护理英语文献PBL

护理英语文献PBL A comparison of problem-based and traditional education on nursing students’ critical thinking dispositions KEYWORDS Critical thinking; Problem-based learning; Baccalaureate nursing Summary Determining the critical thinking (CT) levels of students in undergraduate nursing schools is important in terms of establishing the methods of education that should be used. Although there is some evidence that active learning approaches like problem-based learning are effective in developing CT, the findings are inconclusive. This descriptive analytic study compared levels of critical thinking among senior nursing students (N=147) in two educational programs, one of which used a problem based learning (PBL) model while the other used a traditional model. The California critical thinking disposition inventory (CCTDI) was used as a data collection tool. Comparisons between the groups were made using t-test analysis. There was a significant difference (p < 0.05) between the critical thinking disposition scores of the seniors in the PBL school and those in the school implementing the traditional model. Analysis of sub-scale scores showed significant differences in truth-seeking and open-mindedness. These findings add to the evidence that the active and self-directed nature of PBL encourages students’ ability to think critically, be tolerant of the ideas of others and evaluate conflicting information before reaching a conclusion. _c 2007 Elsevier Ltd. All rights reserved. Introduction Determining the scope of health issues of individuals,families and communities and providing needed care are the primary roles of the professional nurse in the contemporary world. Nurses can offer the public better care only if they can adapt to the steadily increasing complexities of the health care environment, to rapidly changing health care demands and to advances in technology(Distler, 2007). Critical thinking is widely accepted as being associated with the provision of quality care. It is defined by the American Philosophical Association Project as ‘‘purposeful, self-regulatory judgment which results in interpretation, analysis, evaluation and inference and is founded on the conceptual criteria upon which a judgment is based’’ (Facioneand Facione, 1996). Critical thinking is seen toencompass the ability to recognize an existing problem as well as an inquisitive attitude that seeks proof of the evidential. It involves gathering knowledge about the accuracy of this proof and the ability to make use of this knowledge and attitude (Daly, 1998; Simpson and Courtney, 2002). In a practice profession such as nursing, where rapid changes are experienced and decision-making is of vital significance, critical thinking is of great importance (Distler, 2007; Beckie et al.,2001). Developing critical thinking skills in nursing is essential in establishing a scientific foundation for the profession, for creating a discipline in which truth is sought and implemented, and where use of theoretical perspectives are increasingly being tested and utilized (Daly, 1998; Maynard, 1996; Youngblood and Beitz, 2001). The power of critical thinking allows nurses to logically assess their own experiences and training and apply the results of this evaluation to patient care. The ability of nurses to cope with problems, their skills in determining patient needs and providing systematic care are all dependent upon their critical thinking skills (Maynard, 1996). Competence in critical thinking is one of the expectations of nursing education. It is a part of professionalism and included within undergraduate nursing school curricula and is a part of the criteria for the accreditation and assessment of undergraduate and graduate nursing education programs (Daly, 1998;Vaughan-Wrobel et al., 1997; McCarthy et al.,1999). Determining the critical thinking levels of students in undergraduate nursing schools is important in terms of planning interventions in this area and establishing the methods of education that should be used. Although there is some evidence that active learning approaches like problem-based learning are effective in developing CT, the findings are inconclusive. The purpose of this study was to determine if there is a difference in the critical thinking dispositions among senior undergraduate nursing students studying in a problem-based learning program compared to those enrolled in a traditional education program. Literature review Critical thinking among nursing students has been explored from various perspectives and Seldomridge and Walsh provide an overview in their review article (Seldomridge and Walsh, 2006). Several researchers have examined the development of critical thinking skills as students progressed through their educational programs and conflicting results have been reported. For example in a crosssectional study conducted by Profetto-McGrath(2003) CT skills and dispositions of baccalaureate nursing program did not change over the years in the program. Stewart and Dempsey (2005) reported similar findings. Conversely, McCarthy et al. (1999) reported significant increases in both skills and dispositions to CT in the scores of the senior students compared to their sophomore counterparts. Ip et al. (2000) explored whether there were differences in the critical thinking skills of nursing students in the different years in their program where a classic educational model was being implemented.The students showed a generally negative disposition toward critical thinking. Other studies have examined the effect on CT of different education models, particularly PBL compared to traditional education. In a qualitative study conducted in Australia, nursing students who completed a four-week PBL experience within a ‘traditional’ discipline-structured nursing program reported that they developed their critical thinking skills. They stated the PBL approach promoted critical thinking and problem solving, active participation in the learning process and the integration and synthesis of a variety of knowledge (Cooke and Moyle, 2002). Beckie et al. (2001) found that the critical thinking scores of nursing students working with a new curriculum that incorporated clinical decision-making and Socratic thinking skills, group ctivities and active participation in the program were significantly higher than their counterparts in traditional curriculum programs. Choi (2004) reported different findings in his study that explored the effects of a problem-based learning approach on students’ critical thinking, problem- solving and metacognitive abilities, as he found that the problem-based learning model developed students’ problem-solving skills but had no effect on critical thinking abilities. Tiwari et al. (2003) established that the critical thinking scores of Australian nursing students were higher than those of Chinese students and they attributed this both to the active educational model used in the Australian school and to cultural differences. A recent study by Tiwari et al. (2006) used an experimental design where students in the firstyear of the BScN program were randomized to PBL or traditional education. The PBL students scored significantly higher on critical thinking compared to those educated in the traditional stream of the program. The possibility of contamination, due to discussion and sharing of experiences between the two groups of students studying in the same program, limits the applicability of the findings. Altogether these studies suggest a generally positive influence of PBL on the development of critical thinking. However, the studies are primarily cross-sectional and within one education program and few have compared CT level in graduating students from different educational programs, when CT should be evident as an educational outcome. This study was implemented to explore the critical thinking dispositions of nursing students enrolled in a problem-based program compared to nursing students enrolled in a traditional program. Methods Design The research used a descriptive analytic design to compare the effects of PBL and traditional education on senior undergraduate nursing students’ critical thinking dispositions. Setting The study was conducted with students from two schools of nursing in Izmir, Turkey, one of which uses a traditional approach to learning and the other problem-based learning. In the traditional program the education occurs primarily in the classroom in lecture format and it is usually noninteractive. This approach is viewed as an efficient way to cover a large body of knowledge, although there are acknowledged limitations to this method of instruction. The implementation of such an educational program relies largely on memorized knowledge, offering the student ready-made information with limited incentive to stimulate the student’s thinking process. There is the suggestion that this often stifles creativity in students and can adversely affect the development of critical thinking skills (Simpson and Courtney, 2002). PBL is a student-centered educational method that uses an integrated approach, where students work with problems selected from real-life situations. In the PBL model school students work with peers in small groups to identify learning goals, then engage in self-study and return to discuss and apply new learning. Problem-based learning isdesigned to strengthen students’ abilities to analyze and synthesize and develop individual problem- solving and critical thinking skills, although the extent to which this occurs continues to be debated (Dicle, 2001; Kocaman et al., 2003). Sample The research involved 52 fourth-year students at the PBL model nursing school (response rate = 100%) and 95 fourth-year students at the school where the traditional educational model was implemented (response rate = 76%). Ethical review Permission was obtained in advance from the Ethical Review Boards of the two Schools of Nursing where the research was conducted. The aim of the study was explained to the students and participation was entirely voluntary. Data collection A sociodemographic data collection form and the California critical thinking disposition inventory were used as data collection tools. The data were collected in the middle of the final semester of the final year of the program. The questionnaires were distributed during class time and students were asked to complete and return them afterthe class was completed. Sociodemographic data collection form This form comprised four questions about the student’s age (open-ended question), working status, mother–father’s educational level (closed questions).The latter items were included as they provide some insight into the background of the participating students. The California critical thinking disposition inventory The CCTDI, developed by Facione and Facione(1996), is a 75 item Likert scale tool with a Cronbach’s alpha for the total scale of 0.92. It has seven sub-scales: truth-seeking (12 items; alpha 0.71),open-mindedness (12 items; alpha 0.73), analyticity(11 items; alpha 0.72), systematicity (10 items;alpha 0.74), critical thinking and self-confidence(10 items; alpha 0.78), inquisitiveness (10 items; alpha 0.80) and maturity (10 items; alpha 0.75).Total points from the seven sub-scales determinean individual’s critical thinking disposition. A person receiving less than a total of 280 points on the scale is taken to be of low disposition for critical thinking while the critical thinking tendency of a person receiving more than 350 points is high(Facione et al., 1994). The Turkish version of the scale, which was translated and tested for psychometric properties by Kokdemir (2003), was used in this study. The 75 items on the original scale were reduced to 51 items as a result of item-total point correlation analysis and the Cronbach’s alpha was found to be 0.88. Factor analysis of the 51 item scale resulted in six sub-scales and Cronbach’s alpha coefficients were 0.61 for truth-seeking (7 items), 0.75for analyticity (11 items), 0.75 for open-mindedness (12 items), 0.78 for inquisitiveness (8 items), 0.77 for self-confidence (7 items) and 0.63 for systematicity (6 items). In our study a Cronbach’s alpha of 0.85 was found for the total scale and sub-scale reliabilities were 0.64 for truth-seeking, 0.61 for analyticity, 0.79 for open-mindedness, 0.66 for inquisitiveness, 0.75 for self-confidence and 0.56 for systematicity. The California critical thinking disposition inventory uses a six-item Likert-type scale from 1 ‘‘Iabsolutely do not agree’’ to 6 ‘‘I absolutelyagree’’. The Turkish version is scored by summing the items, dividing that total by the number of items and multiplying by ten, so that the minimum value of each sub-scale is 10 and maximum value is 60 and the range for the total scale is from 60 to 360. Individuals scoring less than 240 points on the total scale are considered to have a weak disposition toward critical thinking, while those scoring higher than 300 are assessed as having a high disposition for critical thinking (Kokdemir, 2003). Data analysis The primary outcome measure was the students’critical thinking disposition. The data were analyzed using SPSS. Independent samples t-test were used to compare CCTDI scores between the PBL and traditional education programs. A test of hypothesis with p-value < 0.05 was considered as significant. Results The two groups of students were comparable on all demographic variables (Table 1). Critical thinking disposition scores were 266.0 ? 24.0 for students enrolled in the PBL model school compared to255.8 ? 23.7 for the students in the traditional model school. A statistically significant difference was found between these critical thinking disposition scores (p < 0.05) (Table 2). When the student scores on the sub-scales of the California critical thinking disposition inventory were examined by educational model, statistically significant differences were seen in the ‘‘openmindedness’’and ‘‘truth-seeking’’sub-scales of critical thinking disposition between the students of the two schools (p < 0.05). There were no significant differences in the two schools on the ‘‘analyticity’’, ‘‘systematicity’’, ‘‘inquisitiveness’’ and ‘‘self-confidence’’ sub-scales of the critical thinking disposition scale (p > 0.05) (Table 3). Discussion Our findings provide additional support that PBL is an effective model for increasing critical thinking dispositions of nursing students. Although the critical thinking disposition of the students in both schools were in the medium range, the difference in the critical thinking disposition points scored by the students was found to be statistically significant in favor of the school that was implementing PBL. This adds support also to the contention that PBL enhances the ability of students to integrate theory with practice and engage in critical thinking (Lee et al., 2004). However, it is noteworthy that neither group of students achieved the score of 300 that is considered the threshold for high disposition for critical thinking. In our study, there was a significant difference between critical thinking disposition scores in the‘‘open-mindedness’’ and ‘‘truth-seeking’’ subscales for nursing students in the two nursing schools where different educational models were being implemented. The truth-seeking sub-scale measures the disposition to evaluate alternatives or differing thoughts. A high score in this sub-scale shows that the individual has a greater tendency to seek the truth, to question, to be objective even in the face of information that is contrary to his/her own thoughts. It is believed that the difference between the student scores may be due to the emphasis in PBL on developing students’ questioning and information-seeking skills and their discussion and application of new learning within the tutorials. This finding differs from the studies of Ip et al. (2000), Tiwari et al. (2003, 2006) where students scored lowest on truth-seeking. The PBL and traditional model students also differed significantly on open-mindedness, which reflects a person’s tolerance of different approaches and sensitivity to one’s own mistakes. The fundamental logic in open-mindedness involves the individual’s considering not only his/her own thoughts but also the thoughts of others in the decision-making process. Open-mindedness may be related to the focus on small group work, where students work closely with peers and giving and receiving feedback is an expectation. The lack of difference in the other sub-scales is worthy of further investigation. For example faculty in the PBL program spend considerable time developing scenarios they expect will stimulate curiosity and desire to learn in their students yet the students in this study scored lower than those in other reported studies (Ip et al., 2000; Tiwari et al., 2003, 2006). The scores on self-confidence did not differ between programsalthough they were at a similar level to those reported by Tiwari et al. (2003, 2006) and higher than those of Ip et al. (2000). Conclusions Overall, the results corroborate findings from other studies that found critical thinking is enhanced when active learning approaches like PBL are used.‘‘Open-mindedness’’ and ‘‘truth-seeking’’ sub-dimensions scores of the nursing students in the PBL program were also higher than their conventionally educated peers. There are limitations to the study that must be acknowledged. The response rates are different between the two schools, and although the two groups of respondents are comparable, those who chose not to participate in the study may differ in some way from those who did in some manner that might influence the results.Also the study relied on a self-report measure, as has the other research in this area. There are continuing calls for different approaches to measuring CT that are more specific to nursing (Worrell and Profetto-McGrath, 2007). Until that occurs, using such measures as the CCTDI provides some guidance and encouragement that PBL is a more effective educational approach than the usual traditional approaches in fostering CT in students. Students did not achieve high levels of CT in either the PBL or the conventional models nor did they score high or differ significantly on sub-scales of analyticity, inquisitiveness, self-confidence or systematicity.This suggests the need for continuing efforts by educators to emphasize the development of these skills within both PBL and traditional curricula. References Beckie, T.M., Lowry, L.W., Barnett, S., 2001. Assessing critical thinking in baccalaureate nursing students: a longitudinal study. Holistic Nursing Practice 15 (3), 18–26. Choi, H., 2004. The effects of PBL (problem-based learning) on the metacognition, critical thinking, and problem solving process of nursing students.Taehan Kanho HakhoeChi 34 (5), 712–721. Cooke, M., Moyle, K., 2002. Students’ evaluation of problembased learning. Nurse Education Today 22 (4), 330–339. Daly, W., 1998. Critical thinking as an outcome of nursing education. What is it? Why is it important to nursing practice? Journal of Advanced Nursing 28 (2), 323–331. Dicle, O., 2001. Deg?is_en t?p eg?itimi ve probleme dayal? o?g?renme yo?nteminin temel felsefesi. Dokuz Eylu?l U?niversitesi T?p Faku?ltesi Dergisi 1 (1), 112–116. Distler, J.W., 2007. Critical thinking and clinical competence: results of the implementation of student-centered teaching strategies in an advanced practice nurse curriculum. Nurse Education in Practice 7, 53–59. Facione, N.C., Facione, P.A., 1996. Externalizing the critical thinking in knowledge development and clinical judgment. Nursing Outlook 44, 129–136. Facione, N.C., Facione, P.A., Sanchez, C.A., 1994. Critical thinking disposition as a measure of competent clinical judgment: the development of the California critical thinking disposition inventory. The Journal of Nursing Education 33 (8), 345–350. Ip, W.Y., Lee, D.T.F., Lee, I.F.K., Chau, J.P.C., Wootton, Y.S.Y., Chang, A.M., 2000. Disposition towards critical thinking: a study of Chinese undergraduate nursing students. Journal of Advanced Nursing 32 (1), 84–90. Kocaman, G., Bahar, Z., K?z?lc?, S., Seren, S., 2003. Hems_irelik Eg?itiminde Probleme Dayal? O? g?renme Modelinin Uygulanmas? ve Sonuc?lar?n?n Incelenmesi. _Izmir. Kokdemir, D., 2003. Belirsizlik Durumlar?nda Karar Verme ve Problem C?o?zme. Ankara U? niversitesi Sosyal Bilimler Enstitu?su? Sosyal Psikoloji Anabilim Dal? Doktora Tezi, Ankara. Lee, W.M., Wong, F.K., Mok, E.S., 2004. Problem-based learning: ancient Chinese educational philosophy reflected in a modern educational methodology. Nurse Education Today 24 (2), 136–144. Maynard, C.A., 1996. Relationships of critical thinking ability to professional nursing competence. The Journal of Nursing Education 35 (1), 12–18. McCarthy, P., Schuster, P., Zehr, P., McDougal, D., 1999. Evaluation of critical thinking in a baccalaureate nursing program. The Journal of Nursing Education 38 (3), 142–144. Profetto-McGrath, J., 2003. The relationship of critical thinking skills and critical thinking dispositions of baccalaureate nursing students. Journal of Advanced Nursing 43 (6), 569–577. Seldomridge, LA., Walsh, CM., 2006. Measuring critical thinking in graduate education: what do we know? Nurse Educator 31(3), 132–136. Simpson, E., Courtney, M., 2002. Critical thinking in nursing education: literature review. International Journal of Nursing Practice 8, 89–98. Stewart, S., Dempsey, L., 2005. A longitudinal study of baccalaureate nursing students’ critical thinking dispositions. Journal of Nursing Education 44 (2), 81–85. Tiwari, A., Avery, A., Lai, P., 2003. Critical thinking disposition of Hong Kong, Chinese and Australian nursing students. Journal of Advanced Nursing 44 (3), 298–307. Tiwari, A., Lai, P., So, M., Yuen, K., 2006. A comparison of the effects of problem-based learning and lecturing on the development of students’ critical thinking. Medical Education 40, 547–554. Vaughan-Wrobel, B.C., O’Sullivan, P., Smith, L., 1997. Evaluating critical thinking skills of baccalaureate nursing students. The Journal of Nursing Education 36 (10), 485–488. Worrell, J.A., Profetto-McGrath, J., 2007. Critical thinking as an outcome of context-based learning among post RN students: a literature review. Nurse Education Today 27 (4), 286–292. Youngblood, N., Beitz, J.M., 2001. Developing critical thinking with active learning strategies. Nurse Educator 26 (1), 39–42.