Elsevier

Nurse Education Today

Volume 34, Issue 1, January 2014, Pages 67-72
Nurse Education Today

The effect of reflective writing interventions on the critical thinking skills and dispositions of baccalaureate nursing students

https://doi.org/10.1016/j.nedt.2013.04.002Get rights and content

Summary

Background

The importance of critical thinking is well-documented by the American Association of Colleges of Nursing and the National League for Nursing. Reflective writing is often used to increase understanding and analytical ability. The lack of empirical evidence about the effect of reflective writing interventions on critical thinking supports the examination of this concept.

Objectives

Study objectives were:

  • To test the effectiveness of a novel reflective writing intervention, based on Paul's (1993) model of critical thinking, for improving critical thinking skills and dispositions in nursing students.

  • To determine the common characteristics of high-scoring participants.

  • To determine relationships between scores and institution, gender, age, ethnicity, or experience.

Design

This study used an experimental, pretest–posttest design.

Settings

The setting was two schools of nursing at universities in the southern United States.

Participants

The convenience sample included 70 fourth-semester students in baccalaureate nursing programs.

Methods

Randomly assigned control and experimental groups completed the California Critical Thinking Skills Test (CCTST) and the California Critical Thinking Dispositions Inventory Test (CCTDI). The experimental group completed six reflective writing assignments. Both groups completed the two tests again.

Results

Results showed that the experimental group had a significant increase (p = 0.03) on the truthseeking subscale of the CCTDI when compared to the control group. The experimental group's scores increased on four CCTST subscales and were higher than the control group's on three CCTST subscales.

Conclusions

The results of this study make it imperative for nursing schools to consider including reflective writing—especially assignments based on Paul's (1993) model—in nursing courses. If future studies, testing over longer periods of time, show significant increases in critical thinking, those interventions could be incorporated into nursing curriculum and change the way nurse educators evaluate students.

Introduction

Critical thinking is generally thought of as a process of analyzing, synthesizing, and/or evaluating information (Paul and Scriven, 1987). For decades, the concept of critical thinking has been recognized as an essential outcome for students at all levels and in all disciplines (Reed and Kromrey, 2001). Critical thinking is an important concept in nursing curricula because practicing nurses need these skills to complete nursing actions that directly affect patient outcomes. These actions include analyzing each patient's situation, weighing possible nursing measures, considering patients' feelings and circumstances, and recognizing when it's appropriate to seek alternative treatments. The American Association of Colleges of Nursing (AACN) (2008) has emphasized the importance of graduating nurses who can apply critical thinking in all practice situations in order to improve patient health outcomes. The National League for Nursing (NLN) has stated that, to facilitate learning effectively, nurse educators must “create opportunities for learners to develop their critical thinking…skills” (National League for Nursing, 2005, p. 1).

Critical thinking skills also can help students pass the National Council of State Boards of Nursing (NCSBN) Registered Nurse certification test (NCLEX-RN). For example, a recent study of 218 baccalaureate nursing students showed that those who passed the NCLEX-RN scored significantly higher on critical thinking tests than those who failed (Giddens and Gloeckner, 2005). To promote high NCLEX-RN pass rates—and help alleviate the current nursing shortage—it is imperative that nursing faculty find ways to help build students' critical thinking skills.

While the importance of equipping nurses with critical thinking skills is well-documented, it is unclear how best to accomplish this goal. Simply providing content does not produce problem-solving and analytical skills during patient interactions or teach post-interaction reflection or evaluation (McGuire et al., 2009). Yet published research shows that junior and senior level nursing students score higher on critical thinking tests than their freshman and sophomore counterparts (McCarthy et al., 1999). Further, students in baccalaureate nursing programs (BSN) had higher critical thinking scores than individuals in other degree tracks, such as Associate Degree Nurses (ADN) (Shin et al., 2006). While educators use reflective writing, writing assignments based on student experience, to increase understanding and the ability to reason and analyze (Kennison, 2006), there is little empirical evidence regarding this strategy's effectiveness in increasing critical thinking skills.

Section snippets

Literature

Several studies have compared California Critical Thinking Skills (CCTST) and California Critical Thinking Dispositions Inventory (CCTDI) test scores between samples — the same instruments used in this study. One study proposed that BSN students have higher scores than ADN and RN-to-BSN students (Shin et al., 2006). Two studies supplied evidence that test scores increase during a nursing program (McCarthy et al., 1999, Thompson and Rebeschi, 2000), while another showed that the increase was not

Analytical Framework

Paul's model for critical thinking was the guiding framework for this study (Paul, 1993). According to Paul and Scriven (1987, p.1), critical thinking is the intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information—gathered from or generated by, observation, experience, reflection, reasoning, or communication—as a guide to belief and action. According to Paul (1996) critical thinking disposition includes

Aims

The aims of this study were:

  • To test the effectiveness of a novel reflective writing intervention, based on Paul's (1993) model of critical thinking, for improving critical thinking skills and dispositions in baccalaureate nursing students during an eight-week clinical rotation

  • To determine common characteristics among participants who earn high scores on the instruments

  • To determine if there are relationships between scores and institution, gender, age, ethnicity, and/or health care experience

Design

This study consisted of a reflective writing intervention that was administered to a group of baccalaureate nursing students. The design for this study was experimental, and more specifically, a level III pretest–posttest design. A level III study uses an experimental design to test variables. This study included an experimental group (whose members completed an intervention between pretest and posttest), a control group (whose members completed pre- and posttest), and random assignment of

Discussion

The experimental group's total CCTST and CCTDI scores did not increase significantly following the intervention. The control group's total CCTST and CCTDI scores did not increase significantly from the pre- to the post-intervention test. The most noteworthy result was the significant increase in the experimental groups' CCTDI truthseeking subscale score when compared to the control group. This increase may be explained by accepting that the intervention helped make students more “eager to seek

Conclusion

This study tested the effectiveness of a novel reflective writing intervention, based on Paul's (1993) model of critical thinking, for improving critical thinking skills and dispositions in baccalaureate degree nursing students during an eight-week clinical rotation. Although there was only one significant subscale increase between the control and experimental groups from pre- to post-intervention tests, much valuable information was gleaned from this study. An innovative intervention that used

Role of the Funding Source

The researchers would like to acknowledge the Delta Epsilon and Gamma Chi Chapters of Sigma Theta Tau International for the research grants that partially funded this dissertation study. The funding helped researchers pay for gift card incentives, travel for data collection, and the data collection instruments.

References (31)

  • B.L. Adams

    Nursing education for critical thinking: an integrative review

    Journal of Nursing Education

    (1999)
  • D.G. Allen et al.

    Writing to learn: a reconceptualization of thinking and writing in the nursing curriculum

    Journal of Nursing Education

    (1989)
  • American Association of Colleges of Nursing

    The Essentials of Baccalaureate Education for Professional Nursing Practice

    (2008)
  • D.J. Bartlett et al.

    Measuring change in students' critical thinking ability: implications for health care education

    Journal of Allied Health

    (2002)
  • J.T. Broadbear et al.

    An approach to teaching for critical thinking in health education

    Journal of School Health

    (2000)
  • College Entrance Examination Board

    Writing: a ticket to work…or a ticket out. A survey of business leaders

  • M. Craft

    Reflective writing and nursing education

    Journal of Nursing Education

    (2005)
  • J. Emig

    Writing as a mode of learning

    College Composition and Communication

    (1977)
  • N.C. Facione et al.

    Critical thinking disposition as a measure of competent clinical judgment: the development of the California Critical Thinking Disposition Inventory

    Journal of Nursing Education

    (1994)
  • A. Fisher et al.

    Designing HIV/AIDS Intervention Studies: An Operations Research Handbook

    (2002)
  • J. Giddens et al.

    The relationship of critical thinking to performance on the NCLEX-RN

    Journal of Nursing Education

    (2005)
  • K.T. Heinrich

    The intimate dialogue: journal writing by students

    Nurse Educator

    (1992)
  • S.P.S.S. Inc.

    PASW Statistics for Windows, Version 18.0

    (2009)
  • M. Ingram

    Critical thinking in nursing: experience vs. education (Doctoral dissertation). UMI Number: 3304800

  • M. Kataoka-Yahiro et al.

    A critical thinking model for nursing judgment

    Journal of Nursing Education

    (1994)
  • Cited by (74)

    • Effects of reflective learning based on visual mind mapping in the fundamentals of nursing course: A quasi-experimental study

      2022, Nurse Education Today
      Citation Excerpt :

      and iii) what conclusions did you come to by the end of the learning? Those questions were formulated using educational reflective writing strategies (Naber and Wyatt, 2014). III) After each student completed the learning reflection, the teachers scored each reflective writing according to the self-designed evaluation criteria including the completeness of the reflection (covering the above three aspects), the depth of reflection, critical thinking, and the writing quality such as the logic and fluent of writing, and then feedback was provided to students.

    • Effects of high-fidelity simulation on the critical thinking skills of baccalaureate nursing students: A causal-comparative research study

      2020, Nurse Education Today
      Citation Excerpt :

      Development of critical thinking does not necessarily involve a single teaching strategy such as simulation or is there the concept that one strategy is far more effective than another (Farashahi and Tajeddin, 2018). Other teaching modalities such as problem-based learning (Gholami et al., 2016; Kong et al., 2014; Orique and McCarthy, 2015), concept mapping (Burrell, 2014; Lin et al., 2015; Orique and McCarthy, 2015; Yue et al., 2017), and reflective journaling (Naber et al., 2014; Naber and Wyatt, 2014; Padden-Denmead et al., 2016; Zori, 2016) have shown a positive impact to increase critical thinking skills. Simulation is one variable, however, that has consistently been a part of this particular nursing program's curriculum since its inception in 2006.

    View all citing articles on Scopus
    1

    Tel.: + 1 865 974 6804; fax: + 1 865 974 3569.

    View full text