Term Paper. Topic: Evidence Based Practices to Guide Clinical Practices

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Quantitative Research on Critical Thinking and Predicting Nursing Students’ NCLEX-RN Performance Elizabeth M. Romeo, MS, CRNP, FNP

AbSTRACT The concept of critical thinking has been influential in

several disciplines. Both education and nursing in general have been attempting to define, teach, and measure this concept for decades. Nurse educators realize that critical thinking is the cornerstone of the objectives and goals for nursing students. The purpose of this article is to review and analyze quantitative research findings relevant to the measurement of critical thinking abilities and skills in undergraduate nursing students and the usefulness of critical thinking as a predictor of National Council Licen- sure Examination-Registered Nurse (NCLEX-RN) perfor- mance. The specific issues that this integrative review ex- amined include assessment and analysis of the theoretical and operational definitions of critical thinking, theoretical frameworks used to guide the studies, instruments used to evaluate critical thinking skills and abilities, and the role of critical thinking as a predictor of NCLEX-RN out- comes. A list of key assumptions related to critical think- ing was formulated. The limitations and gaps in the litera- ture were identified, as well as the types of future research needed in this arena.

H igher education has attempted to change the way in which the nursing curriculum is structured (Ad- ams, 1999). It is no longer acceptable to teach only

knowledge-based facts and skills; instead, the emphasis has shifted toward guiding students to become lifelong, in- dependent critical thinkers (Lee, 2007). Starting in the late 1980s, colleges of nursing moved from evaluation of the cur- riculum to assessment of student outcomes (Riddell, 2007). Nursing faculty must continue this shift from an emphasis on teaching nursing content to one focusing on the applica- tion of nursing knowledge (Adams, 1999; Del Bueno, 2005). The application of nursing knowledge within the nurs- ing process is enhanced through utilization of the process of critical thinking (National League for Nursing [NLN], 2007). Nurse educators remain accountable for creating and implementing curricula that produce graduate nurses who are able to use critical thinking skills to formulate ap- propriate clinical and nursing judgments (Henriques, 2002; Hoffman, 2006; NLN, 2007; Youssef & Goodrich, 1996).

The National Council of State Boards of Nursing (NCSBN) is an organization through which boards of nursing act collaboratively on matters of public health, safety, and welfare (NCSBN, 2007). This organization is also responsible for the development of the licensing ex- aminations in nursing. Because the NCSBN considers critical thinking to be an important component in nursing education and the National Council Licensure Examina- tion-Registered Nurse (NCLEX-RN) measures graduates’ competency for entry into practice, it is presumed that critical thinking is one element of nursing that is tested by the NCLEX-RN (Giddens & Gloeckner, 2005). According to the NCSBN, the majority of items on the NCLEX-RN are written at the application and analysis level of Bloom’s taxonomy. Successful performance on the NCLEX-RN re- quires the use of critical thinking to correctly answer ques- tions at this cognitive level (Wacks, 2005; Wendt, 2003; Wendt & Brown, 2000).

Received: October 30, 2008 Accepted: October 27, 2009 Posted: March 31, 2010 Ms. Romeo is Clinical Instructor, Gwynedd-Mercy College, School

of Nursing, Gwynedd Valley, Pennsylvania. The author has no financial or proprietary interest in the material

presented herein. Address correspondence to Elizabeth M. Romeo, MS, CRNP,

FNP, Clinical Instructor, 405 Stonebridge Road, Perkasie, PA 18944; e-mail: [email protected].

doi:10.3928/01484834-20100331-05

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METhod FoR INTEgRATIvE REvIEw

The process that was used for this integrative review was the template proposed by Whittemore and Knafl (2005). Their method for conducting an integrative review includes the following five stages: a problem identification stage, with the definition of relevant terms; a literature search stage, to identify all significant literature on the topic; a data evaluation stage, with the recommendation to include similar designs; a data analysis stage that en- compasses data reduction, data display, data comparison, conclusion drawing, and verification; and a final presenta- tion stage that is generally reported in a table or diagram- matic form (Whittemore & Knafl, 2005).

Problem Identification Stage and Identification of Relevant Terms

Critical thinking is an attribute that enhances one’s skill in problem solving and decision making. The purpose of this article is to review and analyze recent quantitative research findings relevant to measuring critical thinking abilities and skills in undergraduate nursing students and critical thinking’s role as a predictor of NCLEX-RN performance. The specific issues that this integrative re- view will examine include assessment and analysis of the theoretical and operational definitions of critical thinking, theoretical frameworks used to guide the studies, tools to evaluate critical thinking skills and abilities, and the role of critical thinking as a predictor of NCLEX-RN outcomes. A list of key assumptions related to critical thinking will be formulated. The limitations and gaps in the literature will be identified, as well as the types of future research needed in this area.

Theoretical definitions of Critical Thinking Nursing has evolved from a simplistic occupation to a

complex and highly technical profession; therefore, nurses have changed from being task-oriented team members to becoming autonomous health care providers (Allen, Ru- benfeld, & Scheffer, 2004). Due to the increasing complex- ity of the clinical setting, the need to develop and nur- ture critical thinking skills is paramount (Frye, Alfred, & Campbell, 1999). A concise definition of the concept of critical thinking is one that various disciplines continue to struggle with today (Akerson, 2001; Allen et al., 2004; Frye et al., 1999; Kataoka-Yahiro & Saylor, 1994).

The studies reviewed in this integrative review in- cluded a variety of definitions of critical thinking. The definition offered by Paul (1993) is that it is a method of examining one’s thinking with the goal of improving the thought process to make it clearer and more accu- rate (Frye et al., 1999). In the study conducted by Wacks (2005), the definition of critical thinking used was from the work of Watson and Glaser (1980), who defined it as a combination of one’s attitudes, level of knowledge, and skills. Akerson (2001) offered yet another definition of critical thinking that is specific to nursing and is based on the work of Kataoka-Yahiro and Saylor (1994). Accord-

ing to Akerson, critical thinking is a process involving critical, reflective, and reasonable thinking about prob- lems specific to nursing practice that do not have a single answer and is centered on deciding what to do or believe. It also has been defined as a cognitive procedure that drives problem solving and decision making (Henriques, 2002). Frost (2000) offered another definition of critical thinking that is specific to nursing: critical thinking is a process involving critical, reflective practice with a basis in sound reasoning of intelligent minds that are commit- ted to safe and effective patient care. The process of criti- cal thinking is best measured from a holistic perspective encompassing both abstract thinking and the practice skills that are unique to the nursing environment (Hoff- man, 2006).

one of the first intensive research studies done to de- velop a widely accepted theoretical definition for critical thinking was undertaken in 1990 by means of the Delphi method. A panel of 46 experts from the United States and Canada from different scholarly disciplines participated in this 2-year project in an effort to globally define critical thinking. Peter Facione, PhD, is internationally known for his work on the definition and measurement of critical thinking. His research on teaching and assessing critical thinking has been ongoing for the past 40 years. Dr. Fa- cione was a prominent member of The Delphi Report in 1990, which defined critical thinking as a decisive, self- regulated judgment that promotes a forum in which to ad- dress clinical and professional nursing issues in an effec- tive method. According to Facione (1990), “critical thinking is essential as a tool of inquiry” (p. 3). The ideal critical thinker continually draws on past experiences and one’s knowledge base to honestly and openly assess and resolve complex issues in an orderly fashion (Facione, 1990; mor- ris, 1999; morris, 1998).

Stewart and Dempsey (2005) defined critical thinking from the specific standpoint of the American Philosophi- cal Association (1990), which describes critical thinking dispositions. These dispositions include attributes such as “habits of the mind, intellectual virtues, a character- ological profile, and a set of attitudes toward thinking pro- cesses” (Stewart & Dempsey, 2005, p. 81). Critical think- ing has also been defined as a vibrant, purposeful, logical process that results in articulate decisions and judgments. The process of critical thinking in this definition encom- passes interpretation, analysis, evaluation, inference, explanation, and self-regulation (Whitehead, 2006). The final study reviewed did not provide a definition of critical thinking (Youssef & Goodrich, 1996).

one definition of critical thinking that is important to nursing and was not found in any of the reviewed studies is the definition based on the work of Scheffer and Ruben- feld (2000). They also used the Delphi technique with five rounds of input to achieve a definition of critical thinking specifically for the discipline of nursing. The participants in that study consisted of an international panel of expert nurses representing 9 countries and 23 states in the Unit- ed States who worked from 1995 to 1998 to develop the fol-

Journal of Nursing Education • Vol. 49, No. 7, 2010 379

QUANTITATIvE RESEARCH oN CRITICAL THINKING

lowing consensus definition of critical thinking in nursing (Scheffer & Rubenfeld, 2000):

Critical thinking in nursing is an essential component of professional accountability and quality nursing care. Criti- cal thinkers in nursing exhibit these habits of the mind: confidence, contextual perspective, creativity, flexibility, in- quisitiveness, intellectual integrity, intuition, open-mind- edness, perseverance, and reflection. Critical thinkers in nursing practice the cognitive skills of analyzing, applying standards, discriminating, information seeking logical rea- soning, predicting and transforming knowledge. (p. 357)

LITERATuRE SEARCh

data Collection The literature review was conducted via hand, Inter-

net, and database searches from January to April 2008. Computer searches used the Cumulative Index for Nursing and Allied Health Literature, ProQuest Nurs- ing Journals, and Pubmed. Search words that were used in various combinations in- cluded “critical thinking,” “nursing, students,” “research instruments,” “quantitative research,” “pretest-posttest,” and “NCLEX-RN results.” The Cumulative Index for Nursing and Allied Health Literature, ProQuest, and Pubmed data- bases produced 20, 10, and 23 articles, respectively, which were selected based on specific inclusion and exclusion cri- teria. The inclusion criteria were studies that were quanti- tative in design, research articles published in professional journals, and dissertations written in English, and they in- volved undergraduate nursing students, described the use of a critical thinking assessment tool, and were published between 1988 and 2008.

Undergraduate nursing students were the population selected because the majority of studies pertaining to critical thinking are based on this group. The inclusion of studies that contain a quantitative critical thinking tool was necessary to measure the independent variable. The rationale for the dates of the search was to coincide with the implementation of the current format for the NCLEX- RN as a pass/fail examination. Exclusion criteria included qualitative research, graduate nursing students compris- ing the population, editorials and articles published prior to 1988, studies involving a specific intervention to en- hance critical thinking with no correlation to NCLEX-RN outcomes, abstracts without full text, case studies, letters, or secondary sources.

There were 8 articles that met the criteria for inclu- sion in this project. An ancestry search and citation-in- dex search were conducted on the 8 articles, which were initially found in the 3 different Internet databases. An

additional 4 articles that met the criteria were found, for a total of 12 relevant articles for this integrative re- view.

data Analysis and Interpretation This integrative review revealed four different meth-

ods that have been used to study the critical thinking abilities of nursing students in comparison to NCLEX-RN outcomes. The first method used was the measurement of critical thinking abilities at the beginning and at the end of the nursing curriculum, which was used as a predictor of NCLEX-RN success. A second method measured criti- cal thinking abilities once at either the beginning or the end of the nursing program and examined students’ criti- cal thinking abilities as a predictor of NCLEX-RN suc- cess. The third method used in one study measured criti- cal thinking by means of repeated measurements taken

five times over the course of the students’ education. The final method that was used in three studies examined the differences between two distinct types of students in regard to their critical think- ing abilities and NCLEX-RN scores. The analysis and in- terpretation of the articles are categorized by these methods. A summary table of the studies is located in the Table.

Key Assumptions from Integrative Review Several assumptions of critical thinking that were ei-

ther implied or explicitly stated became apparent in the course of this review (Hall, 1996; Stewart & Dempsey, 2005; Wacks, 2005):

l Critical thinking is widely accepted as a skill that is necessary in the practice of professional nursing.

l Critical thinking skills can be taught, learned, and measured.

l Students in the studies make an honest effort to per- form well on the tests.

data Comparison The state of the science in regard to studies that have

been conducted on critical thinking in nursing education and practice is expansive, as found during the process of this integrative review. However, few studies have exam- ined critical thinking as a predictor of NCLEX-RN perfor- mance. Several limitations in these studies were identified in the process of this review. Some of the major limitations identified were related to the lack of a theoretical or con- ceptual framework, sampling issues, the definition of criti- cal thinking, and measurement tools. The lack of quanti- tative studies available that use critical thinking as an independent variable and NCLEX-RN as the dependent variable substantiate the need for further research.

The lack of quantitative studies

available that use critical thinking as an

independent variable and NCLEX-RN as

the dependent variable substantiate the

need for further research.

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Theoretical Frameworks most quantitative research has the common underly-

ing goal of testing the relationships that are suggested by theories. of the 12 studies that were reviewed, only 5 in- cluded a theoretical framework that guided the research (Akerson, 2001; Hoffman, 2006; morris, 1999; Wacks, 2005; Whitehead, 2006). Because there is currently not one accepted theory of critical thinking, each of the 5 stud- ies used a different theory, which further demonstrated the infancy of the state of the science in studying critical thinking. The remaining research studies did not include any framework or theory as a guide for the study.

Theoretical definition of Critical Thinking Because there is currently a lack of an accepted frame-

work for critical thinking, there is not a widely acknowl- edged and accepted theoretical definition. As previously noted, there is a plethora of both theoretical and opera- tional definitions for critical thinking. As a discipline, nursing is in need of agreement on and acceptance of one of the current, concise theoretical definitions of critical thinking for use in education and clinical practice (Adams, 1999; Frye et al., 1999; Hall, 1996; Stewart & Dempsey, 2005). Interestingly, neither of the current nursing- specific definitions of critical thinking—the one developed by the NLN for clinical nursing practice or the definition from the work of Scheffer and Rubenfeld (2000)—were used as the theoretical definition for critical thinking in any of the studies that were analyzed. Because the theo- retical definition of critical thinking is directly related to a critical thinking theory, the exploration of these two fac- tors needs be conducted simultaneously. The operational definitions of critical thinking will remain tool specific, with a need to continue studying the reliability and valid- ity of the measures of critical thinking.

Critical Thinking Measurement Tools The California Critical Thinking Skills Test. The

majority of the valid and reliable tools available to mea- sure critical thinking skills and abilities are not specific for use with nursing students. The measurement tool that was used most frequently was the California Critical Thinking Skills Test, which yielded mixed findings in the reviewed studies. The California Critical Thinking Skills Test is a 34-item multiple choice test that measures over- all critical thinking skills, in addition to 5 subscales that specifically assess analysis, evaluation, inference, and deductive and inductive reasoning (Brunt, 2005; Phillips, Chestnut, & Rospond, 2004). This is a timed test of 45 minutes, with a maximum score of 34 on the skills test (Brunt, 2005).

Positive relationships of critical thinking skills and NCLEX-RN success were found in half of the studies that used this tool (Giddens & Gloeckner, 2005; Hall, 1996; morris, 1999), although no statistical significance was found in the remainder of the studies with the California Critical Thinking Skills Test (Akerson, 2001; Henriques, 2002; morris, 1998).

The California Critical Thinking Disposition In- ventory. The California Critical Thinking Disposition In- ventory (CCTDI) is designed to measure a student’s procliv- ity to think critically (Phillips et al., 2004). There are seven identified dispositions or “habits of the mind” that are the elements of one’s character that move one toward using critical thinking skills. Each section has several questions that evaluate specific thought habits; there is a subscale score for each of the 7 subscales, in addition to a total score for the test. For each subscale, a score below 40 indicates a general weakness in that area, and a score above 50 rep- resents a consistent strength. A total CCTDI score below 280 represents serious overall deficiencies in the student’s critical thinking dispositions and a score above 350 shows overall strengths (Giddens & Gloeckner, 2005; Phillips et al., 2004). The 7 dispositions are as follows:

l Truth-seeking is a desire to gain the best knowledge, even if it undermines one’s preconceptions or beliefs.

l open-mindedness is a tolerance of views other than your own, as well monitoring oneself for possible bias.

l Analyticity is demonstrated by the demand for ap- plication of reason and evidence, awareness of problem situations, and an inclination to anticipate consequences.

l Systematicity relates to one’s focus on approaching all levels of problems and valuing organization.

l Critical thinking self-confidence is the trusting of one’s own reasoning skills.

l Inquisitiveness relates to one’s curiosity and eager- ness to acquire knowledge and learn explanations.

l Cognitive maturity is indicative of prudence in mak- ing, suspending, or revising judgment. It is awareness that multiple solutions can be acceptable (Facione, 2007; Phillips et al., 2004).

Construct validity of the CCTDI was reported by Stew- art and Dempsey (2005) as being established by Facione and Facione (1992). validity for this instrument was not reported in the remainder of the studies (Giddens & Gloeckner, 2005; Henriques, 2002). Giddens and Gloeck- ner (2005) were the only ones who reported statistically significant findings when the total mean CCTDI exit scores were found to be higher in the first-time NCLEX- RN pass group than in the failure group.

The Watson-Glaser Critical Thinking Appraisal Tool. The Watson-Glaser Critical Thinking Appraisal (WGCTA) is a tool available to measure critical think- ing abilities with three different forms of the instrument available. Form A and Form B are parallel tools available for use as pretest and posttest measurements, and Form S is the latest, shortest version of the instrument (Wacks, 2005). The WGCTA Form S is composed of 16 scenarios and 40 items to be answered. This instrument has been found to be appropriate for assessing critical thinking ability in individuals with at least a ninth grade education. The as- sessment is divided into five subsets: inference, recogni- tion of assumptions, deduction, interpretation, and evalu- ation of arguments. In the liberal arts setting, upper-level students have higher scores than do entry-level students on the WGCTA (Frye et al., 1999).

Journal of Nursing Education • Vol. 49, No. 7, 2010 381

QUANTITATIvE RESEARCH oN CRITICAL THINKING

The WGCTA total score and various subsets of the score were found to be significant predictors of NCLEX-RN per- formance (Frye et al., 1999; Wacks, 2005). In contrast, Hall’s (1996) literature review suggested that WGCTA may not be a valid measure of critical thinking in nurs- ing students because it does not measure the cognitive process underlying the nursing process. The WGCTA may not be an accurate measure of the reasoning needed for critical thinking and, ultimately, for making reasonable clinical decisions. The question that arises both implicitly and explicitly in these studies is the appropriateness of non-nursing-specific tools as reliable and valid measures of critical thinking abilities in nursing students.

other Critical Thinking Tools There were five lesser known tools specifically de-

signed to measure critical thinking in nursing students that were used by different researchers. These include the Assessment Technologies Institute’s (ATI) instru- ment, the Critical Thinking Assessment (CTA) test, and three tests by the Educational Resources Incorporated (ERI): the Nurse Entrance Test (NET), the Critical Think- ing Process Test (CTPT), and the RN Assessment Test. A final critical thinking mea- surement tool is the Scale of Judgment Abilities in Nurs- ing (SJAN).

The CTA is a 40-item ob- jective instrument that was developed to determine stu- dents’ performance on spe- cific critical thinking skills at the beginning and end of the nursing program. There are six to eight questions for each critical thinking skill on the test. The goal of the diagnostic pretest is for development of instructional strategies by nursing faculty to enhance higher thinking skills. The posttest measures the student outcomes after the instructional intervention and, as such, readiness for the NCLEX- RN. The six competencies that are incorporated into the ATI CTA are interpretation, analysis, evaluation, inference, explanation, and self-regulation (Whitehead, 2006). This particular nursing-specific tool used to mea- sure critical thinking has only been available since 2000 (Whitehead, 2006).

ERI designed three different tests to measure criti- cal thinking at various times during the nursing cur- riculum; however, only two of the tests will be described in this integrated review. The first test that was used to measure critical thinking skills in nursing students is the CTPT. This tool assesses the following five levels of abstract thinking: prioritizing/discriminating, inferen- tial reasoning, goal setting, application of knowledge, and evaluation of predicted outcomes (Hoffman, 2006).

The second test provided by ERI is the RN Assessment Test, used by both Stewart and Dempsey (2005) and Hoffman (2006) to assess the critical thinking abilities of nursing students prior to graduation. This assess- ment test provides a total score plus 32 subscale scores. Five of the subscales are related to critical thinking and are labeled as prioritizing/discriminating, infer- ential reasoning, main idea and predicting outcomes, application and knowledge, and evaluating predicted outcomes.

The SJAN is another instrument that examines the professional judgment of nursing students in four areas: legal/ethical, problem solving and decision making, com- munication, and leadership functioning (Youssef & Go- odrich, 1996). The purpose of the test is to examine an in- dividual’s ability to understand and apply knowledge. The tool is composed of 28 multiple-choice questions and has an equal number of questions in the four content areas. Reliability and validity of the SJAN were not addressed by the authors.

The tools that were developed to be used specifically with nursing students also had differing results. The ERI

tests results were found to have no statistical signifi- cance in relation to critical thinking and were even deemed a measure of safe practice rather than a direct measure of critical thinking (Stewart & Dempsey, 2005). Hoffman (2006) reported the exact opposite findings in her study using the three ERI tests that revealed a predic- tive relationship of critical thinking skills and NCLEX- RN pass rates. The ATI CTA and SJAN were used in stud- ies that compared two diverse

groups of nursing students and their critical thinking abil- ities. Neither study found significant differences between the groups’ critical thinking skills; however, no attempt was made in either study to correlate critical thinking to NCLEX-RN scores (Whitehead, 2006; Youssef & Goodrich, 1996) (Table).

Sampling Issues The majority of the studies used nonrandomized,

convenience samples due to the nature of the indepen- dent variable of critical thinking as not being conducive to manipulation. Sample sizes ranged from 24 (Akerson, 2001) to 437 nursing students (Hoffman, 2006). In gen- eral, the majority of studies included primarily nursing students at the BSN level with two studies that included only ADN students (Wacks, 2005; Youssef & Goodrich, 1996) and one study that compared the critical think- ing of BSN and ADN students (Whitehead, 2006). The majority of the authors stated that their studies were

The current state of science on

measurement of critical thinking in nursing

students reflects a lack of adequate

sample sizes to effectively determine the

relationship of critical thinking scores and

NCLEX-RN outcomes.

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p o si

tio n s

o ve

r th

co u

rs e o

f th

e n

u rs

in g c

u rr

ic u lu

m .

H a ll

(1 9 9 6 )

C T,

N C

L E

X -

R N

, C

o g n iti

D e ve

lo p m

e n t

N o n e id

e n tifi

e d

C o

rr e

la tio

n a

l, n

o n

- e xp

e ri

m e

n ta

l d e

si g

n 1

0 5

n io

r B

S N

s tu

d e

n ts

f ro

m a

n ve

n ie

n ce

s a

m p

C C

T S

T a

n d

L E

P t e

st s.

N C

L E

X -R

N A

s a

g ro

u p ,

d id

n o t

d e m

o n st

ra te

C T

a b ili

ty . C

T a

n d fi

n a n ci

a l

st a

tu s

w e re

s ig

n ifi

ca n t

p re

d ic

to rs

o f

N C

L E

X -R

N s

u cc

e ss

H e n ri

q u e s

(2 0 0 2 )

C T,

N C

L E

X -

R N

o n e id

e n tifi

e d

R e

tr o

sp e

ct iv

e c

o rr

e la

tio n

a l

d e

si g

n . C

o n ve

n ie

n ce

m p

le o

f 1

5 2

B S

st u

d e

n ts

C C

T D

I, C

C T

S T,

N C

L E

X -R

N , P

re -

N u

rs in

g G

u id

a n

ce t e

st s

co re

s, N

D R

sc o

re s,

D R

T s

co re

T h

e C

C T

D I

a n d C

C T

S T

d id

n o t

re ve

a l a

s ta

tis tic

a l

si g

n ifi

ca n ce

in p

re d ic

tin g N

C L E

X -R

N s

u cc

e ss

. T h e b

e st

re d ic

to rs

f o r

N C

L E

X -R

N s

u cc

e ss

w e re

t h e N

D R

T a

n d D

R T

o re

H o ff m

a n

(2 0 0 6 )

C T,

N C

L E

X -

R N

P e rr

y’ s

E th

ic a l

a n d I

n te

lle ct

u a l

D e ve

lo p m

e n t

S ch

e m

D e

sc ri

p tiv

e c

o rr

e la

tio n

a l

a n

a ly

si s

o f se

co n

d a

ta f ro

m a

c o

n ve

n ie

n ce

m p

le a

t a

B S

N p

ro g ra

co m

p a

ri n

g 4

3 7

s tu

d e

n ts

ra d

iti o

n a

l, n =

3 1

8 a

n d

a cc

e le

ra te

d , n

= 1

1 9

)

E R

I: N

E T,

C T

P T,

a n

d R

N A

ss e

ss m

e n

t Te

st . C

T P

T m

e a

su re

d t w

ic e . (

C T

P T

ro n

b a

ch ’s

a lp

h a

= 0

.9 3

. V a

lid ity

d d

re ss

e d

w h

e n

s tu

d e

n ts

’ s co

re s

im p

ro ve

d f ro

m p

re te

st t o

p o

st te

st .

R N

A ss

e ss

m e

n t te

st : C

ro n

b a

ch ’s

lp h

a =

0 .9

0 t o

0 .9

4 . V

a lid

ity a

d d

re ss

e d

b y

d e ve

lo p

e r

w ith

in cr

e a

se in

s co

re s

fr o

m p

re te

st t o

p o

st te

st .)

N E

T r

e a d in

g c

o m

p re

h e n si

o n s

co re

s (a

ft e r

co m

p le

tin g 1

n u

rs in

g c

o u rs

e )

w e re

h ig

h ly

p re

d ic

tiv e o

n R

N A

ss e ss

m e n t

a n

d N

C L E

X -R

N . C

T P

T a

n d R

N A

ss e ss

m e n t

sc o re

s (a

t e n d

o f p

ro g ra

m )

w e re

p re

d ic

tiv e o

f N

C L E

X -R

N .

M o rr

is (

1 9 9 9 )

C T,

N C

L E

X -

R N

B e n n e r’s

N o vi

to E

xp e rt

ilk in

so n ’s

d e sc

ri p tio

n o

f th

e n

u rs

in g

p ro

ce ss

D e

sc ri

p tiv

e c

o rr

e la

tio n

a l

st u

d y

w ith

8 3

s e

n io

r B

S N

C T

S T

g iv

e n

o n

C D

M N

S -c

lin ic

a l d

e ci

si o

n m

a ki

n g

L o w

p o si

tiv e s

ta tis

tic a l s

ig n ifi

ca n ce

b e tw

e e n C

T a

b ili

ty a

n d

N C

L E

X -R

N p

a ss

r a te

s. N

o s

ig n ifi

ca n ce

b e tw

e e n t

h e fi

rs t

a n d

se co

n d s

e n io

r se

m e st

e r

C T

s co

re s.

M o rr

is (

1 9 9 8 )

C T,

N C

L E

X -

R N

N o n e id

e n tifi

e d

E x

p o

st f a

ct o

c o

rr e

la tio

n a

l w

ith B

S N

8 2

s tu

d e

n ts

C C

T S

T F

o rm

s A

( ju

n io

r ye

a r)

a n

d B

e n

io r

ye a

r) ; N

L N

P A

X -R

N N

o s

ig n ifi

ca n t

d iff

e re

n ce

b e tw

e e n p

re te

st a

n d p

o st

te st

C T

b ili

ty . T

h e v

a ri

a b le

s e t

a s

a w

h o le

w a s

re la

te d t

o e

xi t

C T

o re

s, b

u t

n o o

n e v

a ri

a b le

d e m

o n st

ra te

d a

n in

d e p e n d e n t

re la

tio n sh

ip t

o C

T. N

o c

o m

b in

a tio

n o

f va

ri a b le

s w

a s

p re

d ic

tiv e

o f N

C L E

X -R

N o

u tc

o m

e s.

Journal of Nursing Education • Vol. 49, No. 7, 2010 383

QUANTITATIvE RESEARCH oN CRITICAL THINKING

Ta b

l e

C ri

ti c a l T

h in

k in

g i

n N

u rs

in g

e d

u c a ti

o n

S tu

d y

C o

n c e p

ts T

h e o

ry D

e s ig

n a

n d

S a m

p le

To o

l R

e li a b

il it

y a

n d

V a li d

it y

R e s u

lt s

S te

w a rt

D e m

p se

y (2

0 0 5 )

C T,

N C

L E

X -

R N

N o n e id

e n tifi

e d

L o

n g

itu d

in a

l d e

sc ri

p tiv

d e

si g

n . A

c o

n ve

n ie

n ce

m p

le o

f 5

5 B

S N

u d

e n

C C

T D

I, E

R I, a

n d

N C

L E

X -R

N C

C T

D I

su b sc

a le

s a n d t

o ta

l s co

re w

e re

b o th

s ta

tis tic

a lly

g n

ifi ca

n t

w ith

t h e C

T s

u b sc

a le

o f

in fe

re n tia

l r e a so

n in

h a vi

n g a

c o rr

e la

tio n t

o G

P A

. W ilc

o xo

n s

ig n e d r

a n ks

s h o w

e d

n o

s ig

n ifi

ca n t

d iff

e re

n ce

s b e tw

e e n C

T d

is p o si

tio n s

o f

th o

se w

h o p

a ss

e d a

n d t

h o se

w h o f a ile

d N

C L E

X -R

N . E

R I

R N

a ss

e ss

m e n t

sc o re

s d id

n o t

co rr

e la

te w

ith a

n y

C C

T D

I su

b sc

o re

s— in

te rp

re te

d t

o m

e a n t

h a t

E R

I d o e s

n o t

re fle

ct a

ro p

e n si

ty t

o C

W a ck

s (2

0 0 5 )

C T,

N C

L E

X -

R N

B a n d u ra

R e

tr o

sp e

ct iv

e , d

e sc

ri p

tiv e

rr e

la tio

n a

l d e

si g

n .

C o

n ve

n ie

n ce

s a

m p

le o

f 2

6 6

s tu

d e

n ts

f ro

m a

A D

N p

ro g ra

W G

C TA

( F

o rm

S )

A C

T, G

P A

, a

n d

C L

E X

-R N

. A ll

m e

a su

re d

o n

u p

o n

a d

m is

si o

n . (

C ro

n b

a ch

’s a

lp h

co e

ffi ci

e n

t =

0 .8

1 . C

o n

te n

t va

lid ity

e xa

m in

e d

in s

e ve

ra l s

e tt in

g s

a n

co rr

e la

te s

w ith

s p

e ci

fic o

b je

ct iv

e s

o f

e d

u ca

tio n

a l p

ro g ra

m s.

)

A C

T t

o C

T (

W G

C TA

) (p

= 0

.0 0 0 6 )

a n d W

G C

TA t

o N

C L E

X -

R N

( p

< 0

.0 0 2 )

w e re

s ig

n ifi

ca n t.

N o o

th e r

co m

b in

a tio

n s

w e re

g n ifi

ca n t;

W G

C TA

w a s

st ro

n g e st

p re

d ic

to r

o f

N C

L E

X -R

p e

rf o rm

a n ce

W h ite

h e a d

(2 0 0 6 )

C T,

N C

L E

X -

R N

N o t

id e n tifi

e d

b y

n a m

e —

co m

p e te

n ci

e s

P ilo

t st

u d

y w

ith a

n ve

n ie

n ce

s a

m p

le o

f 2

0 9

s tu

d e

n ts

( N

a tiv

E n

g lis

h , n

= 1

9 2

, N

o n

n a

tiv e

E n

g lis

sp e

a ki

n g

, n =

1 7

)

A T

I C

TA -p

re te

st -p

o st

te st

. ( C

ro n

b a

ch ’s

lp h

a =

0 .6

9 4

. V a

lid ity

b a

se d

o n

t h

e w

o rk

f F

a ci

o n

e a

n d

F a

ci o

n e

a n

d r

e se

a rc

fr o

m T

h e

D e

lp h

i P ro

je ct

N o

s ta

tis tic

a lly

s ig

n ifi

ca n t

d iff

e re

n ce

s w

ith N

C L E

X -R

p a

ss a g e r

a te

s a n d C

T s

co re

s b e tw

e e n g

ro u p s.

Y o u ss

e f &

o o d ri

(1 9 9 6 )

C T,

N C

L E

X -

R N

N o n e id

e n tifi

e d

A p

ro sp

e ct

iv e

s tu

d y.

o n ve

n ie

n ce

s a

m p

o f 9

4 A

D N

s tu

d e

n ts

ra d

iti o

n a

l, n

= 4

6 a

n d

cc e

le ra

te d

, n

= 4

8 )

S JA

N t o

a ss

e ss

C T

g iv

e n

d u

ri n

g s

e co

n d

m e

st e

r a

n d

1 8

m o

n th

s la

te r

d u

ri n

th e

la st

w e

e k

o f th

e p

ro g ra

m . S

TA I

w a

s g

iv e

n t w

ic e

t o

m e

a su

re a

n xi

e ty

a t

th e

b e

g in

n in

g o

f se

m e

st e

r a

n d

1 w

e e

k b

e fo

re fi

n a

ls . N

C L

E X

-R N

. R e

lia b

ili ty

a n

va lid

ity n

o t a

d d

re ss

e d

. S JA

N s

h o w

e d

n o

a tis

tic a

l s ig

n ifi

ca n

t d

iff e

re n

ce s

b e

tw e

e n

e 2

g ro

u p

S TA

I re

su lts

a t

th e b

e g in

n in

g o

f th

e s

e m

e st

e r

b o th

g ro

u p s

h a

d h

ig h e r

st re

ss t

h a n a

t th

e e

n d ,

w ith

t h e a

cc e le

ra te

d g

ro u p

h a vi

n g h

ig h e r

st re

ss le

ve ls

t h a n t

h e t

ra d iti

o n a l g

ro u p . A

t th

e n

d o

f th

e s

e m

e st

e r,

b o th

g ro

u p s

h a d lo

w e r

st re

ss w

ith o u t

a n y

si g n ifi

ca n t

d iff

e re

n ce

s b e tw

e e n t

h e 2

g ro

u p s.

N C

L E

X -R

p a

ss a g e r

a te

s b e tw

e e n t

h e 2

g ro

u p s

w e re

n o t

si g n ifi

ca n t.

C T

= c

ri tic

a l t

h in

ki n g ; N

C L E

X -R

N =

N a tio

n a l C

o u n ci

l L ic

e n su

re E

xa m

in a tio

n f o r

R e g is

te re

d N

u rs

e s;

B S

N =

b a ch

e lo

r o f

sc ie

n ce

in n

u rs

in g ; C

C T

S T

= C

a lif

o rn

ia C

ri tic

a l T

h in

ki n

g S

ki lls

T e

st ; G

P A

= g

ra d

p o in

t a ve

ra g e ; S

A T

= S

ch o la

st ic

A p tit

u d e T

e st

; W G

C TA

= W

a ts

o n G

la se

r C

ri tic

a l T

h in

ki n g A

p p ra

is a l;

C C

T D

I =

C a lif

o rn

ia C

ri tic

a l T

h in

ki n g D

is p o si

tio n

I n ve

n to

ry ; L

E P

= L

e a

rn in

g E

n vi

ro n

m e

n t P

re fe

re n

ce ;

N D

R T

= N

e ls

o n -D

e n n y

R e a d in

g T

e st

; D R

T =

D ia

g n o st

ic R

e a d in

e ss

T e st

; E R

I =

E d u ca

tio n a l R

e so

u rc

e I

n co

rp o ra

te d ; N

E T

= t

h e N

u rs

e E

n tr

a n ce

T e

st ; C

T P

T =

C ri

tic a

l T h

in ki

n g

P ro

ce ss

T e

st ; C

D M

N S

C lin

ic a l D

e ci

si o n

-M a ki

n g in

N u rs

in g S

ca le

; N L N

P A

X -R

N =

T h e N

a tio

n a l L

e a g u e f o r

N u rs

in g P

re -A

d m

is si

o n R

N e

xa m

in a tio

n ; A

D N

= A

ss o ci

a te

D e

g re

e in

N u

rs in

g ; A

C T

= a

s ta

n d

a rd

iz e

d a

ch ie

ve m

e n

t e xa

m in

a tio

n f o r

co lle

g e a

d m

is si

o n s;

A T

I =

A ss

e ss

m e n t T

e ch

n o lo

g ie

s In

st itu

te ; C

TA =

C ri

tic a l T

h in

ki n g A

ss e ss

m e n t;

S JA

N =

S ca

le o

f Ju

d g m

e n t A

b ili

tie s

in N

u rs

in g

; S TA

I =

T h

e S

ta te

-T ra

it A

n xi

e ty

ve n to

ry .

(C o

n ti

n u

e d

)

RomEo

conducted in one school of nursing and in a limited geo- graphic area, which greatly reduced the generalizability of the findings beyond their specific populations. In ad- dition, the small sample sizes were identified as prob- lematic by several researchers (Akerson, 2001; Frye et al., 1999; Hall, 1996; morris, 1999; morris, 1998; Stew- art & Dempsey, 2005) and the authors of only two of the studies reported that a power analysis was calcu- lated to determine the number of subjects needed to ad- dress statistical and practical significance (Henriques, 2002; Hoffman, 2006). The current state of science on measurement of critical thinking in nursing students reflects a lack of adequate sample sizes to effectively determine the relationship of critical thinking scores and NCLEX-RN outcomes. A final limitation related to sample size is the high degree of attrition that is found with longitudinal studies in this population (Stewart & Dempsey, 2005).

IMPLICATIoNS FoR NuRSINg EduCATIoN ANd NuRSINg RESEARCh

The quest for identifying variables that are related to NCLEX-RN outcomes continues as programs of nurs- ing strive to adequately prepare students for success on the licensure examination and in their future nursing careers (Giddens & Gloecker, 2005; morris, 1999). Ad- equate critical thinking abilities and skills have been identified as a major component of the NCLEX-RN and one’s ultimate success on this examination (Giddens & Glockner; Hall, 1996; Hennriques, 2002; Hoffman, 2006). There is a need to create quantitative nursing- specific tools that are rigorous, reliable, and valid to ad- equately assess critical thinking abilities and disposi- tions (morris, 1999; morris, 1998; Stewart & Dempsey, 2005; Youssef & Goodrich, 1996). Further research is needed to develop a nursing-focused critical thinking instrument to adequately measure critical thinking skills and abilities in nursing students (Hall, 1996). These measures of critical thinking abilities need to be designed for specific use with both beginning and gradu- ating nursing students. Utilization of these measures is an area that requires immediate attention in nursing research to identify those individuals who need to im- prove their skills. Additional exploration and research are then necessary to determine whether these quantifi- able measures can be used to examine the role of critical thinking skills and NCLEX-RN results.

NCLEX test-takers who failed the examination and those who passed on their first attempt need to be studied in greater detail to determine whether there is a statisti- cally significant difference between the critical thinking skills of those who failed and those who passed (Akerson, 2001; morris, 1998). In addition, further quantitative stud- ies are needed to determine whether other factors, such as attention to the setting, timing, and consequences of ad- equate effort in the testing situation might also influence critical thinking outcomes and success rates of first-time

NCLEX test-takers (morris, 1999; morris, 1998; Wacks, 2005; Whitehead, 2006).

CoNCLuSIoN

Critical thinking is an essential component in the competency of nurses in today’s health care environment (Henriques, 2002). The NLN Accrediting Commission (2007) and the American Association of Colleges of Nurs- ing (2008) have both mandated that nursing education in- clude content and activities specifically designed for the development and measurement of critical thinking skills. Continued empirical research needs to be conducted to better understand the role of critical thinking as a pre- dictor of NCLEX-RN outcomes. To meet these demands, nursing’s regulatory bodies must first agree on a definition of critical thinking for the discipline and then, after deter- mining a clear definition, settle on an applicable theory of critical thinking for nursing educators to use as a frame- work in curriculum development. Until nursing comes to accept a consensus definition of critical thinking, the disci- pline will continue to be disjointed in describing, teaching, and evaluating this skill in the profession. once critical thinking is adequately defined, nursing faculty and stu- dents will have a clearer understanding of the role and degree of critical thinking that is used in the NCLEX-RN. This research related to critical thinking and NCLEX-RN will aid nursing faculty in meeting one of their many re- sponsibilities as an educator.

REFERENCES Adams, B. (1999). Nursing education for critical thinking: An in-

tegrated review. Journal of Nursing Education, 38, 111-119. Akerson, D. (2001). The relationship between critical thinking,

work experience, and study. Unpublished doctoral disserta- tion, Saint Louis University, Saint Louis, missouri.

Allen, G., Rubenfeld, m., & Scheffer, B. (2004). Reliability of as- sessment of critical thinking. Journal of Professional Nursing, 20(1), 15-22.

American Association of Colleges of Nursing. (2008). The essen- tials of baccalaureate education. Retrieved from http://www. aacn.nche.edu/Education/pdf/BEdraft.pdf

American Philosophical Association. (1990). Critical thinking: A statement of expert consensus for purposes of educational as- sessment and instrument. The Delphi Report: Research find- ings and recommendations prepared for the committee on pre- college philosophy. (ERIC Document Reproduction Service No. ED 315-412.)

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