ReviewEvaluation of tools used to measure critical thinking development in nursing and midwifery undergraduate students: A systematic review
Introduction
The development of critical thinking (CT) skills has long been recognised as a priority in tertiary education. The landmark Delphi study by the American Philosophical Association (APA) produced an international expert consensus definition of critical thinking. Critical thinking is described as purposeful, self-regulatory judgement which results in interpretation, analysis, evaluation, and inference (Facione, 1990). Critical thinkers consider events or issues in a controlled, purposeful, focussed and conscious way (Mong-Chue, 2000).
Critical thinking is a crucial skill for nurses and midwives who, like other healthcare clinicians, need to effectively manage complex care situations in fast paced environments that demand increasing accountability (Mong-Chue, 2000, Muoni, 2012, Pucer et al., 2014). The processes of clinical decision-making and problem-solving require advanced CT skills (Muoni, 2012). CT is also essential for clinicians to critique and apply evidence, especially in situations where uncertainty regarding ‘best practice’ remains unclear (Scholes et al., 2012).
Although the development of students' higher order cognitive abilities is recognised as important in nursing and midwifery education, the measurement of these vital skills is inconsistent or neglected (Walsh and Seldomridge, 2006). The measurement of CT is important to identify deficits and developments in students' cognitive capacities as well as demonstrate the effectiveness of teaching strategies. The purpose of this systematic review was to evaluate tools used to measure CT development in nursing and midwifery undergraduate students.
A search of major databases CINAHL, Ovid Medline, ERIC, Informit, PsycINFO and Scopus, was conducted in September 2014. The search was limited to English language articles published in peer reviewed journals during 2001–2014. This period was chosen as the results of a Delphi study to define CT in nursing was published in 2000 (Scheffer and Rubenfeld, 2000). Scholarly work about CT in nursing would have further developed since that publication.
The inclusion criteria were original research studies that utilised experimental designs to assess CT development in undergraduate nursing and/or midwifery students. Papers were excluded if CT was not specifically measured on more than one occasion; the sample was post-graduate students, full text was not available in English, discussion papers that did not involve original research, or did not use an experimental design.
Five search terms were entered into the databases with the article title, abstract and body all searched. The search terms used were as follows:
- 1.
“critical thinking” AND midwife*;
- 2.
“critical thinking” AND midwife* AND measure*;
- 3.
“critical thinking” AND midwife* AND evaluat*;
- 4.
“critical thinking” AND students, nursing AND measure*; and
- 5.
“critical thinking” AND students, nursing AND evaluat*.
The search was conducted sequentially using the search engines and search terms. An initial search, filtering for date, language and source of publication, identified 1191 papers. Once duplicates were excluded, each identified citation was reviewed using the inclusion and exclusion criteria and filtered through three screening levels i.e., (i) title screening; (ii) title and abstract screening; and (iii) full-text screening. Articles that were not relevant or did not meet the inclusion criteria were discarded. Finally 35 papers were included. No papers involving midwifery undergraduate students met the inclusion criteria and hence the samples in all of the papers are undergraduate nursing students.
Twenty-one (60%) of the 34 studies reviewed utilised one of four standardised commercially available measures of critical thinking. These were the California CT Disposition Inventory (10 studies), the California CT Skills Test (5 studies), the Watson–Glaser CT Appraisal (3 studies) and Health Services Reasoning Test (3 studies). Two studies used both the Californian CT Skills Test and California CT Disposition Inventory. All of these tools have reported psychometric reliability and validity allowing comparison across settings, disciplines, and time. Relatively few of the included studies (9 out of 21) undertook a reliability analysis of the tool for their current context. There were twelve other measurement tools utilised in the studies reviewed. See Table 1 for a comparison of tools employed in the studies reviewed.
Included studies were listed in a summary table (Table 2) during the search. The studies are presented in groups according to the tool utilised. After the initial search all articles identified in subsequent searches were checked against articles in the summary table and duplicates excluded. Each article was also entered into a reference management database (endnote) including the search term and engine used to locate each article. A quality appraisal process was performed using the Critical Appraisal Skills Programme (CASP) tool (CASP, 2013) and one article of poor quality was excluded. The excluded study is identified in the summary table. Following the quality appraisal process 34 papers were selected for review.
Section snippets
Results
All 34 studies measured CT skill development or change, either following completion of a specific educational intervention or an undergraduate nursing programme. Most studies were conducted in Western countries namely USA (n = 20), United Kingdom (n = 1), others were conducted in Taiwan (n = 4), Korea (n = 3), China (n = 2), Iran (n = 1), Hong Kong (n = 2), Turkey (n = 1), and Slovenia (n = 1).
Discussion
This review included studies from 9 different countries using 16 different tools. This section discusses the findings in relation to the reliability, validity and factor domains of the standardised tools and then examines the non-standardised tools.
The reliability of tools used to measure CT in nursing practice was not reported consistently and varied considerably. Only two authors of new tools reported on internal stability using a test–retest, and at best, split-half reliability for internal
Conclusion
There was limited reporting of the reliability of tools in the included studies. Overall there was relatively little emphasis placed on validity of newly developed tools. Inconsistent results were found in studies using standardised tools, placing doubt of the reliability of these tools in the nursing context. On examination of the domain concepts construct validity was questionable with several non-standardised tools used.
Nursing and midwifery education needs to prepare graduates to work
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