 ; Lee & Son, 2021 ). Both NGNs and student nurses should be exposed to different clinical scenarios for improving learning transfer to apply learned nursing knowledge to simulated nursing situations and improve their self-confidence ( Oanh et al., 2021 ). Simulation in particular can help NGNs and student nurses develop self-confidence ( Komasawa et al., 2018 ; Lee & Son, 2021 ). In contrast, the participants in traditional teaching courses in this study had no previous experience in the medical field. They lacked experience in dealing with clinical issues and were not as confident in their clinical judgment as experienced nurses and the participants in PBL courses might be. Therefore, we propose that clinical supervisors train novice nurses to develop analytical skills and a truth-seeking attitude through clinical simulation, allowing novice nurses to develop confidence and gain experience in solving problems.

Teaching strategy was the factor explaining the most variance in CT disposition. Consistent with the findings of this study, recent research has indicated that PBL strategies are superior to traditional teaching strategies in developing CT disposition among NGNs ( Pu et al., 2019 ; Westerdahl et al., 2020 ; Zheng et al., 2021 ). Because PBL is based on information processing theory, cognitive theory, situated learning theory, and constructivism ( Barrows & Tamblyn, 1980 ), it emphasizes training in seeking or connecting with other people's experience and building problem-solving skills through case studies. Learners use previous knowledge, developing possible solution paths and taking an approach to clinical judgment. In applying learned knowledge to clinical situations, learners develop CT disposition ( Seibert, 2021 ). Learners also experience meaningful learning through active participation in the learning process. Conversely, direct transfer of knowledge to individuals does not produce experience ( Stranford et al., 2020 ). Thus, students educated through PBL have stronger CT disposition than those taught through traditional teaching strategies ( Pu et al., 2019 ).

Traditional teaching strategies are superior when heavy memorization work is required ( Solomon, 2020 ). In contrast, PBL motivates learners to think logically. Further, case studies are derived from clinical problems. Therefore, learners can develop CT disposition through the process of thinking and problem solving when discussing ethical issues or common clinical problems ( Škėrienė & Jucevičienė, 2020 ). By contrast, PBL strategies may not be effective for learning drug names, languages, or subjects that are best conveyed through narration or recitation ( Tang et al., 2020 ). We discovered that the longer students were exposed to PBL, the stronger was their CT disposition. Research suggests that increasing exposure to PBL increases the opportunities for learners to encounter realistic situations and solve problems therein; this case solving process also indirectly induces self-directed learning and group discussion in pursuit of conclusive evidence. Learners therefore have the opportunity to understand the problems in depth, collect relevant data, analyze and discuss solutions, and share different learning experiences, thereby taking responsibility for self-directed learning ( Devine et al., 2020 ; Oh et al., 2021 ).

Limitations

The current understanding of CT disposition and influencing factors on NGNs during their transition to professional nurses is limited. To our knowledge, this is the first study to examine CT disposition and influencing factors on NGNs. However, our results should be interpreted with consideration of its limitations. First, the data were nonprobability convenience samples collected from two regional teaching hospitals. This limitation may affect the applicability of the results; future studies should recruit more diverse samples of participants or longitudinal studies may be required to extend the findings reported here. Second, in this study, all CCTDI measurements were obtained from electronic records and not taken directly by the investigator. However, this may not impact the validity of the data because the measurements are routinely explained and checked by the first author before they are entered into the electronic database.

This study explored the CT disposition of NGNs and its influencing factors. The CT disposition among NGNs was generally weak. The NGNs especially showed limited systematicity, truth seeking, and self-confidence. Conversely, NGNs exposed to PBL strategies had applied their skills in professional nursing courses; generally, the longer they were exposed to such strategies, the stronger was their CT disposition. In conclusion, we recommend introducing PBL strategies into professional nursing courses intended to develop CT disposition among NGNs so that learners may acquire problem-solving skills from situational case studies. This approach may also increase the quality of professional care because case studies are derived from real clinical situations, meaning that NGNs can develop both CT disposition and self-confidence before they enter the industry.

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The authors acknowledge all participants who contributed to this study.

Hsiao-Ling Wu, PhD, RN, is Assistant Professor, Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan City; and Assistant Professor, Department of Nursing, Shu-Zen Junior College of Medicine and Management, Kaohsiung City, Taiwan. Der-Fa Lu, PhD, RN, is Professor, College of Nursing and Health Sciences, University of Wisconsin-Eau Claire, Eau Claire, Wisconsin. Pei-Kwei Tsay, PhD, is Associate Professor, Department of Public Health and Center of Biostatistics, College of Medicine, Chang Gung University, Taoyuan City, Taiwan.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

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Background:

Critical thinking disposition is important to facilitate professional judgment for novice nurses. The goals of this study were to describe critical thinking disposition among newly graduated nurses and to examine the factors that impact the development of critical thinking disposition.

This study employed a cross-sectional research design.

The mean critical thinking score was 244.11 ( SD = 44.70), with the highest mean scores earned on the inquisitiveness subscale ( M = 38.46, SD = 7.10). The lowest subscale scores were for systematicity ( M = 34.81, SD = 5.54), truth seeking ( M = 33.12, SD = 6.42), and self-confidence ( M = 29.26, SD = 6.90). Critical thinking dispositions were significantly associated with teaching strategies during the educational period, problem-based learning courses, and length of exposure to problem-based learning.

Conclusion:

Findings provide information to understand the disposition toward critical thinking in novice nurses and can serve as a reference in efforts to improve novice nurses' critical thinking skills. [ J Contin Educ Nurs . 2023;54(5):233–240.]

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The relationship of critical thinking skills and critical thinking dispositions of baccalaureate nursing students

Affiliation.

• 1 Faculty of Nursing, University of Alberta, Alberta, Canada. [email protected]
• PMID: 12950562
• DOI: 10.1046/j.1365-2648.2003.02755.x

Background: Critical thinking is essential to nursing practice; therefore, knowledge and understanding of nursing students' critical thinking skills (CTS) and related dispositions are important to nurse educators. This paper presents the results of a non-experimental study conducted in spring 1998, identifies implications for nurse educators, and offers recommendations for future research.

Aim: The aim of the study was to investigate the CTS and critical thinking dispositions (CTD) of students enrolled in a 4-year baccalaureate programme at a university in Western Canada.

Methods: The study used a cross-sectional design. Data collection occurred during regularly scheduled classes. A volunteer sample of 228 students from all 4 years of the baccalaureate programme completed a background/demographic questionnaire, the California Critical Thinking Skills Test, and the California Critical Thinking Disposition Inventory. The reliability of the test and inventory were established using the Kuder Richardson 20 and Cronbach Alpha respectively. Both descriptive and inferential statistical analyses were carried out.

Findings: Critical thinking mean scores increased from years 1 to 4 with the exception of year 3. However, there was no statistically significant difference among the four student groups. Although differences in critical thinking disposition scores were not statistically significant, students' scores differed significantly on the systematicity subscale. There was a significant relationship between students' overall CTS and CTD scores.

Conclusions: Approximately 38% of the students in the current study had adequate levels of CTS and 85.5% of the students had adequate levels of CTD. Results indicate a need for students' continued development in these areas. Dispositions are crucial to critical thinking; without them critical thinking does not happen or may be substandard.

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Curriculum framework to facilitate critical thinking skills of undergraduate nursing students: A cooperative inquiry approach

Christian makafui boso.

1 Department of Nursing and Midwifery, Faculty of Medicine & Health Sciences, Stellenbosch University, Cape Town South Africa

2 School of Nursing and Midwifery, College of Health and Allied Sciences, University of Cape Coast, Cape Coast Ghana

Anita S. van der Merwe

Janet gross.

3 Peace Corps Liberia, Mother Patern College of Health Sciences, Stella Maris Polytechnic, Monrovia Liberia

Associated Data

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Critical thinking (CT) is vital in assisting nurses to function efficiently in the ever‐changing health care environment. A CT‐based curriculum framework provides the impetus necessary to drive the acquisition of CT skills of students. Yet, there is no known CT‐based framework contextualized to developing countries where seniority tradition is a norm. Therefore, the aim of this study was to develop a CT‐based curriculum framework to facilitate the development of CT skills of nursing students in developing countries.

Cooperative inquiry.

Using purposive sampling, 11 participants comprising students, educators and preceptors developed a CT‐based curriculum framework.

Findings were organized into a framework illustrating interconnected concepts required to foster CT skills of nursing students. These concepts include authentic student–facilitator partnership, a facilitator that makes a difference; a learner that is free to question and encouraged to reflect; a conducive and participatory learning environment; curriculum renewal processes and contextual realities.

1. INTRODUCTION

Nurses in today's volatile and complex health care environment need to be able to critically appraise information when giving care (Dozier et al.,  2021 ; Whiteman et al.,  2021 ). Nursing regulatory bodies worldwide such as the Nursing and Midwifery Council of Ghana ( 2015 ) and the South African Nursing Council ( 2014 ) recognize critical thinking (CT) as crucial for nurses. These bodies require that nursing curricula promote CT skills of students (Dozier et al.,  2021 ; Gholami et al.,  2016 ). The rationale is that individuals with CT skills are potentially able to make good clinical judgements (Dozier et al.,  2021 ; Gholami et al.,  2016 ) which may lead to good patient outcomes (Ward‐Smith,  2020 ).

Critical thinking‐based curricula adopt learning outcomes, instructional methods and assessment approaches that are grounded on the principles of CT. Such CT‐based curricula create a participatory and democratic learning environment for students. Students will be empowered if they are allowed to take risks, encouraged to make inputs, permitted to share their opinions and if their mistakes are rectified with dignity (Raymond et al.,  2017 ). Thus, as consistent with Billings & Halstead ( 2005 ) view, a curriculum should aim at enhancing active learning and the student–faculty interaction (as cited in Billings & Halstead,  2005 ). Learning environments where divergent views are suppressed (Raymond et al.,  2017 ), and the educator is seen as the authority of information (Boso & Gross,  2015 ) do not promote CT in students.

A considerable number of reforms in higher education have stressed the need to facilitate CT skills of students (Butler,  2012 ). CT courses have been introduced in different academic disciplines such as nursing, law, sociology, psychology and philosophy. Despite the attention CT has received, there remains doubt whether graduates are being prepared to think critically (Butler,  2012 ). At the heart of this challenge is the fact that the concept of CT has not been incorporated into the teaching methods of many educators (Billings & Halstead,  2005 ). For example, educators construct questions that are mostly at the lower level of thinking (Amoako‐Sakyi & Amonoo‐Kuofi,  2015 ). This suggests that educational institutions may be failing in their quest to develop CT skills of students (Dunne,  2015 ).

In many developing countries, nursing schools encounter challenges that may further compound the challenge of assisting students to engage in CT skills. For example, in Ghana, challenges such as limited resources in nursing schools (Talley,  2006 ) have been reported. Specifically, a lack of qualified educators (Bell et al.,  2013 ), infrastructural and logistical constraints (Talley,  2006 ), inappropriate instructional methods and large class sizes (Wilmot et al.,  2013 ) are some of the challenges affecting nursing education. Also, as indicated in the authors' previous articles (Boso et al.,  2020 , 2021c ), sociocultural norms uphold the seniority tradition. Traditionally, seniority is valued in most global societies. The aged are viewed as the source of knowledge, power and authority, thus seniority is a dominant cultural norm (Chen & Chung,  2002 ). For example, an individual is not expected to disagree or question an authority figure in public even if the authority figure appears to be wrong (Donkor & Andrews,  2011 ). The seniority tradition has been noted as a challenge to facilitating the CT skills of students (Chan,  2013 ; Raymond et al.,  2017 ). Meanwhile, the complexity of fostering CT skills of students has often been underestimated leading to diverse conceptualizations of CT (Dwyer et al.,  2014 ). Diverse conceptualizations could impede the development of CT skills of students.

Notwithstanding these challenges, a CT‐based curriculum framework could provide the needed impetus to foster the development of CT skills of students. A curriculum framework could provide ‘a means of conceptualizing and organizing the knowledge, skills, values, and beliefs critical to the delivery of a coherent curriculum that facilitates the achievement of the desired curriculum outcomes’ (Billings & Halstead,  2005 , p. 167). More importantly, a CT‐based framework provides a participatory and effective learning environment for both the learner and the educator (Dozier et al.,  2021 ; Duron et al.,  2006 ) even in societies where the seniority tradition is strongly adhered to. Yet, these authors could not identify a known curriculum framework to drive the facilitation of CT skills in the context of developing countries where the seniority tradition is a norm.

2. AIM OF THE STUDY

The aim of this study was to develop a CT‐based curriculum framework to facilitate the development of CT skills of nursing students in developing countries.

3. BACKGROUND

This study was underpinned by an eclectic model derived from Dwyer et al.'s ( 2014 ) and Duron et al.'s ( 2006 ) frameworks of CT development (see Figure  1 ). This eclectic model addressed four interconnected concepts relating to the exploration of experiences of students and educators towards CT skills facilitation namely CT, memory, comprehension (Dwyer et al.,  2014 ) and instructional activities (Duron et al.,  2006 ). These concepts are further explicated.

Eclectic model of critical thinking development adopted from Duron et al.'s ( 2006 ) and Dwyer et al.'s ( 2014 ) models of CT. Permission to adapt was obtained.

3.1. Critical thinking

There is no agreement about the definition of CT (Raymond et al.,  2018 ) and its relationship with memory and comprehension (Dwyer et al.,  2014 ). According to Davies and Barnett ( 2015 ), there are three main approaches to CT, namely, ‘skills‐and‐judgement’, ‘skills‐plus‐propensity’ and ‘skills‐plus‐disposition‐actions’ perspectives. The skills‐and‐judgement perspective of CT views CT as the possession of a set of characteristic skills. The skills‐plus‐propensity perspective highlights both skills and dispositions aspects of CT. While the ‘skills‐plus‐disposition‐actions’ view, also known as criticality, sees CT beyond skills and disposition to include actions/activism. The skills‐plus‐propensity view on which this study is based recognizes that activism is an outcome of CT and not necessarily an aspect of CT. Thus, Facione's ( 1990 ) definition accepted for the purposes of this study illustrates skills‐plus‐propensity perspective of CT: ‘…purposeful, self‐regulatory judgment which results in interpretation, analysis, evaluation, and inference, as well as explanation of the evidential, conceptual, methodological, criteriological, or contextual considerations upon which that judgment is based…’ (Facione,  1990 , p. 5).

Though Facione's definition has been criticized for being long‐winded and difficult to implement (Davies & Barnett,  2015 ), its use for CT assessment in nursing education is evident (Raymond et al.,  2017 ). Dwyer et al.'s ( 2014 ) model incorporate both reflective judgement (skills) and self‐regulatory functions of metacognition (disposition) as requirements for CT consistent with Facione's ( 1990 ) definition. Self‐regulation refers to the individual's ability, willingness and perceived need to think critically when solving problems.

3.2. Memory

Critical thinking skills are dependent on what information one can remember (Dwyer et al.,  2014 ). Information is either stored in short‐ or long‐term memory. Dwyer et al. ( 2014 ) assert that through deliberate attention or perception processes, information is stored as short‐term memory (working memory). This short‐term memory includes two sub‐systems—phonological loop and visuospatial sketchpad; a central executive (attention focussing process that relates to long‐term memory) and episodic buffer (storage centre that integrates new information from working memory with existing memory from long‐term memory) (Baddeley,  2010 ). Through manipulation, information in short‐term memory may be encoded as long‐term memory. Long‐term memory is stored as schemas (categorization of knowledge based on how it will be used).

3.3. Comprehension

Meaningfully organizing information into schemas for future retrieval requires understanding or comprehension (Dwyer et al.,  2014 ). Comprehension encompasses the ability to translate or interpret information based on previous learning (Huitt,  2011 ). Long‐term memory and comprehension are fundamental processes for CT application (Dwyer et al.,  2014 ).

3.4. Instructional activities

Duron et al. ( 2006 ) designed a 5‐step model to provide a practical impetus in the acquisition of CT skills. This model focuses on steps that educators should take to foster the CT skills of students. The 5‐step framework requires that educators first determine learning objectives. The educator should identify the behaviours that the students should exhibit by the time they exit a course. The objectives should correspond to the higher order of Bloom's taxonomy. Secondly, the importance of teaching through questioning is underlined. The educator should design appropriate questions and questioning techniques to encourage discussion. The questions should vary and be concise to generate student participation. Particularly, divergent questions encourage CT. Thirdly, practice before assessing is considered important – inclusive of learning experiences that encourage active and experiential learning. Fourthly, the educator should continuously review, refine and improve instructional activities for CT skills. These include strategies such as evaluating students' participation through teaching, diary and journaling. Lastly, educators need to provide feedback and assessment of learning. Thoughtful, purposeful and timely feedback should be provided to students on their performance.

It is the contention of these authors that a CT‐based curriculum framework should address factors that either impede or enhance the students' abilities to memorize information (attention/perception processing), comprehend, reflectively make judgement (ability to analyse, evaluate and create) and engage in self‐regulation functions (disposition towards CT). Pursuant to this view, these authors observed classroom instructional practices (Boso et al.,  2020 ), explored the experiences of students and educators (Boso et al.,  2021c ) and assessed the CT disposition of students (Boso et al.,  2021b ). These studies revealed a number of issues that informed the development of a CT‐based curriculum framework. For example, challenges such as seniority tradition, large class size; negative attitude, lack of commitment and inappropriate assessment styles/methods of educators; background and culture, learning practices, lack of comprehension of the participant, distractive behaviour of students (Boso et al.,  2020 , 2021c ) were identified. Though students had a confident disposition towards reasoning, they did not have a mindset of truth‐seeking (Boso et al.,  2021b ). Lack of involvement of students in curriculum reviews and continuous professional development programs on CT for faculty were also identified as challenges in developing CT skills of students (Boso et al.,  2021c ). Also, educators' examination questions about a higher order of thinking constituted <6% (Boso et al.,  2021a ).

4.1. Research design

This article is the concluding part of a larger project (see Boso et al.,  2020 , 2021a , 2021b , 2021c ) that sought to develop a CT‐based curriculum framework. The study used participatory action research (PAR), specifically, cooperative inquiry (CI) as an overarching research design to develop a CT‐based curriculum framework. CI is one of the approaches embedded in PAR (Mash,  2014 ; Mash & Meulenberg‐Buskens,  2001 ) and is used interchangeable with PAR in this article. PAR inter alia assists in problem solving (Hart & Bond, 1995 ; Mash,  2014 ), promotes organizational improvement (Hart & Bond, 1995), bridges the theory–practice gap (Mash,  2014 ; Rolfe, 1996 ) and allows users to be involved (Beresford, 2006 ).

4.2. Study setting, population and sampling

The study was conducted in the nursing school of an accredited publicly funded university in Ghana. There were approximately 527 nursing students and 16 full‐time faculty members. Like many educational institutions in developing countries, the school had challenges such as a lack of sufficient qualified faculty, and infrastructural and logistical constraints that may militate against assisting students to acquire CT skills. For example, class sizes could range from 50 to 150 students.

The study participants included students who had been enrolled in the degree nursing program for at least a year, nurse educators with current full‐time appointments with at least a year of teaching experience, preceptors and coordinators of CT‐based medical programs. It is believed that these participants had been associated with the nursing educational system long enough to provide rich data on their experiences and expertise. Furthermore, using diverse stakeholders in the study aided in providing balanced perspectives.

Twelve participants comprised 3 educators (with 1 being a coordinator of a CT‐based medical program), 2 preceptors, 6 students and the researcher himself were part of the cooperative inquiry group (CIG). Pertinent to the tenets of cooperative inquiry, these CIG were to collaboratively engage to develop a CT‐based curriculum framework. To select students for the CIG, presentations on the purpose and nature of the study were made in their respective classrooms. A list of those who agreed to participate in the study was compiled based on the different educational levels. Individuals were randomly selected and contacted through email or telephone. Similarly, a list of preceptors was obtained. In the Ghanaian context, preceptors are clinical nurses who instruct students during clinical placement. They were contacted and those who were willing to participate were ranked based on their educational level and experience. Two preceptors with Master's degrees in nursing were selected to participate in the study as their clinical experience and educational background provided the necessary expertise towards developing the CT‐based curriculum framework. Two educators were randomly selected while the coordinator of the CT‐based medical program (also an educator) was purposively invited through email and/or telephone. The CIG was engaged throughout the entire research process to identify ideas, observe, and reflect on results to develop a framework to foster CT skills of students. Seven steps of the research process evolved till the aim of the study was met. Different data sets—qualitative and quantitative—were gathered and analysed, culminating in the development of the framework.

4.3. Summary of research process

In this study, O'Leary's cycle of action research as described by Koshy et al. ( 2011 ) was adopted. The process alternates from observation, reflection and planning to action. Seven steps from observation to action were followed during the entire research project (see Figure  2 ). The cooperative inquiry group members were engaged throughout the seven steps of the research process. In total, three workshop meetings were held.

Summary of research process.

4.3.1. Step 1

Data were collected on the instructional practices/activities of the selected school from September 2017 to March 2018. These data sets were to aid the CIG in understanding current practices and to provide the baseline data for the development of the framework. Factors that either inhibited or enhanced perception/attention processing and comprehension of information and reflective judgement (analysing, evaluating and creating) according to Dwyer et al.'s ( 2014 ) were identified. Prior to data collection, the participants were exposed to the research methodology and methods at a training workshop held in September 2017. Nine participants—the first author (initiating researcher), two preceptors, one educator and five students—were able to attend this session. The first author introduced the CIG members to the Nominal Group Technique (NGT). The NGT is considered one of the most frequently used formal consensus building techniques (Harvey & Holmes, 2012 ). The NGT includes five stages, namely: (1) introduction and explanation, (2) silent generation of ideas, (3) sharing ideas—round robin, (4) group discussion/clarifying and (5) voting and ranking. Measures to ensure the rigour of inquiry were discussed and agreed upon. Two educators who were unable to attend the session were met individually and the purpose and methods of the study were discussed with them.

4.3.2. Step 2

The analysed data from step 1 were presented to the CIG members at a second meeting held in March 2018. Nine participants—three educators, two preceptors, three students and the first author—were present at this meeting. The CIG deliberated on the results obtained through group discussions facilitated by the first author. Upon reflection, CIG agreed that the data provided enough basis for a draft framework to be considered. Vital issues about instructional practices had been elicited.

4.3.3. Step 3

Following the reflection on the data, the CIG through the Nominal Group Technique (NGT) facilitated by the first author designed a draft framework. Three questions were formulated for the NGT session, namely, (a) What concept(s) should be included in the framework that will facilitate CT skills of nursing students? (b) How should these elements/components/concepts/variables be related? and (c) What should the structure of the framework be?

At the first stage of introduction and explanation of the NGT, purpose of the study, NGT procedure and the three questions for the NGT procedure were reiterated to provide all members with the same point of reference. At the second stage of the NGT, members were allocated 5 minutes to generate ideas for the framework. Seventy‐six concepts were generated. These concepts were collated at the third stage of the NGT process. The fourth stage saw the concepts discussed, their meanings sought and consolidated. Through consensus, some concepts or synonyms were removed, leaving a total of 45 concepts. For example, the concept learner replaced and/or represented similar concepts such as student and nursing students. Likewise, facilitators replaced educators and/or lecturers. The 45 concepts were further consolidated (categorized) into nine. These included learner (and associated characteristics), educator/facilitator (and associated characteristics), teaching methods/style, learning environment, institutional support, assessment, technology, review system and curriculum. At the final stage, the CIG members voted to rank the concepts in order of importance. Learner, facilitator, teaching methods, learning environment and assessment were the five most ranked concepts. The first author was tasked to develop the draft framework with the concepts and relationships for the CIG members to review individually and for subsequent evaluation by students and educators for its applicability. Accordingly, the draft framework was designed by the first author together with one of the CIG members and subsequently distributed to all CIG members for input.

The draft framework suggested that the teaching‐learning process needed to be a caring professional relationship between the learner and the facilitator. This relationship should be the heart of the curriculum. The draft framework included six concepts/components which included: (a) caring professional relationship; (b) facilitator; (c) learner; (d) learning environment; (e) outcome setting, system review and advocacy and (f) contextual dynamics.

4.3.4. Step 4

The draft framework was made available to six educators and eight students in the selected school to review/comment on its applicability. The following questions accompanied the draft framework: How applicable is this framework in facilitating CT skills of students? What do you believe are the strength(s)/weakness(es) of this framework? What concept(s) do you believe should be removed and/or added to the framework to make it more applicable? Three educators and six students evaluated the draft framework. Given that these groups of participants are part of the nursing school, their views about the applicability of the framework were important to consider when implementing the framework in a real‐life situation.

4.3.5. Step 5

The students' and educators' comments and critiques about the draft framework were carefully analysed thematically by the first author. The draft framework was evaluated as applicable by all participants (3 applicable, 6 very applicable). The reasons for their choices included that the framework was simple, realistic, comprehensive (essential factors included), improved relationships for easier communication, made the facilitator a role model, made the learner an active participant and the learner's view was encouraged. Considering the strengths of the framework, the evaluators thought the framework was well structured, bridged gaps in the learner–facilitator relationship, comprehensively covered most factors of education, and covered current trends, and legal/regulatory issues.

The following were seen as the weaknesses of the draft framework by the evaluators: (a) difficulty to elicit commitment from all; (b) challenges associated with the hard environment; (c) possibility of being misused by students; (d) possible failure of the authentic student–facilitator partnership; (e) perceived difficulty to explain complex concepts/processes such as outcome setting, advocacy, system review and (f) possible lack of CT skills of learners and facilitators. They also thought concepts like culture, time, students' involvement, external motivation and career counselling should be included in the framework.

4.3.6. Step 6

The results of the evaluation of the draft framework were presented to the CIG at a workshop facilitated by the first author in May 2018. The comments and critiques of the framework were reflected on by the CIG for possible revision. Eight participants—two preceptors, five students and the first author were present at this 5‐h workshop. The CIG members considered the weaknesses identified during the evaluation as rather systemic challenges in the selected school and not of the framework. In their view, a framework should represent the ideal. Also, the CIG members thought culture, time and students' involvement were already captured.

4.3.7. Step 7

A revised framework was designed to reflect the views of the evaluators of the draft framework. Some concepts/processes were fine‐tuned, and others were further explicated by the members (see Results section for more details). For example, the caring professional relationship was altered to authentic student–facilitator partnership. Likewise, more extended phrases were used to provide further explication to the facilitator, learner and learning environment. Through NGT, ownership was suggested and added to the definition of authentic student–facilitator partnership. The CIG held the assertion that ownership will enhance responsible learner and educator behaviour. The final framework is presented in the Results section.

The results from the cooperative inquiry were organized into a framework illustrating interconnected concepts required to foster CT skills of nursing students in developing countries. The framework proposes six key interconnected thematic priorities (see Figure  3 ) to drive the development of CT of students. The concepts/themes included in the final framework were (a) authentic student–facilitator partnership, (b) a facilitator that makes a difference, (c) a learner that is free to question and encouraged to reflect, (d) a conducive and participatory learning environment, (e) curriculum renewal processes and (f) contextual realities. These six concepts are important components that should drive a curriculum based on CT principles. The concepts which emanated from the CIG discussions are described below.

Critical thinking‐based curriculum for undergraduate nursing program.

5.1. Authentic student–facilitator partnership

The authors of this study suggest that the central focus of the teaching–learning process should be authentic partnership between the learner and the facilitator (Raymond et al.,  2018 ). This view is motivated by the evidence of dysfunctional learner–facilitator relationships coupled with heightened students' perceptions of mistrust, lack of support, lack of emotional connectedness and lack of democratic practices informed by cultural realities identified (Boso et al.,  2020 , 2021c ). These authors define authentic student–facilitator partnership as a supportive, empathetic, learner‐directed, mutually respectful, accountable and democratic learning relationship which focuses on assisting a learner to engage in meaningful learning experiences toward the development of CT skills.

It is suggested that the educator takes responsibility for the optimum functioning of this partnership (Billings & Halstead,  2005 ; Mangena & Chabeli,  2005 ; Raymond et al.,  2017 ). However, both the student and the facilitator (Raymond et al.,  2018 ) should feel a sense of ownership of the teaching and learning process. The findings of this study suggest that factors relating to both students and facilitators could either facilitate or inhibit the fostering of CT skills acquisition. Consequently, both the student and the facilitator should be committed to setting up appropriate boundaries to govern this partnership. These boundaries should include adherence to educational justice—creating equal opportunities, fair evaluation, fair criticism and non‐discrimination on the basis of gender, race or religious status (Boozaripour et al.,  2018 ). Adherence to boundaries is likely to enhance the perception of trust and ownership.

5.2. A facilitator that makes a difference

We see the facilitator as the leader, role model, mentor and guardian of the student for a purposeful learning experience towards CT skills acquisition. It was evident in this study that the facilitator's approach to classroom management and general attitude towards students and cultural realities influenced how students engaged in the teaching and learning process (Boso et al.,  2020 , 2021c ). Cultural competence in healthcare is a global standard; thus, the facilitator should be aware of the influence of cultural tendencies (Chan,  2013 ; Donkor & Andrews,  2011 ) on the student–facilitator partnership. The facilitator should become a role model in terms of how he/she collaborates and communicates (Raymond et al.,  2018 ) as well as his/her punctuality to class. These general effective teaching tenets are required to set the tone for the reflective engagement of students towards the acquisition of CT skills. For example, a lack of punctuality will limit the amount of instructional time required for students to think critically. Also, the facilitator should demonstrate CT tenets in his/her teaching.

Furthermore, the facilitator needs to demonstrate scholarly attributes and experience in teaching, clinical skills, and theoretical nursing knowledge; be student‐centred, empathetic, supportive; and enthusiastic about the nursing profession and teaching (Billings & Halstead,  2005 ; Mangena & Chabeli,  2005 ; Raymond et al.,  2018 ). The facilitator needs to connect with the learner on an emotional level (Raymond et al.,  2018 ). It is proposed that the facilitator should use tools such as CT‐oriented learning outcomes/objectives, appropriate assessment for CT and active learning teaching approaches/methods. In addition, teaching and assessment methods should vary and should be driven by appropriate questioning techniques (Duron et al.,  2006 ; Raymond et al.,  2018 ). These questioning techniques should predominantly target higher‐order of thinking to help students to engage in appropriate thinking moments (Duron et al.,  2006 ).

5.3. A learner that is free to question and encouraged to reflect

The learner is the inquirer/discoverer of knowledge guided by the facilitator in an educational program. It was noted in this study that students were influenced by the Ghanaian cultural realities (Boso et al.,  2020 , 2021c ) that did not allow them to question authority (Donkor & Andrews,  2011 ) and the type of assessment/teaching methods to which they are exposed. These authors posit that to assist in fostering CT skills of learners, the students should not see themselves as a receptacle in which content/information is dumped, but rather as rational individuals who can decide for themselves regarding truth. Therefore, students should adopt CT‐oriented learning practices that ensure a reflective view of content/information for self‐determination and lifelong learning. This encourages facilitators to share their CT with students (Raymond et al.,  2018 ). In addition, they should be encouraged to be self‐motivated and self‐directed.

Strategies needed to promote CT skills in students should include the use of CT‐oriented learning outcomes/objectives, appropriate assessment for CT and active learning teaching methods. Additionally, teaching and assessment methods should vary and should be driven by appropriate questioning techniques (Duron et al.,  2006 ; Raymond et al.,  2018 ) which should target higher order of thinking to help students to engage in appropriate thinking moments (Duron et al.,  2006 ).

5.4. Conducive and participatory learning environment

The authentic student–facilitator partnership between the learner and the facilitator occurs in a conducive learning environment that promotes CT (Mangena & Chabeli,  2005 ; Raymond et al.,  2018 ). This environment has two components: hard and soft. The hard environment involves a library, learning space and technology. Appropriate use of technology should be employed in the teaching–learning process. This study showed that students were engaged in distractive use of social media and technology in the classroom (Boso et al.,  2020 ). Guidelines for the use of technology/social media should be available to help learners and facilitators derive maximum benefits from these tools. Also, institutional support is required for the provision of appropriate technology, learning space, appropriate class size and library resources for a meaningful learning experience (Raymond et al.,  2017 , 2018 ).

The soft environment involves the intangible safe, empathetic and democratic atmosphere created to encourage the learner to share his/her views freely. This conducive atmosphere should permeate the entire school environment. This helps to establish emotional connectedness between the students and other role players in the educational environment (Raymond & Profetto‐McGrath, 2005 ; Raymond et al.,  2017 , 2018 ). It was noted in this study that students did not feel adequately supported, and were not regularly engaged in curriculum reviews and other matters that directly affect their learning (Boso et al.,  2021c ). Consequently, we propose the establishment of a system of support (including financial aid) for students and practical avenues for students' engagements based on a consultative process involving students and other role players. Additionally, school managers should provide support to facilitators through staff development programs on CT. Assisting faculty development in the area of CT instructional methods will help educators to infuse CT tenets in their own courses (Mangena & Chabeli,  2005 ; Raymond et al.,  2017 , 2018 ). Measures such as assigning facilitators with teaching assistants should be adopted to give facilitators more time to engage in CT instructional practices (Shell,  2001 ). Facilitators in this study expressed the concern of inadequate time to engage students, partially due to the absence of teaching assistants.

5.5. Curriculum renewal processes

We propose that renewal processes should be adopted for a CT‐oriented curriculum as a whole and of parts as deemed necessary and considering local, national and international trends. The aim of these processes should be to encourage continuous feedback and review that will lead to curriculum improvement (Duron et al.,  2006 ). Students and other role players should be engaged in the curriculum renewal processes. In reviewing the curriculum, contemporary CT assessment theory and practices should be used. Furthermore, the renewal process should adhere to the standards of curriculum review processes. Also, the relevance of courses should be continuously examined to ensure that they attract students' engagement towards CT skills. Consistent with CT activism tenets (Davies & Barnett,  2015 ), advocacy should be encouraged to effect changes that may be occasioned by observations from the curriculum review. Particularly, educators should be encouraged to engage in advocacy to effect changes that may be necessary to assist students to acquire CT skills.

5.6. Contextual realities

A curriculum does not exist in a vacuum. It should be designed and operated in a specific context (Billings & Halstead,  2005 ). The learning process and the extent to which one can address CT skills are influenced by contextual realities. These contextual realities include the program of study, the global/national trends and policies and legal/regulatory framework. For example, as an undergraduate nursing program, CT is highly recommended as a competency (World Health Organization,  2009 ). It is therefore suggested that CT should be taught as a course and teaching methods that support CT be infused into all courses of the program. Global and national trends and policies need to be considered. For example, international development goals, disease patterns and burdens, employer expectations and needs, international best practices and standards, and availability of health facilities and clinical staff for clinicaleducation should guide the curriculum. Additionally, legal/regulatory bodies' requirements need to be adhered to. In the Ghanaian under graduate nursing context, the requirements of the Ghana Tertiary Education Commission (formerly of the National Accreditation Board), the Nursing and Midwifery Council of Ghana and the university in which the program is undertaken would be essential to consider.

6. ETHICAL CONSIDERATIONS

Research Ethics Committee approveal was obtained from the Health Research Ethics Committee of Stellenbosch University (Ref. No. FS17/05/106) and the university in which the study was conducted (name withheld to ensure the anonymity of participants). Written permission was sought from the dean of the selected school. All participants including students, nurse educators and preceptors provided informed consent. Given that this was a PAR, the owner of the authorship and the findings were made explicitly clear to the participants as suggested by Mash ( 2014 ). The names and the contributions of participants were kept confidential and the group was supported by the researcher throughout the study.

7. LIMITATION OF THE STUDY

The quality of a PAR is dependent on how the initiating researcher can unmask and diffuse power differentials. The power relational challenges inherent in many studies may be perpetuated (Scotland, 2012). Given that a hierarchical situation and power inequalities could arise because of the involvement of students, the students' representation was increased to form half of the cooperative inquiry group. Also, training of the cooperative inquiry group was carried out to address coercion, collaboration and partnership. The Nominal Group Technique was adopted for decision‐making to ensure that no one's view was disproportionately rated above others. In addition, the absence of one or two members at different times may have influenced the flow and consistency of ideas generated.

8. CONCLUSION

Conducting a study with the purpose of developing a framework of CT development is appropriate for different reasons. Consistent with the context of this study where the seniority tradition exists which may negatively influence the student–faculty relationship, this curriculum framework emphasized the importance of authentic interaction between students and the faculty in facilitating the CT skills of students. The recommended framework derived may suggest a wider implication for nursing schools and universities to provide CT‐based continuous professional development programs for their nurse faculty. Additionally, the study findings may have implications for monitoring and evaluation activities with the view of improving standard setting and teaching–learning experiences of students.

Based on this study, it is envisaged that nurse educators, who play a pivotal role in nursing education, will find reasons to refine their instructional practices. Also, further research focussing on different contexts of CT in Ghana may be useful. Most importantly, this framework may provide direction for how a curriculum can be predicated on CT, thereby removing arbitrariness.

AUTHOR CONTRIBUTIONS

All the authors made substantial contributions to the manuscript. CMB, ASVDM and JG conceived and designed the study. CMB collected data, analysed and drafted the manuscript. ASVDM and JG supervised the study and made critical revisions to the paper.

FUNDING INFORMATION

No external funding.

CONFLICT OF INTEREST STATEMENT

We do not have any conflict of interest to report.

ACKNOWLEDGEMENTS

We wish to acknowledge Victor Angbah for assisting in data collection. We also express our gratitude to the study participants. Furthermore, we express our profound gratitude to the authority and staff of the educational institution used for this study.

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• DOI: 10.3928/01484834-20120427-05
• Corpus ID: 41079565

Measuring critical thinking dispositions of novice nursing students using human patient simulators.

• R. Wood , Coleen E. Toronto
• Published in Journal of Nursing Education 1 June 2012
• Education, Medicine

32 Citations

Critical thinking disposition of nursing students: a quantitative investigation., cognitive-behavioural reflective training for improving critical thinking disposition of nursing students, effects of a critical thinking course for korean nurses in rn-bsn program, the relationship between the california critical thinking disposition inventory and student learning outcomes in baccalaureate nursing students., the effect of high fidelity simulation training on critical thinking and problem solving skills in nursing students in turkey, critical thinking and caring in nursing students, improving the new graduate and undergraduate student nurses' critical thinking ability through the use of simulation in nursing: a systematic review of literature, effective factors in critical thinking disposition in nursing students, development and validation of simulation teaching strategies in an integrated nursing practicum, student nurses’ perceptions of the role of high-fidelity simulation in developing decision-making skills for clinical practice: a qualitative research study, 15 references, study of critical thinking skills in nursing students and nurses in japan., critical thinking disposition as a measure of competent clinical judgment: the development of the california critical thinking disposition inventory., the development of an alternative method in the assessment of critical thinking as an outcome of nursing education., critical assumptions: thinking critically about critical thinking., patient simulator sessions and critical thinking., validity evidence for using a general critical thinking test to measure nursing students' critical thinking, debriefing: the most important component in simulation, integration of simulation across the undergraduate curriculum: student and faculty perspectives, measuring critical thinking: one step forward, one step back, combining simulation, instructor-produced videos, and online discussions to stimulate critical thinking in nursing students, related papers.

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• Volume 14, Issue 8
• Exploring the link of personality traits and tutors’ instruction on critical thinking disposition: a cross-sectional study among Chinese medical graduate students
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• LingYing Wang 1 ,
• WenLing Chang 2 ,
• http://orcid.org/0000-0002-1507-7890 HaiTao Tang 3 ,
• WenBo He 4 ,
• http://orcid.org/0000-0002-6682-8279 Yan Wu 3 , 5
• 1 Critical Care Medicine Department, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University , Chengdu , China
• 2 School of Population Health & Environmental Sciences , King’s College London , London SE1 1UL , UK
• 3 Department of Postgraduate Students, West China School of Medicine/West China Hospital, Sichuan University , Chengdu , China
• 4 Institute of Hospital Management, West China Hospital, Sichuan University , Chengdu , Sichuan , China
• 5 College of Marxism, Sichuan University , Chengdu , China
• Correspondence to Yan Wu; wuyan{at}wchscu.cn

Objectives This study aimed to investigate the associations between critical thinking (CT) disposition and personal characteristics and tutors’ guidance among medical graduate students, which may provide a theoretical basis for cultivating CT.

Design A cross-sectional study was conducted.

Setting This study was conducted in Sichuan and Chongqing from November to December 2021.

Participants A total of 1488 graduate students from clinical medical schools were included in this study.

Data analysis The distribution of the study participants’ underlying characteristics and CT was described and tested. The Spearman rank correlation coefficient was used to evaluate the correlation between each factor and the CT score. The independent risk factors for CT were assessed using a logistic regression model.

Results The average total CT score was 81.79±11.42 points, and the proportion of CT (score ≥72 points) was 78.9% (1174/1488). Female sex (OR 1.405, 95% CI 1.042 to 1.895), curiosity (OR 1.847, 95% CI 1.459 to 2.338), completion of scientific research design with reference (OR 1.779, 95% CI 1.460 to 2.167), asking ‘why’ (OR 1.942, 95% CI 1.508 to 2.501) and team members’ logical thinking ability (OR 1.373, 95% CI 1.122 to 1.681) were positively associated with CT while exhaustion and burn-out (OR 0.721, 95% CI 0.526 to 0.989), inattention (OR 0.572, 95% CI 0.431 to 0.759), Following others’ opinions in decision-making (OR 0.425, 95% CI 0.337 to 0.534) and no allow of doubt to tutors (OR 0.674, 95% CI 0.561 to 0.809) had negative associations with the formation of CT disposition in the fully adjusted model.

Conclusions Factors associated with motivation and internal drive are more important in the educational practice of cultivating CT. Educators should change the reward mechanism from result-oriented to motivation-maintaining to cultivate students’ CT awareness.

• risk factors
• public health

Data availability statement

Data are available on reasonable request.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2023-082461

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STRENGTHS AND LIMITATIONS OF THIS STUDY

Our study focused on postgraduate medical students, and the sample size was relatively large.

Previous research on critical thinking has focused primarily on Europe, the USA and Japan. Hence, researching critical thinking in Chinese populations is a valuable addition to this area.

Given the traditional limitations of cross-sectional studies, the findings of this study cannot be used as direct evidence of a causal relationship between potential influences and outcomes. Nevertheless, they can provide clues to reveal causal relationships.

Introduction

Critical thinking (CT) is reasoned, reflective thinking that decides what to believe or do. The emphasis is on reasonableness, reflection and decision-making. 1 CT is even more important in the medical field, where a lack of CT can lead to delayed or missed diagnoses, incorrect cognition and mismanagement. The centrality of CT is reflected in the competency framework of health professions and is a core skill of healthcare professionals. 2–6 Six crucial skills have been proposed to operationalise the definition of CT: interpretation, analysis, evaluation, inference, explanation and self-regulation. Specifically, interpretation involves comprehending the significance of information and conveying it effectively to others. Analysis requires piecing together fragmented data to decipher their intended purpose. Inference entails identifying and leveraging relevant information to formulate logical conclusions or hypotheses. Evaluation necessitates assessing the trustworthiness of a statement or information. Explanation aims to clarify shared information to ensure its comprehensibility to others. Finally, self-regulation pertains to regulating one’s thoughts, behaviours and emotions. 7–9

The role of CT in assisting medical students in navigating complex health scenarios and resolving clinical issues through sound decision-making is paramount. Extensive research has established positive correlations between CT and clinical proficiency, 10 11 academic excellence 12 and research capabilities. 13 Consequently, the Institute for International Medical Education has emphasised ‘CT and research’ as one of the seven crucial competencies that medical graduates must possess, as outlined in the Global Minimum Essential Requirements. 14 Similarly, the Ministry of Education in the People’s Republic of China has underscored the importance of ‘scientific attitude, innovation and CT’ as essential requirements for Chinese medical graduates. 15

Research on CT in medical students has been carried out to varying degrees in Western countries and many Asian countries. 16 17 Some scholars have pointed out that Western methods, including CT and clinical reasoning, are used in thinking skills education worldwide. However, there are significant differences between Chinese and Western culture, especially educational culture while cultural differences affect ways of thinking 17 18 ; therefore, previous research may not be able to reflect the actual situation of Chinese students and teaching methods may not apply to them. Most Western students tend to possess assimilating learning styles, enabling them to excel in student-centred learning environments. Conversely, Eastern students often exhibit accommodating learning styles that align more with teacher-centred instruction. 19 The discipline-based curriculum in China may not adequately foster the development of CT dispositions among Chinese medical students. This curriculum typically comprises isolated phases (theory, clerkship and internship), limited faculty–student interaction and a knowledge-focused evaluation system. 20

Previous research has suggested that a range of personal characteristics, including gender, major, blended learning methods, increased self-study hours, heightened self-efficacy in learning and performance, exposure to supportive environments and active participation in research activities, contribute to varying degrees of CT dispositions and skills. 21–24 A study conducted in Vietnam revealed that age, gender, ethnicity, educational level, health status, nursing experience, tenure at the current hospital, familiarity with ‘CT’ and job position all influence CT ability. 25 Furthermore, teacher support is paramount to learners’ mental and psychological development. This support encompasses educators’ empathy, compassion, commitment, reliability and warmth towards their students. 26 According to Tardy’s social support paradigm, 27 teacher support is defined as providing informational, instrumental, emotional or appraisal assistance to students, irrespective of their learning setting. Supportive teachers prioritise fostering personal relationships with their students and offering aid, assistance and guidance to those in need. 28 Practical teacher assistance can make students feel comfortable and inspired, motivating them to invest more effort in their studies, engage more actively in educational pursuits and achieve superior educational outcomes. 29

Current CT research on mainland Chinese medical students focuses on the impact of undergraduates’ experiences and classroom instruction. However, for postgraduates, their tutors play a more critical role in education and cultivation. According to Wosinski’s study, 30 tutors should be trained to effectively guide the teamwork of undergraduate nursing students during the problem-based learning (PBL) process to achieve their goals. There is no analysis of the influencing factors of CT focused on medical postgraduates.

Therefore, assessing the tutor’s effect on postgraduates’ CT disposition. This study investigated the associations between CT disposition and personal characteristics and tutors’ guidance among medical graduate students, which may provide a theoretical basis for cultivating CT.

Study design and participants

Study design.

This was a cross-sectional observational study. The project team sent 1525 electronic questionnaire links to WeChat groups of full-time medical graduate students in higher medical institutions in Sichuan and Chongqing between November and December 2021. After removing incomplete and duplicate questionnaires, a total of 1488 valid questionnaires were returned for an effective rate of 97.57%.

Sampling procedure

We employed a random sampling method to select medical graduate students carefully and used PASS V.15.0 software to calculate the sample size for different analyses and outcome scenarios. In the estimation of the sample size with the proportion of CT disposition as the primary outcome, we considered p=0.5, adopted the two-sided Z value under the significance level of a=0.05, and the sample size was the largest when the sampling error was 3%, which was 1067. Moreover, estimating of sample size with the correlation coefficient as the primary outcome, we considered r=0.1 according to the results from the prestudy, and the test power was 0.9; thus, we obtained n=1048. The sample size should be at least 1334 considering a 20% non-response rate.

The inclusion criteria were as follows: (1) full-time medical graduate students (clinical medicine, medicine technology, integrative Chinese and Western medicine, medical laboratory, nursing and so on) in higher medical institutions in Sichuan and Chongqing and (2) after reading the introduction to the research, participants voluntarily agreed to participate and electronically signed the study’s informed consent form. The exclusion criterion was a refusal to participate in the study.

Procedure and data collection

The electronic questionnaire we used consisted of a condensed version of the Critical Thinking Measurement Scale, which was used to evaluate participants’ scores on CT disposition and a Potential Influencing Factors Questionnaire, which investigated participants’ underlying information, personal factors and education-related factors. To increase the response rate, we told the students how long it might take to fill out this questionnaire when we sent the questionnaire link to WeChat groups. Moreover, our participants all had master’s degrees or above whose understanding ability and compliance were better. We also sent reminders to all invited participants three times, and the survey lasted approximately 1 month.

Critical Thinking Measurement Scale

We used the Chinese version of the short-form critical thinking disposition inventory (SF-CTDI-CV), which is based on the CTDI-CV reported by Huang. 31 The CTDI-CV includes seven subscales, namely Truth Seeking, Open-mindedness, Analyticity, Systematicity, Critical Thinking Self-confidence, Inquisitiveness and Cognitive Maturity, which have good reliability and validity (0.90 for the overall Cronbach’s alpha and 0.89 for the overall Content Validity Index). 32 Huang removed ineffective questions based on the CTDI-CV and obtained a simplified scale with 18 items of three factors, which increased the proportion of total explained variation and had better reliability and validity than the original version. Huang selected items according to important indicators in factor analysis, including factor loading and communality. Specifically, Huang removed items whose factor loading was less than 0.4 or whose commonality was less than 0.3. Each item of the SF-CTDI-CV has six options (Likert scale) from 1 to 6 (1 means complete agreement and 6 means disagree entirely); the higher the score is, the stronger the CT tendency. 31 The Kaiser-Meyer-Olkin (KMO) value for SF-CTDI-CV is 0.90 while the p value of Bartlett’s test is less than 0.05, indicating that this short-form inventory has ideal structural validity. A total score of 72 or more indicates a CT disposition, and all participants were divided into two groups according to whether they possessed essential characteristics of thinking.

Potential Influencing Factors Questionnaire

The Potential Influencing Factors Questionnaire was based on previous research and interviews. The interviewees including senior education practitioners and invited medical postgraduate students, focused on their experiences and feelings regarding medical education in China. We compiled an interview outline and invited a total of 22 professionals, including 9 doctoral candidates, 5 doctoral supervisors, 2 counsellors and 6 young backbone teachers, to participate in the interviews. The interview schedule is flexible, but to ensure efficiency, we controlled the interview duration for each participant to within 40 min. After the interviews, we used professional NVivo V.11.0 software to analyse the collected interview data thoroughly.

The Potential Influencing Factors Questionnaire consists of 10 questions in the essential information section, 35 questions in the influencing factors section and 3 flexible questions, for 48 valid entries. The essential information section includes gender, age, secondary education background, higher education major, level of education, type of degree, full-time work experience, type of household registration, the highest level of parental education and whether the respondent was from an only child family. The influencing factors section can be grouped into two main areas: ‘personal factors’ and ‘educational factors’, with personal factors including the individual characteristics section. The educational factors include the practice and training, tutor and team, and educational environment section. This study defines every potential factor as an ordinal variable, with greater rank, depth and frequency of the corresponding factors. For reliability, Cronbach’s alpha=0.795 indicates that the questionnaire’s reliability is good enough for investigation. The content validity of the questionnaire was tested to determine whether the content met the objectives and requirements of the study. Most of the items of the influencing factors questionnaire were selected from previous literature, and the content validity was good. The KMO values and p values for the Bartlett’s test of sphericity for every aspect indicate that the structural validity of the questionnaire is good (see more details in online supplemental table S1 ).

Supplemental material

In the questionnaire design process, we first formed a preliminary framework concerning previous qualitative and quantitative research. Then we conducted interviews with educators, doctoral supervisors and representatives of medical postgraduate students according to the initial framework to understand their work experience in the practice of medical postgraduate education in China. Then, the questionnaire was supplemented according to the frequently mentioned items in the interviews. Finally, a questionnaire focusing on whether personal and educational pathways influence the formation of CT disposition was developed, as well as the key points of CT cultivation.

Data collection and organisation

The project team designed the electronic questionnaire based on the Influencing Factors Questionnaire and Critical Thinking Measurement Scale. Excel 2019 collated the raw data exported from the electronic questionnaire platform. Using the electronic questionnaire platform, answer completion settings rule out the possibility of logical anomalies. Samples with missing answers on the Critical Thinking Inventory were eliminated. Participants who were missing other information were asked to fill in as much as possible through the telephone number they had left. Those who were unable to do so were eliminated. Each factor in the influencing factors section was assigned a value in steps of 1 from lowest to highest (eg, the four categorical variables were assigned values of 1, 2, 3, and 4; 1 for never and 4 for always).

Students and public involvement

Former students were involved in the preparatory phase of this study. They reviewed the informed consent form and provided feedback.

Statistical analysis

The data were analysed by using SPSS V.24.0 software. The distribution of the study participants’ underlying characteristics and CT were described and tested. Continuous variables are described as the mean±SD, and t-tests or one-way analysis of variance (ANOVA) were used for hypothesis tests. Categorical variables are expressed as composition ratios and χ 2 tests are used for hypothesis tests. Correlation analysis: The Spearman rank correlation coefficient was used to evaluate the correlation between each factor and the CT score. Difference analysis: Trend ANOVA was used to test whether there was a trend change in CT scores at different levels of each potential influencing factor. A t-test was used to compare the differences in the levels of influencing factors between different CT trait groups. Factors with differences between groups were included in a multivariate unconditional logistic regression model. We fitted several multivariate logistic regression models to evaluate potential confounding variables. By comparing the χ 2 value, the −2-likelihood ratio, the Akaike information criterion, and the practical meanings of this study’s interesting factors, the final model in which X variables could explain most of the Y variables (CT scores) was chosen. The above tests were performed at 0.05, and a p<0.05 was considered statistically significant.

Essential characteristics

A total of 1488 medical graduate students were included in this study, with an average age of 26.63±3.72 years. Most of the participants had a science background in high school (96.84%), a higher education major in clinical medicine (78.43%) and had never participated in full-time work (71.91%). Most of the participants were female (65.93%), lived in urban areas (61.69%), had parents with junior school education or below (39.18%), were not the only child in the family (51.48%), scientific graduate students (51.61%) and had a master’s degree (55.51%). Among all the research subjects, the average total CT score was 81.79±11.42 points, and the proportion of CT (score ≥72 points) was 78.9% (1174/1488). The essential characteristics of the included subjects are shown in table 1 .

• View inline

Participants’ essential characteristics and the distribution of critical thinking dispositions

Distribution of CT disposition

Table 1 demonstrates the distribution of CT disposition among the study participants. For the essential CT scores, participants with urban residence, higher parental education, only-child families, a science background before admission, science-based graduates, longer full-time employment and higher education levels had significantly greater CT scores (p<0.05). According to the CT questionnaire used in this project, subjects with a score more excellent than 72 points were considered to have an apparent CT disposition. The results showed that among our participants, women (80.80% vs 75.10%), science students (79.50% vs 61.70%) and PhD students (81.60% vs 76.80%) had a more significant proportion of CT disposition (p<0.05).

CT scores are linearly correlated with impact factor scores

Table 2 shows the correlation between each factor and the CT scores. The Spearman correlation coefficients suggested that most terms related to personal factors were correlated with CT scores (p<0.001). Sense of achievement (r=0.324), curiosity (r=0.480) and following others’ opinions in decision-making (r=−0.292) were strongly correlated with CT scores. Regarding educational factors, all factors in the practice and training section, all factors in the tutor and team section, and most factors in the educational environment impacted CT scores (p<0.001). Factors in the tutor and team section were more strongly related to CT scores, such as teaching students according to their aptitude (r=0.247) and tutors asking heuristic questions (r=0.242). Only no allow of doubt to tutors hurt the CT scores (r=−0.179, p<0.001).

The correlation between the potential influencing factors and the score of critical thinking

Factors influencing CT disposition

Univariate analysis.

The influencing factors associated with CT disposition are presented in table 3 . Univariate analysis revealed that in terms of personal factors, a sense of achievement, curiosity and interpersonal skills were all possible facilitators of CT disposition (p<0.05), and the group with CT disposition had higher average scores. In contrast, fatigue and burn-out, inattention and following others’ opinions in decision-making were possible hindering factors. Regarding educational factors, most factors in the ‘practice and training’ section, all factors in the ‘tutor and team’ section, and some factors in the ‘educational environment’ section were impact factors on CT disposition. In the practice and traning section, academic performance (p<0.001), number of intensively reading (p<0.001), paper writing (p=0.001), participation in academic conferences (p=0.009), completion of scientific research design with reference (p<0.001), time for extracurricular reading (p=0.006), summarisation and reflection (p<0.001), asking ‘why’ (p<0.001) and knowledge of critical thinking (p<0.001) were all positively related to CT disposition. For the tutor and team section, participants with CT disposition had higher scores for the following factors (p<0.01): tutors sharing thinking methods, communicating learning and life with tutors, tutors asking heuristic questions, encouragement of using ‘possible’ and ‘potential’, advocation of logical thinking training and lifelong learning, teaching students according to their aptitude and team members’ logical thinking skills. No allow to doubt tutors hurt CT disposition (p<0.001). The use of multifunctional classrooms (p<0.001) and having active classes (TBL class, flipped class, p=0.006) in the educational environment section were also correlated with CT disposition.

Impact factors

Multivariate logistics regression analyses

Multivariate logistics regression analysis demonstrated that female (OR 1.405, 95% CI 1.042 to 1.895), curiosity (OR 1.847, 95% CI 1.459 to 2.338), completion of scientific research design with reference (OR 1.779, 95% CI 1.460 to 2.167), asking ‘why’ (OR 1.942, 95% CI 1.508 to 2.501) and team members’ logical thinking ability (OR 1.373, 95% CI 1.122 to 1.681) were the promoting factors for the development of CT disposition after adjusting for other confounding factors. However, exhaustion and burn-out (OR 0.721, 95% CI 0.526 to 0.989), inattention (OR 0.572, 95% CI 0.431 to 0.759) and following others’ opinions in decision-making (OR 0.425, 95% CI 0.337 to 0.534) and no allow of doubt to tutors (OR 0.674, 95% CI 0.561 to 0.809) may be hindering factors for the formation of CT disposition in the fully adjusted model ( table 4 , adjusted R 2 =0.323).

Multifactor regression model

This cross-sectional study explored the factors influencing the CT disposition of Chinese medical graduate students in terms of both personal and educational factors. A total of 78.9% of the participants in this study had positive CT dispositions (score ≥72, 1174/1488), and women were 40.5% more likely than men to have CT dispositions (OR 1.405, 95% CI 1.042 to 1.895). Multivariate logistics regression analysis revealed that among personal factors, curiosity was the promoting factor while exhaustion and burn-out, inattention and following others’ opinions in decision-making may be the hindering factors. For educational factors, completing the scientific research design with reference, asking ‘why’ and the high logical thinking ability of team members were associated with CT disposition. However, no allow of doubt to tutors may hinder the disposition of CT.

According to our demographic information, our study revealed a greater prevalence of CT disposition among women, aligning with Zhai’s findings. 22 Several factors may contribute to this observed gender disparity. A systematic review established that men tend to engage more with objects while women prefer interpersonal interactions. 33 Women are more inclined to engage in dialogue and foster their understanding through collaborative learning, often exhibiting a more receptive mindset. Second, a study using fractional anisotropy measures derived from diffusion tensor imaging in 425 participants, including 118 males, revealed that divergent thinking in females correlates positively with fractional anisotropy in the corpus callosum and the right superior longitudinal fasciculus. 34 Conversely, it correlates with fractional anisotropy in the right tapetum in males. Zhang et al ’s 34 research sheds light on the sex-specific structural connectivity within and between hemispheres that underpins divergent thinking. These gender differences in creativity may reflect the inherent diversity between males and females in society. However, Faramarzi and Khafri 35 reported contrasting results. They concluded that although the results differed between the sexes, the likely cause was females’ higher education level rather than a difference due to gender. Several studies concur that self-esteem is a principal determinant of CT. 22 35 Barkhordary et al , 36 in their study of 170 third-year and fourth-year nursing students in Yazd, identified a significant link between CT and self-esteem. Pilevarzadeh et al further demonstrated that students with higher self-esteem exhibit more robust CT skills. 37 Self-esteem is defined as ‘an individual’s overall subjective emotional assessment of their worth’. 38 Bleidorn et al 39 conducted a groundbreaking large-scale, cross-cultural study with an internet sample of 985 937 participants, examining gender and age differences in self-esteem across 48 nations. They discovered significant gender differences, with males consistently reporting higher self-esteem levels than females, which may influence their responses to negative feedback to some degree.

In the section on personal factors, the results of this study on personal internal and external environmental factors such as curiosity, burn-out and inattention are consistent with previous studies. 40–45 The relationship between these internal and external environmental factors and cognitive capacity has been described in cognitive load theory, 46 particularly the role of ‘working memory’, the capacity to process information. Specifically, researchers 47 reported on a consensus on CT teaching, assessment and faculty development compiled by a high-level team recommended by 32 medical schools across the USA. Learners’ personal attributes, characteristics, perspectives and behaviours are critical components of their motivation to prepare for and engage in deeper learning and laborious clinical reasoning. Distractions and interruptions, on the other hand, can reduce attention to important issues, affecting learners’ ability to engage in clinical reasoning and their CT skills. 48 Making decisions based on the opinions of others in this study may reflect the participants’ interdependent view of self, which was identified by Futami et al 49 as a negative factor for CT dispositions.

Regarding the educational factors, learning methods and research group membership characteristics were more strongly associated with CT disposition than learning frequency and learning form. Completing the scientific research design with reference and asking ‘why’ are learning methods that promote the formation of CT for medical graduate students. Research 50 suggests that CT requires a persistent effort to test any belief or supposed form of knowledge according to the evidence supporting it and the further conclusions it tends to help. Completing scientific research design with reference is the specific manifestation of evidence-based reasoning in the scientific research field, which may be why it affects the formation process of CT. Furthermore, similar to our research, much research has explored the crucial role that questioning or problem-based thinking plays in CT. 47 51–53 Our research also suggested that the teaching style of the group supervisor and the logical thinking ability of other group members also impacted CT dispositions. Although no previous research has explored the role-specific behaviours of subject mentors and peers in CT disposition from a quantitative perspective, Futami et al 49 reported higher CT scores for subjects who had connections with research experts, suggesting a positive influence of research mentors on CT. Self-esteem positively affects CT, and overbearing instructors may undermine students’ self-esteem and, thus, their CT disposition. Moreover, several authors 47 53 54 have argued that professors’ encouragement of students to express uncertainty, to question and assess the quality of knowledge learnt, and to improve team members’ logical thinking skills are all positively associated with CT, consistent with our findings.

The CT scores in our study were lower than those in several Western countries among medical students, 55 56 possibly because of differences in educational culture and methods. In China, medical education comprises three stages: primary medical education, clinical education and internships. Primary medical education introduces students to the medical world. The delivery of traditional courses used to be prescribed and even dull simply because teachers were accustomed to a conventional teaching style and were afraid of making changes to course delivery. 57 The strategies to develop reflective and CT in nursing students in eight countries indicated that reflexive CT was found in most curricula, although with diverse denominations. The principal learning strategies used were PBL, group dynamics, reflective reading, clinical practice and simulation laboratories. The evaluation methods are the knowledge test, case analysis and practical exam. 58

The importance of early clinical exposure is universally acknowledged, particularly in developing countries where its value is profoundly esteemed. For instance, the South African Health Professions Council has spearheaded educational reforms for medical professionals, enabling first-year medical students to participate in healthcare visits. These visits aim to enrich the comprehension of future professional environments and foster a more profound passion for medicine. 59 Notably, most students perceived these visits as invaluable learning experiences, leaving them better prepared for medical practice. Similarly, Chinese medical colleges offer comparable programmes spanning 1–2 weeks. A Peking University study using questionnaires and reports revealed that all students benefited from these activities, gaining perceptual knowledge of clinical work. Remarkably, 61.5% of students reported that their early clinical exposure had significantly assisted them. 60

Interestingly, there was a more significant proportion of PhD students with a CT disposition in our study. This may be because doctoral research is more in-depth and complex, requiring students to engage in more detailed, rigorous and innovative thinking based on their existing knowledge. During the research process, doctoral students must constantly question, analyse, evaluate and reconstruct knowledge, which undoubtedly exercises and enhances their CT abilities. 61 However, this does not imply that master’s students possess lower CT skills than doctoral students. The master’s programme also emphasises cultivating CT, although possibly differing in depth and breadth. Both stages have unique development paths and manifestations in terms of CT. Regardless of the stage, graduate students should focus on developing their CT skills to address challenges in academic research and life.

Our research revealed that factors influencing CT motivation appear to be more closely linked to CT tendencies in personal and educational components. Miele and Wigfield 50 suggested that the factors affecting students’ critical analytical thinking motivation can be divided into two aspects: quantity and quality, the quantitative relationship between motivation and CT, that is, whether students have sufficient motivation to make high-level spiritual efforts. This is reflected in our study regarding curiosity, burn-out, distraction, an interdependent self-view and influence by research team members. The qualitative relationship is the willingness of students to engage in CT, which corresponds to the desire to ask ‘why’ and to refer to existing evidence to complete a research design in this study. This suggests that internal motivation may play an essential role in CT and that educators should focus more on maintaining students’ motivation and building awareness than on the frequency of rigid external research training and curriculum formats. Students are actively promoted and encouraged to apply CT in practice. At the same time, the existing overly outcome-oriented reward mechanism is changed, and assessment criteria are enriched, for example, by including ‘whether you ask interesting questions’ as one of the criteria for classroom assessment to motivate people to become more proactive learners. Recently, medical education has garnered considerable attention and traditionally assumes that medical students are inherently motivated by their dedication to specialised training and a highly focused profession. However, motivation plays a crucial role in determining the quality of learning and ultimate success. Its absence may provide a plausible explanation for why teachers occasionally encounter medical students who appear discouraged, have lost interest or abandon their studies, feeling a sense of powerlessness or resignation. 62

To foster CT among medical students, educational reform should encompass several key aspects: (1) Encouraging active learning and exploration: Teachers must urge students to engage actively in the learning process, providing resources and guidance to kindle their intellectual curiosity. This will empower students to seek out challenges, pose inquiries and address them through a critical lens. 63 (2) Implementing heuristic learning and case studies: Educators should incorporate case studies, enabling students to hone their CT, discriminatory skills and decision-making abilities by analysing authentic or hypothetical scenarios. 64 65 (3) Stressing the mastery of professional knowledge: It is imperative to ensure that students grasp the fundamental theories and principles of the medical field, along with proficiency in practical medical skills. 66 (4) Nurturing teamwork skills: Group discussions, collaborative projects and similar activities should be used to cultivate teamwork among medical students. This teaches them to listen attentively, manage team dynamics, and allocate resources effectively, enhancing their CT and problem-solving capabilities. 67 (5) Providing clinical practical experience: Early exposure to clinical practice is crucial in developing students’ analytical and problem-solving skills through firsthand observation and participation in real-life case management. 68 (6) Shifting teachers’ roles: Educators must evolve into mentors and role models for CT, leading by example and inspiring students through their practices and teachings. 69 Collectively, these recommendations for educational reform will empower medical students to address intricate issues they may encounter in their future medical careers, ultimately increasing the quality and safety of healthcare services.

It is worth noting that our questionnaire incorporated many potential entries with high reliability. It mostly also showed differences between the two groups with or without CT disposition in univariate analysis but were not ultimately presented in the regression models. These factors are meaningful for the development of CT but taking into account the simplicity and informativeness of the model, other entries in the model may have represented them. Our model explained more of the variance in CT than regression models from previous studies. 49 70 71

Strengths and limitations

This study has particular strengths. First, the questionnaire for this study was scientific and practice based. The findings of previous studies on personal and educational factors were extensively referenced, and in-depth interviews were also conducted. Second, our study focused on postgraduate medical students and the sample size was relatively large. Postgraduate medical students are the key group for CT development, and the findings obtained among postgraduate medical students are more relevant and better reflect the thinking characteristics of postgraduate medical students. Research from China has considerably enriched the worldwide sample of CT influencing factors. It has been suggested that cultural context strongly influences CT, 72 but previous research on CT has mostly focused on Europe, the USA and Japan. Therefore, researching CT in Chinese populations is a valuable addition to this area. In addition, this study is the first to quantitatively explore the impact of tutor and team on CT disposition. For Chinese postgraduates, tutors and their scientific research teams are the people who have the most contact during their studies. In our previous interviews, educators, tutors and postgraduates all recognised the vital role of tutors in postgraduate education, especially in the cultivation of thinking. Based on interviews and literature extraction, we summarise the specific influence of tutors and teams and present them as numerical indicators to refine the influence of tutors on educational factors to make them more comprehensive and exact.

There are several limitations to our study. First, given the traditional constraints of cross-sectional studies, the findings of this study cannot be used as direct evidence of a causal relationship between potential influences and outcomes. Still, they can provide clues to reveal causal relationships. Second, some influencing factors, such as participation in project submissions, participation in CT courses, attempts at innovation and entrepreneurship, and exchange abroad may need to be revised when measured due to limited educational resources. The lack of opportunity for most students to participate in the projects mentioned above, even if they had the will to do so, may help obscure the correlation between CT and these factors. Our regression models did not include other factors of the same type with higher coverage, such as article writing. This suggests that specific formal factors do not significantly influence CT disposition and that bias may not affect the overall results. In addition, we did not use the CTDI-CV scale. Given the busy workload of postgraduate medical students and the fact that online surveys are challenging to monitor and quality control, to avoid as much as possible the impact of too many questions on the quality of the study and to increase the recall rate, we used a condensed version of the Critical Thinking Scale, which has a greater total explained variance than the CTDI-CV scale and has good reliability and validity.

Conclusions

In conclusion, this study provides a comprehensive scientific assessment of the factors influencing the CT disposition of Chinese medical postgraduates in terms of personal and educational factors. Being curious, completing the scientific research design with reference, asking ‘why’, and having high logical thinking ability among team members were positively associated with CT. Exhaustion and burn-out, inattention, following others’ opinions in decision-making and not allowing to doubt tutors were negatively associated with CT scores. These findings suggest that we pay more attention to factors related to motivation and internal drive in our educational practice, shift from an outcome-focused reward mechanism and focus on motivation maintenance to build students’ CT awareness.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

The research team collected data after obtaining their consent and signatures on the study’s informed consent form. The Ethics Committee of West China Hospital (tertiary), Sichuan University, approved the study in 2021 (Ethics No. 980).

Acknowledgments

The authors want to acknowledge the medical students who participated in this study.

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LW and WC contributed equally.

Contributors LW and WC were involved in designing the study, reviewing the literature, designing the protocol, developing the questionnaire, collecting the data, performing the statistical analysis and preparing the manuscript. TH and W-BH were involved in searching and collecting the data. YW was involved in interpreting the data and critically reviewed the manuscript. YW is responsible for the overall content as the guarantor . All the authors have read and approved the final manuscript.

Funding This study was supported by the Sichuan University Postgraduate Education Reform project (GSSCU2021038).

Competing interests None declared.

Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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The impact of cognitive flexibility on prospective EFL teachers' critical thinking disposition: the mediating role of self-efficacy

• Research Article
• Published: 31 August 2024

Cite this article

• Şenol Orakcı   ORCID: orcid.org/0000-0003-1534-1310 1 &
• Tahmineh Khalili   ORCID: orcid.org/0000-0002-6268-0991 2  

Critical thinking as one of the key skills for success in the 21st-century has been considered by many scholars in teacher education. This study tries to examine the interaction of critical thinking disposition with two other key characteristics of successful teachers: cognitive flexibility and self-efficacy. To this end, a sample of pre-service English as a Foreign Language (EFL) teachers was selected for this study. Based on the findings, a positive and strong relationship between cognitive flexibility and critical thinking disposition, and a positive and robust correlation between self-efficacy and critical thinking disposition were observed. Hence, it can be suggested that teacher-educationists can use this link for designing teacher-training courses with tailored tasks for both in and pre-service teachers. The main contribution of the findings might be beneficial for homogenizing teacher-training courses around the globe with the 21st-century trends. In addition, this line of research can be followed by empirical studies for checking the effectiveness of tailored tasks for provoking teachers’ critical thinking dispositions, cognitive flexibility, and self-efficacy in teaching activities.

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Şenol Orakcı

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Orakcı, Ş., Khalili, T. The impact of cognitive flexibility on prospective EFL teachers' critical thinking disposition: the mediating role of self-efficacy. Cogn Process (2024). https://doi.org/10.1007/s10339-024-01227-8

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Received : 22 March 2024

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DOI : https://doi.org/10.1007/s10339-024-01227-8

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