Journal of Nursing Research h VOL. 18, NO. 2, JUNE 2010
Critical Thinking Competence and Disposition of Clinical Nurses in a Medical Center Rung-Chuang Feng1 & Mei-Jung Chen2 & Mei-Chuan Chen3 & Yu-Chu Pai4* KEY WORDS:
ABSTRACT Background: Critical thinking is essential in nursing practice. Promoting critical thinking competence in clinical nurses is an important way to improve problem solving and decision-making competence to further improve the quality of patient care. However, using an adequate tool to test nurses’ critical thinking competence and disposition may provide the reference criteria for clinical nurse characterization, training planning, and resource allocation for human resource management. Purpose: The purpose of this study was to measure the critical thinking competence and critical thinking disposition of clinical nurses as well as to explore the related factors of critical thinking competence. Methods: Clinical nurses from four different clinical ladders selected from one medical center were stratified randomly. All qualified subjects who submitted valid questionnaires were included in the study. A Taiwan version of the modified WatsonYGlaser Critical Thinking Appraisal and Critical Thinking Disposition Inventory was developed to measure the critical thinking competence and critical thinking disposition of clinical nurses. Validity was evaluated using the professional content test (content validity index = .93). Reliability was assessed with a Cronbach’s alpha coefficient of .85. Data were analyzed using the SPSS for Windows (Version 12.0; SPSS Inc., Chicago, IL). Results: Results showed that competence of interpretation was the highest critical thinking competence factor. Inference was the lowest, and reflective thinking as a critical thinking disposition was more positive. In addition, age, years of nursing experience, and experiences in other hospitals significantly influenced critical thinking competence (p G .05). Factors of age, years of experience, and nurses clinical ladder were shown to affect critical thinking disposition scores. Clinical ladder N4 nurses had the highest scores in both competence and disposition. A significant relationship was found between critical thinking competence and disposition scores, with 29.3% of the variance in critical thinking competence potentially explained by total years of nurse hospital experience. Clinical ladder and age were predictive factors for critical thinking disposition. Commonality was 27.9%. Conclusions and Implications for Practice: Nursing experience and clinical ladders positively affect critical thinking competence and disposition. Issues of critical thinking competence increasingly need to be measured. Therefore, appropriate tools for nursing professions should be further developed and explored for specific areas of practice.
critical thinking competence, critical thinking disposition, clinical nurses.
Introduction In the late 1990s, nursing scholars in the United States, Britain, and Australia started to discuss extensively the importance and influence of critical thinking on the nursing profession. Despite the fact that critical thinking has been considered as a core competence of nursing, many difficulties and issues remain in making critical thinking more prevalent nursing. Definitions of critical thinking are inconsistent (Gordon, 2000), the assessment tool (questionnaire) used to certify critical thinking competence in nurses is of questionable validity (Chau et al., 2001; Stone, Davidson, Evans, & Hansen, 2001), and training programs to develop critical thinking competence in nursing education are neither supported nor appreciated (Adams, Stover, & Whitlow, 1999). Few reports related to critical thinking competence in nursing have been published in Taiwan. Tan (2000) urged that critical thinking competence should be added as the seventh nursing ability to enhance clinical nurse critical thinking competence to improve problem-solving and decision-making capabilities and to improve patient care quality. Numerous studies have targeted topics in nursing education, including teaching strategies (Chen, Chen, Lee, Lee, & Lee, 2006; Tseng et al., 2006) and approaches to evaluating student clinical critical thinking (Su, 2002). However, studies in the area of nurse’s critical thinking competence and disposition are rare. Therefore, it is important 1
RN, MSN, Deputy Director, Department of Nursing, Taipei Veterans General Hospital;
2
RN, MSN, Department of Nursing, Taipei Veterans General Hospital;
3
RN, MSN, Assistant Head Nurse, Department of Nursing, Taipei Veterans General Hospital;
4
RN, MSN, Supervisor, Department of Nursing, Taipei Veterans General Hospital.
Received October 9, 2009 Revised: February 23, 2010 Accepted: March 1, 2010 *Address correspondence to: Yu-Chu Pai, No. 201, Shei-Pai Rd. Sec. 2, Taipei 11217, Taiwan, ROC. Tel: +886 (2) 2871-2121 ext. 2145; Fax: +886 (2) 2875-7649; E-mail:
[email protected]
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to investigate critical thinking competence and better understand the critical thinking competency and disposition for nursing staff at different levels of responsibility.
Aims The purpose of this study was to measure the critical thinking competence and critical thinking disposition of clinical nurses. In addition, the author worked to understand factors of influence related to critical thinking competence and disposition. The correlation between critical thinking competence and disposition was also examined. Study hypotheses included the following: (a) clinical nurses with higher clinical ladder should have better critical thinking competence and disposition, (b) years of nursing experience should influence critical thinking competence and disposition, and (c) critical thinking competency and disposition should be positively correlated.
Literature Review In this era of rapid advances and innovation in medical technology, nurses must be able to use novel thinking patterns to interpret and judge information, to recognize the importance and meaning of nursing care situations, and to make correct judgments in critical clinical situations. Such encapsulates the fundamental principles of critical thinking (Tan, 2000). Nursing staff are expected to use critical thinking competence to make appropriate professional judgments in the face of complicated circumstances. Critical thinking is affected by experience and knowledge gained during nursing practice, which becomes important in relation to the decision-making process, clinical judgment, and professional growth. Critical thinking is a comprehensive clinical judgment-making process that nurses use regularly in their professional practice (ProfettoMcGrath, 2005). Nurses persistently apply critical thinking to processes ranging from assessments to clinical decision making. They prefer to use intuitive and reflective thinking to plan and deliver appropriate nursing responses. Tan (2000) posited that the nursing process is a thinking process that leads novice nurses to analyze and to solve patient problems. With increasing knowledge and experience, nurses should gradually abandon this thinking pattern and develop their intuitive thinking abilities. Hsu (2004) advocated that critical thinking should be applied in the nursing process. In other words, critical thinking is a motivator that drives the nursing process. Critical thinking is highly valued in the current educational systemVespecially in advanced and professional educational systems (Daly, 2001). Therefore, nursing education worldwide should consider critical thinking skills as an important outcome for assessing achievement. Indicators for assessing critical thinking skills involve the four cognitive skills of analysis, inference, generation of alternatives, and evaluation (Daly, 2001). Conclusions made in studies 78
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of critical thinking include the following: (a) Critical thinking is a vital component of successful nursing practice; (b) nursing education efficacy is reflected in critical thinking competence (McCarthy, Schuster, Zehr, & McDougal, 1999); (c) critical thinking correlates with clinical decision making, professional ‘‘nursing cap’’ competence, and the inference norm (Girot, 2000; May, Edell, Butell, Doughty, & Langford, 1999); (d) Researchers should use a qualitative approach to study, to develop, and to assess critical thinking competence as an assessment indicator for nursing education achievement (Haffer & Raingruber, 1998); (e) stimulation can be applied to arouse the critical thinking competence of nursing students; and (f) a specially tailored education strategy that includes problem-based learning, reflective journals, and role modeling may be used to develop effectively student critical thinking competence (Dickerson, 2005; Fonteyn & Cahill, 1998; Price & Price, 2000; Tseng et al., 2006; Williams, 2004). Two nursing education methods, including concept mapping and problem-based learning (Hsu, 2004; Wheeler & Collins, 2003), have previously been shown to enhance critical thinking competence. Yeh and Chen (2005) also reported that interactive videodisc systems improved the critical thinking disposition of students. Whether in terms of basic nursing education or on-thejob training programs, challenges faced by nursing educators include not only the reinforcement of professional knowledge but also the promotion of thinking competence through the application of professional knowledge. Therefore, the evaluation of critical thinking competence of nursing students and clinical nursing staff has become an important issue. In previous studies, nursing experts had applied assessment tools such as critical thinking competence and disposition to evaluate the critical thinking competence of students during a single course or semester (Brunt, 2005). Girot (2000) used the WatsonYGlaser Critical Thinking (WGCT) test to analyze the critical thinking of 82 nursing subjects who were categorized (on the basis of the standing of each on the clinical ladder) into three groups, including novice, clinical staff, and nursing practitioners. Results found (a) no significant differences in critical thinking skills among the groups, (b) students who received professional nursing training in clinical practice had better decision-making competence than students without, and (c) no significant correlation existed between critical thinking competence and development of decision-making competence. Moreover, scholars used critical thinking assessment forms to evaluate nurses, with results varying with the different assessment forms used by researchers. For example, Duphorne and Gunawardena (2005) revealed that critical thinking competence correlated positively with years of work experience and age. Moreover, in area of nursing education, the effectiveness of teaching strategies targeting critical thinking skills and the current state of student clinical critical thinking skills were discussed (Chen et al., 2006; Su, 2002; Tseng et al., 2006). Clinical conference and
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problem-based learning were claimed to correlate positively with critical thinking skills (Su, 2002; Tseng et al., 2006). According to our understanding, no scholarly assessment of critical thinking competence of clinical nurses has yet been published. Taiwan established the ‘‘clinical ladder’’ certification system in 1992 (Chen, Lee, & Chang, 2005). The clinical ladder system is based on Patricia Benner’s (1984) research, which delineated five clinical ladders of expertise in nursing practice on the basis of experiential learning, including novice, advanced beginner, competent, proficient, and expert nurse. Similarly, the clinical ladder system classifies nurses into five clinical ladders, including N (less than 2 months of work experience), N1, N2, N3, and N4. N1 to N4 clinical ladders were differentiated from six indicators of nursing competence including care, management, communication, research, teaching, and continuous self-growth competence. Critical thinking competence is considered the seventh indicator of nursing competence, making it crucial to identify differences among different clinical ladders.
Conceptual Framework The purpose of this study was to identify the critical thinking competence and the disposition of clinical nurses of different clinical ladders (N, N1, N2, N3, and N4). The expectation was that clinical nurses having more years of experience and a higher clinical ladder rating would have a higher score on critical thinking competence and disposition assessment. The theoretical framework guiding this expectation was Patricia Benner’s (1984) novice to expert model. In this study, a novice was defined as a new graduate nurse with less than 2 months of working experience.
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An advanced beginner (N1) performs at a marginally acceptable level. A competent nurse (N2) is able to determine which aspects of a situation are considered more relevant. At the proficient level (N3), a nurse begins to perceive the meaning of a situation through reflection on previous experience and often modifies plans on the basis of changing responses to the event. An expert nurse (N4) has an intuitive grasp of a critical situation and understands deeply what is needed to ensure resolution. The novice to expert framework is the basis for a number of clinical ladders in healthcare and is often used to formalize promotional structures and drive work role competencies (Figure 1).
Methods Subjects A stratified random sampling was adopted in this study. Samples were selected using a two-step process. The 2,300 clinical nurses working at a medical center were each classified at an N1, N2, N3, or N4 level according to clinical ladder system definitions. Once completed, we randomly selected 10% to 15% of the population of each ladder group as our sample population, which totaled 280. The 280 samples were asked to sign informed consent as a condition of participation. Clinical nurses with less than 2 months of work experience (i.e., clinical ladder N) were excluded.
Data Collection Data were collected between January and February 2005 using the modified Taiwan WGCT (Tw-WGCT) Appraisal and the Taiwan Critical Thinking Disposition Inventory
Figure 1. Conceptual framework of critical thinking competence and disposition of clinical nurses in a medical center.
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(TCTDI) questionnaires. The 280 subjects completed these instruments at the same time in a conference room. The instruments were completed in a limited time frame (30Y50 minutes), and 100% was submitted at the end of the period. Eleven were incomplete and invalidated, leaving 269 valid articles for analysis. Approval for the study was obtained from a hospital institutional review board. Informed consent was obtained before data collection.
Instruments Research instruments included a demographic characteristic sheet, a modified Tw-WGCT, and the TCTDI. The WGCT Appraisal (2002) is designed to test a respondent’s logical critical thinking competence. The WGCT originally consists of five domains and a total of 80 items, including inference, recognition of assumptions, deduction, interpretation, and evaluation of arguments. Because some questions on the WGCT were not relevant to Taiwan culture, researchers modified and revised the questionnaire as the Taiwanese version WGCT (Tw-WGCT). Researchers and clinical nursing experts assessed each of the five original WGCT domains and 80 original items. After internal discussions, The Tw-WGCT was pared to a total of 42 questions. Expert validity (content validity index [CVI]) of content, availability, and clarity was scored using a 5-point Likert scale, and questions that received an average score less than 4 were eliminated. Two question were removed, leaving 40 questions total in the final Tw-WGCT version. The instrument earned a CVI of .84 and a Cronbach’s alpha of .85. The final Tw-WGCT contained 40 questions, with each answer worth 2.5 points each. The total score was 100 points. Inference refers to the true or false inference of provided information. Seven questions were included, which were answered as correct, partially correct, not sure, partially incorrect, or incorrect (total possible score = 17.5). Recognition of assumptions refers to the verification of the assumption of the recognized subject, and eight questions were included (total possible score = 20). Eight questions also tested deductive powers, which refers to the ability to provide a correct conclusion on the basis of information and evidence (total possible score = 20). Eight questions were included for interpretation, which refers to judgment of logical analysis under reasonable suspicions, assuming that the hypothesized question was true (total possible score = 20). Answers to the three parts recognition, deduction, and interpretation described earlier were to be shown as either correct or incorrect. Evaluation of arguments refers to differentiation between strong and weak points of an argument (total possible score = 22.5). Nine questions were included with answers of either ‘‘strong’’ or ‘‘weak.’’ The TCTDI was prepared on the basis of a review of the literature (Yeh, 1998) and modified by the research group. TCTDI represents a subjective measurement scale that assesses underlying critical thinking. Ten questions 80
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were used, with question domains including inquisitiveness, system activity analyticity, open-mindedness, and reflective thinking. A 5-point Likert scale was used for scoring, with 1 = unable to accomplish and 5 = completely accomplished.
Validity and Reliability The original WGCT contains five domains with a total of 80 items, all of which were assessed by our researchers. Ten of the 80 items were excluded because of significant cultural difference between Taiwan and United States. Content of the remaining 70 items was assessed by five clinical nursing experts. Items with a CVI greater than .80 were retained, and others were deleted. The CVI of the Tw-WGCT was .84, with reliability assessed by Cronbach’s alpha coefficient ranging from .84 to .90. The alpha value coefficient was .88 in the domain of inference, .90 in recognition assumptions, .84 in deduction, .86 in interpretation, and .89 in evaluation of arguments. The Cronbach’s alpha coefficient was .85 in the TCTDI. Item difficulty and item discrimination of Tw-WGCT questions were also assessed. A pilot study was conducted with 86 clinical nurses who fulfilled random selection criteria to analyze item difficulty (P value) and discrimination (D value). Results revealed P values in the range of .11 to .98 (mean = 0.644). P values within the range of .20 to .80 are acceptable. D values were in the range of .4 to .56 (mean = 0.217). Items with D values greater than .40 were considered excellent, .30 to .39 were considered good, and .20 to .29 as well as those less than .20 were all considered unacceptable. The above results indicate that discrimination and difficulty of the Tw-WGCT were in an acceptable range.
Data Analysis Descriptive statistics were calculated using the SPSS for Windows (Version 12.0; SPSS Inc., Chicago, IL). Descriptive data were available for the entire sample and included age, education level, professional nursing experience, other working experience, and clinical ladder rank. The 11 clinical nurses (3.9%) who did not complete the questionnaires fully were excluded from analysis. A chisquare test was used to analyze factors related to critical thinking competence and disposition. ANOVA and Scheffe tests were used to understand correlations between critical thinking competence and dispositions.
Results Subject Demographic Characteristics A total of 269 valid questionnaires were collected from the study. The average age of subjects was 32.5 years (Table 1), 154 (57.2%) held baccalaureate degree or above, 90 (33.5%) had worked less than 5 years, and 53.2% had no work experience in other hospitals. Fifty-seven subjects
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TABLE 1.
Subject Demographic Characteristics (N = 269) Variable
n
%
Age (years) G25 26Y30 31Y35 36Y40 941
62 61 69 35 42
23.0 22.7 25.7 13.0 15.6
Education level Junior college Baccalaureate
115 154
42.8 57.2
Marriage Single Married
141 128
52.4 47.6
Working experience (years) G2 3Y5 6Y8 9Y11 912
30 60 38 38 103
11.2 22.3 14.1 14.1 38.3
Other hospital experience None Yes
143 126
53.2 46.8
Clinical ladder N1 N2 N3 N4
57 152 37 23
21.2 56.4 13.8 8.6
M
SD
32.48
7.39
10.29
(21.2%) were classified as N1, 152 (56.4%) as N2, 37 (13.8%) as N3, and 23 (8.6%) as N4.
Clinical Nurse Critical Thinking Competence and Disposition Critical thinking competence test results (Figure 2) found an average score for inference competence of 7.0 (35% right answers), for recognition assumptions competence of
Average Age
Working Experience
35.33 30.30
13.67 7.76
25.12 25.10 34.59 34.13
2.71 12.34 11.87 12.86
7.88
11.5 (57.6% right answers), for deduction competence of 13.16 (65.8% right answers), for interpretation competence of 15.6 (78.1% right answers), and for arguments competence of 14.5 (72.6% right answers). The cumulative average score for critical thinking competence was 61.8. From these results, subjects were found to rank highest in interpretation and lowest in inference. Classified by clinical ladder rank, N4 nurses had the highest scores in critical thinking competence, whereas N1 nurses had better
Figure 2. Comparison of critical thinking competence among different nurse clinical ladder levels.
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Figure 3. Comparison of critical thinking disposition among different nurse clinical ladder levels.
scores than either N2 or N3 nurses in inference, recognition assumptions, and evaluation of arguments competencies. TCTDI consisted of inquisitiveness, systematicity and analyticity, open-mindedness, and reflective thinking categories. Results found (Figure 3) that subjects scored the highest (M = 3.84, SD = 0.61) in reflective thinking and lowest in inquisitiveness (M = 3.70, SD = 0.59). Overall, critical thinking in subjects was shown to be only partially developed.
Association Between Demographic Characteristics and Critical Thinking Competence Statistical analysis of nurse personal characteristics and critical thinking competence using chi-square (Table 2) indicated significant differences between deduction and interpretation of critical thinking competence and nursing
TABLE 2.
Comparison Between Demographic Characteristics and Critical Thinking Competence (N = 269) Critical Thinking Competence (# 2)
Item
n
%
Age (years) 25 or younger 26Y30 31Y35 36 or older
62 61 69 77
23.0 22.7 25.7 28.6
Overall Critical Recognition of Evaluation of Thinking Inference Assumptions Deduction Interpretation Arguments Competence 14.30
14.30
32.69*
25.12*
24.98
56.22
Education level Baccalaureate or above 253 94.1 Junior college 16 5.9
8.76
3.03
4.27
1.79
4.43
13.58
Marital status Single Married
1.01
8.96
8.35
13.09*
5.41
25.78
142 52.8 127 47.0
Working experience 5 years or younger 6Y10 years 11 years or older
9.45
30.21**
34.30*
8.41
15.42
43.18
90 33.5 56 20.8 123 45.7
Other working experience No Yes
3.40
11.17
15.12*
8.99
18.07*
36.30**
143 53.2 126 46.8
Clinical ladder N1 N2 N3 N4
21.44
18.71
23.95
25.58*
18.28
50.01
57 21.2 152 56.4 37 13.8 23 8.6
*p G .05. **p G .01.
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staff age (# 2 = 32.69 and 25.12, respectively, p G .05). Comparative analysis revealed interpretation scores of critical thinking competence of subjects between ages 31 and 35 years as significantly higher than that of those aged older than 36 years or younger than 30 years. Work experience was an important characteristic, with years of work experience showing significant differences with recognition of assumptions (# 2 = 30.21, p G.01) and deduction (# 2 = 34.30, p G .05). Subjects with work experience in other hospitals showed better capability in evaluation of arguments (# 2 = 18.07, p G .05) and overall critical thinking competence (# 2 = 36.30, p G .01). The interpretation of critical thinking competence of clinical ladder of nurses also represented a significant difference (# 2 = 25.58, p G .05). No significant difference was identified among different education levels.
Factors Affecting the Critical Thinking Disposition of the Clinical Nurse Chi-square results (Table 3) as well as analysis of personal characteristics and self-evaluation of critical thinking
disposition of nurses indicated no significant difference between education level and work experience in other hospitals. Differences in scores for inquisitiveness (# 2 = 33.49, p G .001), systematic analyticity (# 2 = 64.65, p G .01), openmindedness (# 2 = 35.82, p G .01), reflective thinking (# 2 = 44.01, p G.01), and overall critical thinking disposition (# 2 = 29.06, p G .01) were all significantly associated with age. Work experience factors were found to differ significantly at all critical thinking disposition aspects (# 2 = 28.19, p G .001). Nurse clinical level was related to the highest score among four clinical levels (F = 7.53, p G .001).
Correlations Between Critical Thinking Competence and Critical Thinking Disposition Subjects were divided into the following three groups on the basis of the TCTDI score: low-score group (e3), middlescore group (3.1 to 4.0), and high-score group (Q4.1). Results (Table 4) indicated that on the basis of the critical thinking disposition score analyzed by ANOVA, a significant correlation exists between recognitions assumptions
TABLE 3.
Relationships Between Subject Characteristics and Critical Thinking Dispositions (N = 269) Critical Thinking Disposition (# 2)
Item
n
%
Age (years) 25 or younger 26Y30 31Y35 36 or older
62 61 69 77
23.0 22.7 25.7 28.6
Education level Baccalaureate or above Junior college
253 16
94.1 5.9
Marital status Single Married
142 127
52.8 47.2
Working experience 5 years or younger 6Y10 years 11 years or older
90 56 123
33.5 20.8 45.7
Other working experience No Yes Clinical ladder N1 N2 N3 N4
Systematicity/ Reflective Inquisitiveness Analyticity Open-mindedness Thinking 33.49***
64.65**
35.82**
44.01**
29.06**
7.12
7.65
9.23
3.55
12.51**
22.88*
11.26
12.81
12.83**
24.44***
46.93**
24.07*
25.22*
28.19***
8.90
5.17
1.36
1.38
49.87
18.54
34.37*
22.63**
28.26
143 126
1.19 53.2 46.8 30.57***
57 152 37 23
Overall Critical Thinking Disposition
21.2 56.5 13.8 8.6
*p G .05. **p G .01. ***p G .001.
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TABLE 4.
Correlations Between Critical Thinking Competence and Disposition (N = 269) Critical Thinking Disposition 2 3.1Y4.0 ° Scores (n = 188)
° 1 e3 Scores (n = 19) Variable Inference Recognition of assumptions Deduction Interpretation Evaluation of arguments Overall critical thinking competence
° 3 Q 4.1 Scores (n = 62)
M
SD
M
SD
M
SD
6.84 10.13 12.24 14.47 13.68 11.47
2.87 3.58 3.43 3.29 3.85 1.94
7.05 11.81 13.38 15.72 14.60 12.51
3.29 2.96 3.46 2.72 3.84 2.81
6.90 11.05 12.78 15.65 14.52 12.18
3.09 2.85 2.83 2.97 3.70 1.55
Scheffe Method 29391
29391
F 0.08 3.72* 1.53 1.72 0.05 3.45*
*p G .05.
and overall critical thinking competence. The middle-score group had the highest recognition assumptions (F = 3.72, p G .05) as well as in overall critical thinking competence (F = 3.45, p G .05). Stepwise regression analysis was used to test the variables of age, educational level, years of work experience, and clinical ladder. Results indicated that work experience in other hospitals and years of work experience (F = 12.15, p G .01) can predict nurses’ critical thinking competence, with an explained variance of 29.3%. Clinical ladder and age were predictive factors of critical thinking disposition (F = 9.01, p G .001), with an explained variance of 27.9%.
Discussion and Conclusions Study findings indicated that age, years of work experience, and experience in other hospitals were factors significantly related to critical thinking competence. The latter two were consistent with a report of Duphorne and Gunawardena (2005), which indicated a positive correlation between critical thinking competence and years of work experience as well as age. In this study, the subjects older than 36 years had less interpretation competence than those between 31 and 35 years. This was inconsistent with the findings of Duphorne and Gunawardena. Findings also differed from reports by Hicks, Merritt, and Elstein (2003) and Howenstein, Bilodeau, Brogna, and Good (1996), who indicated a negative correlation between age and years of work experience. In the above research studies, researchers pointed out that nurses with more work experience and those who were older had lower critical thinking competence. They concluded that nurses with more years of work experience and who were older may be categorized as intuitional experts in the working environment because of their proficiency and wealth of experience. As a result, these nurses use and practice critical thinking competence to a lesser extent and therefore scored lower in this facet. 84
Although age and work experience increased together with years of work, clinical ladder does not necessarily do so because this system requires individual effort, relevant training courses, case reports, report writing, teaching, and other inputs to rise upward in the ladder. Promotion upward does not come simply with age or length of work experience. Many nurses remain at the N2 level for years without promotion. It was recommended that practical training, specialist advanced and central curricula, teaching, case reports, administrative projects, intensive care, clinical nurse specialist, and other training courses be adopted using Panel’s report or Problem-Based Learning (PBL) teaching method to enhance nurse critical thinking skills. Future studies may explore this area. Beeken (1997) found a significant correlation between nurse education level and critical thinking competence. However, no significant correlation was shown in this study, which is probably due to different nursing preparation models used (e.g., vocational and academic models). This finding differed from the research of Fero, Witsberger, Wesmiller, Zullo, and Hoffman (2009), who found that nurses with a baccalaureate or associate level degree fared better on the assessment than experienced nurses with diploma level preparation. Results of the study revealed that the factors of nurse age, years of work experience, and clinical ladder were associated with critical thinking disposition. This was consistent with the study of Fero et al. (2009). Fero et al. identified the critical thinking learning needs of new and experienced nurses. The Performance-Based Development System was used to measure nurse performance in recognizing patient condition changes. Their results showed that associate and baccalaureate nurses were more likely to meet expectations as years of experience increased and that new graduates were less likely to meet expectations compared with nurses who had more than 10 years of experience. Older nurses with more years of work experience and a clinical ladder of N4 had a higher critical thinking disposition, which may be due to their better motivation,
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demand, and awareness of critical thinking themselves. A significant correlation was also shown in this study between deduction, interpretation, evaluation of arguments, and overall critical thinking as well as critical thinking disposition. Results were similar to the results of Stanovich and West (1997), who believed that personal reasoning and judgment can be affected by critical thinking disposition. Stepwise regression analysis for predictive factors showed that working experience in other hospitals and years of work experience can help predict critical thinking competence and that clinical ladder and age can help predict critical thinking disposition. Nursing scholars have considered critical thinking competence as an achievement of advanced and professional education (Daly, 2001). It is also important that educators in general want to develop such in students. Teachers of nursing education consider training toward developing critical thinking competence as an important part of the curriculum. Taiwan nursing scholars (Tan, 2000) pointed out the importance of critical thinking competence for nursing and regarded it as the seventh nursing competence. However, no appropriate study tool has been available in Taiwan to help assess the critical thinking competence of clinical nurses. The Tw-WGCT and the TCTDI were tested and adopted to the study of nurses’ critical thinking competence and disposition. Results indicate that age, years of work experience, and working experience in other hospitals are related to critical thinking competence. Age, years of work experience, and clinical ladder correlated significantly with critical thinking disposition. Nurses with higher clinical ladder have better attitudes toward critical thinking disposition. However, clinical ladders had no significant correlation with critical thinking competence scores in graduate school entrance examinations. This indicates that, despite vigorous motivation and awareness of nurses toward critical thinking, nurses still lack these skills. Thorough consideration should be given by teachers of nursing education in clinics and schools to introduce teaching strategies, training, and skills of critical thinking during basic nursing as well as on-the-job education. Finally, the three hypotheses of this study were partially proved: (a) Clinical nurses with higher clinical ladder had significantly better in critical thinking disposition, (b) the critical thinking disposition of clinical nurses were significantly influenced by years of nursing experience, and (c) critical thinking competence and disposition were positively correlated. Research results suggest that the application of a 2-year nursing practical training program, with small class discussion or PBL teaching method, may be beneficial to promoting critical thinking. It may be used in various training programs, including specialties course, central courses, intensive care nursing training, administrative projects, quality control circle, or research. These training programs may enhance the critical thinking skills, the ability of clinical nurses inference, and the argumentative nature of ideas deduction.
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Limitations and Recommendations This study was conducted at only one medical center, restricting its generalization to other medical institutions. Future studies should be conducted to compare an experimental group and a control group as an index for advanced curriculum design and learning achievements. Moreover, the Tw-WGCT for nurses was prepared here for the first time. Sample collection may be expanded in the future. Results also indicated little correlation between nurses’ clinical ladder and critical thinking competence. We recommend that specialty and general nursing training programs with critical thinking strategies should be added in hospitals. Critical thinking strategies should include problem-based learning, tutorial group discussion, role-play, and concept mapping. Critical thinking competence testing should be done before nurse recruitment and after clinical practice to examine the effects of training programs. The critical thinking curriculum may also be used in candidate interview processes to support development of critical thinking competence and to improve nursing staff problem-solving capabilities. Older clinical nurses have better critical thinking disposition but not necessarily critical thinking competence. Therefore, regular cross-training programs for clinical nurses are recommended.
Acknowledgments The authors thank the nurses who participated in this study. This research was supported by the Taipei Veterans General Hospital (research project no. 92-512).
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護理人員之批判性思考能力與意念
Journal of Nursing Research
VOL. 18, NO. 2, JUNE 2010
探討某醫學中心臨床護理人員之批判性思考能力與意念 馮容莊1æ陳美蓉2æ陳美娟3æ白玉珠4*
背 景
批判性思考能力是護理臨床實務重要技能，增進護理人員批判性思考能力是增進問題 解決、決策能力和照護品質管道之一，而選用適當的工具，檢測臨床護理人員的批判 思考能力與意向，可做為人力資源管理者對資源的內涵與素質，培育與分配應用的參 考指標。
目 的
本研究目的為探討某醫學中心不同級階護理人員之批判性思考能力及意向。
方 法
本研究為調查性研究設計，採分層隨機取樣，以某醫學中心N1至N4四種級階之護理人 員為研究對象，研究工具為批判性思考能力及意念量表，研究工具採專家效度，CVI 值.93，信度Cronbach’s α值為 .85，資料以SPSS 12.0 統計軟體分析。
結 果
研究顯示，臨床護理人員在批判性思考五項次能力中以詮釋能力最佳，推論能力最 差；批判性思考意念方面以反省思考性意念最佳，追根究底性意念較差；護理人員的 年齡、工作年資及其他醫院經驗和批判性思考能力相關（p < .05）；年齡、工作年資 及級階則與批判性思考意念有關；臨床級階N4護理人員具較佳的批判性思考能力與意 念；且批判性思考能力及其意向有正相關；其他醫院經驗及工作年資可預測護理人員 批判思考能力之解釋量為29.3%，臨床級階及年齡可預測批判思考意念27.9%。
結 論
護理人員在工作經驗、年資、進階制度下，對批判性思考能力與意念有正向的影響， 亦有相當的預測性解釋量。另本研究針對臨床護理人員設計之批判性思考能力測量工 具，亦可提供未來研究者繼續檢驗與修訂。
關鍵詞：批判性思考能力、批判性思考意念、臨床護理人員。
1
台北榮民總醫院護理部副主任 2台北榮民總醫院護理部護理師 3台北榮民總醫院護理部副護理長 4台北榮 民總醫院護理部督導長 受文日期：98年10月9日 修改日期：99年2月23日 接受刊載：99年3月1日 *通訊作者地址：白玉珠 11217台北市石牌路二段201號
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