Relation between Nurses’ Critical Thinking Disposition and Their Professional Patient Relationship

Background: Critical thinking is a fundamental concept in nursing education and training that helps nurses adapt to changing working environments and circumstances. Nurses require strong critical thinking and reasoning skills to effectively meet the caring needs of patients and their families and collaborate with other healthcare professionals. Objective: to determine the relation between nurses’ critical thinking disposition and their professional patient relationship. Setting: The study was conducted at Alamria general hospital in Alexandria governorate which affiliated to Ministry of Health. Subjects: The subjects of this study comprised of 135 nurses who represent hospital nursing staff (N=208) who worked in Alamria hospital during year 2021-2022. Tools: Two tools were used for data collection. Tool I: California Critical Thinking Disposition Inventory (CCTDI to assess Critical Thinking Disposition. Tool II: Professional Nurse-Patient Relationship Observation Checklist (PNPROC) to assess nurses actual practice of professional nurse-patient relationship. Results: there were statistical significant difference between all items of critical thinking dispositions and professional nurse patient relationship tool Conclusion: Critical thinking disposition is essential to nursing. Critical thinking disposition has a correlation with critical thinking skills. Recommendations: Nurses should attend workshops to enhance critical thinking skills. Modifying regulations and policies regarding nurses’ job descriptions will improve nurses' critical thinking disposition .


Introduction
Nurses are essential members of the healthcare team who play a crucial role in delivering high-quality patient care.Nurses are responsible for assessing, planning, implementing, and evaluating patient care.They collaborate with other healthcare professionals, such as physicians, pharmacists, and therapists, to provide comprehensive care that meets the individual needs of each patient.(Cui et al., 2018) In health care settings, nurses must improve their critical thinking, problem-solving, and decisionmaking abilities because they face complex challenges. .(Elsayed et al., 2020&Ludin, 2018).Critical thinking ( CT ) is an important part of nursing education and essential to th field.It is a necessary component of professional nursing practice because it enables them to comprehend the significance of patient data in addition to identifying and diagnosing patient issues.This enables them to resolve issues in challenging circumstances, make clinical decisions, and communicate effectively and accurately in order to ensure positive outcomes for patients.As a result, critical thinking is a crucial part of professional nursing practise, and it has been argued that critical thinking teaching should be included in the nursing curriculum from the beginning,.( Majumder et al., 2019& Meherali et al., 2015) Critical thinking (CT) has many definitions, the American Philosophical Association gave the definition of CT as follows: "Purposeful, selfregulatory judgement that uses cognitive tools such as interpretation, analysis, evaluation, inference, and explanation of the evidential, conceptual, methodological, criteriological, or contextual considerations upon which judgement is based."Moreover , critical thinking in nursing was mentioned by Kataoka-Yahiro and Saylor (1994) as "reflective and rational thinking about nursing challenges without a single answer.thinking about choosing what to believe and do.. (Futami et.al, 2020;Lorencová et al., 2019) Critical thinking has two dimensions: critical thinking skills and subskills and critical thinking dispositions Regarding critical thinking skills, it is a cognitive skill that relates to nurses' capability to participate in activities.The American Philosophical Association's (APA) Delphi-derived framework of critical thinking consisted of six core skills and their subskills These skills include interpretation, analysis, inference, evaluation, explanation, and selfregulation.(Khavanin et al., 2020;Mslm et al., 2020).
In addition to these skills, the Delphi panel identified an additional dimension to critical thinking in the form of dispositions.This understanding was key for panelists, as they noted that critical thinking skills needed to be paired with complementary dispositions to be 'exercised appropriately and achieve the goal of being a well-rounded critical thinker (Abrami et al., 2015).Critical thinking cannot exist without these attitudes; it would not be possible.A person's critical thinking dispositions (CTD) reveal how they feel about using that ability.Critical thinking abilities and dispositions have a strong positive link with each other.. (Chen et.al, 2020;Dehghanzadeh & Jafaraghaee, 2018).
Critical thinking disposition (CTD) has many definitions.According to Facione (2000), CTD is the ongoing internal motivation to solve problems and is the persistent internal urge to approach issues and make judgements.(Ansori et al., 2018).Ricketts (2003) defined it as "the predisposed attitude one naturally exhibits concerning critical thinking " (Carlos, 2014) Additionally, Profetto (2003) described a critical thinking disposition as a quality or mental habit that is ingrained in one's ideas or behaviours in order to successfully solve issues and arrive at judgements.(Fitriani et al., 2018);moreover, Facione (2007)  of critical thinking dispositions that are culturally sensitive.On the other hand inquisitiveness, openmindedness, and "truth-seeking," regarded as the motivation elements of critical thinking dispositions.Critical thinking ability is assumed to be influenced by learning motivation.Maturity and critical thinking self-confidence are the personality traits of a critical thinking disposition.(Ghadi et al., 2015).
The nursing staff is the backbone of the caring profession, and establishing meaningful relationships with their patient is crucial element of their role.The nursepatient relationship is widely regarded as the fundamental basis of nursing care, and it provides the framework within which nurses carry out their practice.(Hartley et al., 2020).The nursing relationship has been defined by Peplau (1990) as an important therapeutic interaction that works collaboratively with other human processes to promote health and well-being for individuals and communities.(Hartley et al., 2020a;Sharifi et al., 2016).Gordon (2006) envisions the nurse-patient relationship (NPR) as a professional, therapeutic relationship that is developed to satisfy the patient's needs and health outcomes, to protect their safety, and to support them as they work towards recovery or a peaceful death (Strands & Bondas, 2018).
The professional nurse-patient relationship is a relational process where the nurse is aware of and supports the uniqueness of the patient.the nurse builds and sustains this professional relationship by utilising her nursing expertise, caring attitudes, and applying nursing knowledge and skills.(Molin et al., 2016).The College of Nurses of Ontario (2019) defined it as a professional, therapeutic relationship developed to assist nurses in organizing , implementing , and evaluating nursing care intervention that meets patients' health needs (Feo et al., 2021) Many studies argue that professional nursepatient relationships are a cornerstone of quality health care and have positive correlations with the health of patients, increased recovery rates, a sense of safety and protection, improved levels of patient satisfaction, and greater adherence to treatment options.A good nurse-patient relationship reduces the days of hospital stay and improves the quality and satisfaction of both (Feo et al., 2020;Vujani et al., 2020).The Fundamentals of Care Framework (Kitson et al. 2013) providde a useful approach for building professional relationships with patients, based on three critical dimensions that are essential for delivering high-quality fundamental care: the nurse-patient relationship; addressing diverse fundamental needs; and creating a supportive context to achieve these aims.A positive and trusting nurse-patient relationship is the basis for the delivery of fundamental care and forms the core of the framework.
Regardless of the context, length of interaction, or whether a nurse is the primary or secondary care provider, all care in nursing practise recognises two basic principles.Human communication is the first fundamental concept, while professional rules of ethics are the second fundamental principle.Regarding human communication, it is a basic pillar of any type of relationship and must include trust, respect, focus, anticipation, discovery of the patient, professional intimacy, empathy, power, and evaluation (Kitson et al., 2013).
After a literature review, it can be emphasized that nurses are required to provide effective and safe care in a complex relationship of critical thinking.Therefore, the purpose of this study is to determine the relationship between nurses' critical thinking disposition and their professional patient relationship.

Aims of the Study
The aim of the study is to determine the relation between nurses' critical thinking disposition and their professional patient relationship.

Research question
What are the levels of nurses' critical thinking disposition?What are the levels of professional nursepatient relationship?Is there a relation between nurses' critical thinking disposition and their professional patient relationship?Materials and Method Materials Design: A Descriptive correlation research design was used to conduct this study .

Setting:
The This tool was developed by Facione & Facione (1992).It was adopted by the researcher to assess the nurses' dispositions toward critical thinking.It consisted of 75 items divided into seven dispositional characteristics, namely; truth seeking (12 items), open mindedness (12 items), analyticity (11 items), systematicity (11 items), self-confidence (9 items), inquisitiveness (10 items), and maturity (10 items).It was translated into Arabic Scoring system: It is a Likert scale of 5 points ranging from strongly agree =5, agree =4, neutrally =3, disagree =2, strongly disagree =1.For the negative items the score reversed .The tool had eight scores: the seven subscale score and the overall score.The overall score of the tool ranged from 70 to 420 which interpreted as following; 420 to 280 had positive disposition.279 to 210 had ambivalence toward disposition, below 210 had a negative disposition regarding critical thinking.The total score was 138 which interpreted as following; 80% to 100% had very good professional nurse patient relationship 60% to 79% had good professional nurse patient relation.less than 60% had poor nurse patient relationship.Method A written permission to conduct the study was obtained from the Research Ethics Committee at the Faculty of Nursing, Alexandria University An official permission was obtained from Dean of faculty of nursing and the manager of Alamria hospital to collect the data .Tool I was translated into Arabic by the researcher.Tools' content validity were tested by a jury of 5 experts in the related field, for relevance, clarity, accuracy and translation language issues.The recommendation made by the jury members implemented.According to jury opinion, A pilot study carried out on 10% of sample size (13), to ensure the clarity and feasibility of the tools, they excluded from the study sample.The tools' reliability were tested using Cronbach's Alpha test, and all study tools were reliable The tool's I reliability was tested using the Cronbach alpha test, and it was reliable (0.926).The tool's II reliability was tested using the Cronbach alpha test, and it was reliable (0.936).Nurses were selected randomly and proportionally from each department according to their educational level.Data collection were carried out at Alamria general hospital in Alexandria affiliated to Ministry of Health Data collected over period of one month from 30-5-2022 untill 30-6-2022 Tool I was distributed to every nurse participated in research in their break for (20 -30) minutes and they asked to complete it by self-reporting and return it back to the researcher.Tool II was applied by the researcher through concealed observation for the selected nurses.Written consent was obtained from sample nurses to be observed for their professional relationship with patient.

Ethical considerations
• Written informed consent for observational check list was obtained from nurses for their participation after explanation of the study purpose.
• Written witness consent was obtained from the hospital head nurse.• Anonymity and confidentiality of data was assured.• The subject's voluntary participation and the right to withdraw at any time from the study was assured.

Statistical Analysis
Data were fed to the computer and analyzed using IBM SPSS software package version 20.0.(Armonk, NY: IBM Corp.).The Kolmogorov-Smirnov test was used to verify the normality of the distribution.Quantitative data were described using range (minimum and maximum), mean, standard deviation, and median.The significance of the obtained results was judged at the 5% level.

Table (1):
The table shows the distribution of nurses according to their socio demographic data.It was found that, less than half of nurses 40.7 %, in the study had from 30 to < 40 years old, while more than three quarters of them 85.2% were females.Also about three quarters of them 74.1% were married and about two thirds of nurses 62.2% were technical nursing.Furthermore, 23.7% of nurses were working in ICU and more than one third 31.9% had from 5 to 10 years of experience.The table shows a statistically significant positive correlations between nurses critical thinking disposition and professional nursepatient relationship as p < (0.001) related to all items of both tools.

Discussion
Critical thinking is generally linked with the professional nurse patient relationship, which is crucial for patients, contributing to positive care experiences and outcomes.Establishing a professional relationship with patients was identified as an important facet of the nurse's role and as a basis for continued care and treatment.So it was important to study levels of professional nurse-patient relationship (Kwame & Petrucka2021)

Regarding critical thinking disposition
The findings of the current study revealed that the overall critical thinking disposition was ambivalent among the study subjects.Inquisitiveness, analyticality, and self-confidence were the highest dimensions of the nurses' critical thinking disposition inventory.On the other hand, maturity, truthseeking, open-mindedness, and systematicity level were the lowest dimensions of the nurses' critical thinking disposition inventory.
This result came in congruence with the study of Elsayed et al. (2020), who found that nursing management was ambivalent regarding the total critical thinking dispositions and problem solving abilities in Port-Said hospitals.On the same line, Boso et al. ( 2021) and Karami and Shakurnia.(2021) reported that; the critical thinking disposition of the nurses was above average and relatively desirable.Also, Falcó-Pegueroles et al. ( 2021) and Tong et al. ( 2023) stated that there was a satisfactory level of critical thinking disposition among nurses, and the nurses who demonstrated critical thinking in the clinical setting were more self evaluative and comprehensive in their practice.
In contrary, Rababa & Al-Rawashdeh, (2021) showed that critical thinking skills among the nurses were poor in relation to pain management.

Regarding professional nurse-patient relationship:
The study subjects had good levels in their professional relationship with patients, The result of these study indicates statistically significant differences related to all items of professional nurse patient relationship.Dimension of focusing on patient was the highest score of subscale followed by provision of safe environment.On the other hand, the dimension of 'evaluation of nurse patient relationship' and 'discover the patient' are considered as the lowest score.
These results came in congruence with Gholami et al. ( 2016) and Tondo and Guirardello (2017) who found that; therapeutic nurse-patient communication score was average and participants were acquainted with communication skills and used these skills in caring for the patients.
Also these results are in line with those of; AL Lawati et al.( 2019) who found that, the nurses in the primary health care setting provide a safe environment at a very high level and that the perception of patient safety is moderately positive.

Related to correlations between Critical thinking disposition and professional nurse patient relationship:
There were statistical significant positive correlations between nurse's critical thinking disposition and professional nurse-patient relationship related to all items of both tools.(

Regarding to relations between critical thinking disposition and sociodemographic data.
There was a significant relationship between critical thinking disposition and the nurses' educational qualification and work department.These are consistent with, López et al. ( 2020), Van Nguyen and Liu (2021) and Dewi et al. ( 2021) indicated that participants with a bachelor's degree level of education had higher scores in critical thinking disposition than participants with a diploma or associate degree level of education.Regarding the work department, the result came in congruence with Jafari et al. ( 2019) and Ludin ( 2018), who found that the critical thinking ability of the nurses in critical care wards was significantly higher compared to those employed in general wards Related to relations between professional nurse patient relationship and sociodemographic data.
There were statistically significant relations between professional nurse-patient relationship and nurses' age, gender, educational qualification, work department and years of experience.Simmillary; Sibandze and Scafide (2018) and Yau et al. (2019) suggested that educational level had a positive influence on the professional values of nurses.In addition, Molina-mula and Galloestrada (2020) reported that nurses with a younger age and less experience value and respect the patient so they can promote trust with the patient.

Conclusion
According to the study's findings, there were statistically significant differences related to all items of the critical thinking dispositions tool and the professional nursepatient relationship tool.In addition, there was a significant relationship between critical thinking disposition and the nurses' educational qualifications and work department.Also, there were statistically significant relationships between the professional nurse-patient relationship and nurses' age, educational qualification, work department, and years of experience

Recommendations
According to the findings of the study, the following recommendations are made: