Implementation and evaluation of critical thinking strategies to enhance critical thinking skills in...

R E S E A R C H P A P E R

Implementation and evaluation of criticalthinking strategies to enhance critical thinking

skills in Middle Eastern nurses

Elaine Simpson PhD RNManager, Regis Corinya, New Farm, Brisbane, Queensland, Australia

Mary Courtney PhD RNProfessor of Nursing and Assistant Dean (Research), Faculty of Health, Queensland University of Technology, Kelvin Grove, Queensland, Australia

Accepted for publication August 2008

Simpson E, Courtney M. International Journal of Nursing Practice 2008; 14: 449–454Implementation and evaluation of critical thinking strategies to enhance critical thinking skills in

Middle Eastern nurses

The purpose of this study was to develop, implement and evaluate critical thinking strategies to enhance critical thinkingskills in Middle Eastern nurses. Critical thinking strategies such as questioning, debate, role play and small group activitywere developed and used in a professional development programme, which was trialled on a sample of Middle Easternnurses (n = 20), to promote critical thinking skills, encourage problem solving, development of clinical judgment makingand care prioritization in order to improve patient care and outcomes. Classroom learning was transformed frommemorization to interaction and active participation. The intervention programme was successful in developing criticalthinking skills in both the nurse educators and student nurses in this programme. This programme successfully integratedcritical thinking strategies into a Middle Eastern nursing curriculum. Recommendations are as follows: (1) utilizeevidence-based practice and stem questions to encourage the formulation of critical thinking questions; (2) support theneeds of nurse educators for them to effectively implement teaching strategies to foster critical thinking skills; and (3)adopt creative approaches to (i) transform students into interactive participants and (ii) open students’ minds and stimulatehigher-level thinking and problem-solving abilities.

Key words: critical thinking strategies, debate, questioning, role play, small group activity.

INTRODUCTIONThe purpose of this study was to develop, implement andevaluate a new way of learning for 20 Middle Easternnurses, by using critical thinking strategies such as

questioning, debate, role play and small group activity topromote critical thinking skills within a professionaldevelopment programme. Tommie et al.1 point out thatthe diversity and complexity of nursing practice makes itessential to prepare nurses who think critically as well asanalyse, synthesize and evaluate situations.

In 1992 in the USA, the National League for Nursing2

mandated nursing baccalaureate programmes includethe development of critical thinking skills as a core

Correspondence: Elaine Simpson, Regis Corinya, 218 Moray Street,New Farm, QLD. 4005, Australia. Email: [email protected]

International Journal of Nursing Practice 2008; 14: 449–454

doi:10.1111/j.1440-172X.2008.00719.x© 2008 The Authors

Journal compilation © 2008 Blackwell Publishing Asia Pty Ltd

mailto:[email protected]

component in nursing curriculum. Soon after this, health-care accreditation agencies around the world moved toinclude critical thinking as a requirement for nurses whenmaking clinical judgments concerning care provision.3

Brookfield (in Garrison4) succinctly states that criticalthinking is ‘a very constructive activity with the ultimatepurpose of gaining insight for the purposes of changingthings for the better’.

LITERATURE REVIEWMany authors, such as Blair,5 Brookfield,6 Kramer,7

Facione and Facione,8 Kurfiss,9 McPeck10 and Paul,11

support the view that critical thinking is more than a set ofskills. Critical thinkers can provide justifications for theiractions—they have the ability to think through, projectand anticipate the consequences of those actions. Schank12

notes that it is vital for nurses to master the skills ofthinking and reasoning in order to constructively critiquethe value and application of new knowledge. Nowhere isthis process of critiquing the applicability of new knowl-edge more needed, than in nursing education curricula.Therefore, when evaluating curriculum in terms of itsstructure, emphasis needs to be placed on the quality ofthe content and how students are able to process andevaluate the information.13 The literature suggests theimportance of using critical thinking strategies to developcritical thinking abilities.

Miller and Malcolm14 advocate instructional strategiesto foster critical thinking that can be integrated into alllevels of nursing curriculum. The authors further suggesthow this integration will materialize, depends primarilyon faculty members’ level of discussion and participation,as they consider the necessity to increase teaching strat-egies that promote critical thinking. Paul15 notes that it isimportant for educators to ‘abandon methods that makestudents passive recipients of information and adopt thosethat transform them into active participants in their ownintellectual growth’. Nurse educators need to provideopportunities and appropriate teaching methods whenteaching critical thinking, and Bittner and Tobin16 indi-cate that instructional methods to enhance critical think-ing should include creative approaches to open nurses’minds, broaden and augment their ways of thinking andfacilitate the process of problem solving. The followingsections will provide an overview of the preparatory,implementation and evaluation phases undertaken duringthis study.

METHODSPreparatory phase

The preparations of the teaching and learning environ-ment were keys to the success of this programme. Nurseeducators were accustomed to arranging classrooms in amilitary style arrangement and routinely used a didacticteaching style. In order to encourage classroom interac-tion, the classroom used for this programme was arrangedin a ‘U’ shape, which allowed all participants to have eyecontact and to question and interact with each other. Thiswas a totally new experience for nurse educators andstudents. To facilitate group work, four small studentworkrooms were identified and fitted with white/blackboards, as well as video recorders.

Mentorship to nurse educatorsA variety of strategies have been reported as being effec-tive in promoting, attaining and advancing the acquisitionof critical thinking.17–20 Drawing on the literature, fourinstructional methods (questioning, small group activity,role play and debate) were used to foster critical thinkingskills in Middle Eastern nurses during this study, andintegrated into lesson plans within the curriculum. Theeducation manager acted as a mentor to the nurse educa-tors by providing literature and teaching resources onthese critical thinking strategies to upgrade their knowl-edge and instructional techniques. This will be discussedfurther in the implementation phase. Additionally, themanager demonstrated the use of these critical thinkingstrategies in several teaching sessions, until the educatorswere confident in using each such strategy themselves.The manager also provided feedback to nurse educatorsafter they delivered their initial sessions and identifiedstrategies for the nurse educators to improve their criticalthinking teaching skills.

After preparing the teaching and learning environment,the education programme focusing on questioning, smallgroup work, role play and debate was implemented andthis will be discussed in the next section of this paper.

Implementation phase of criticalthinking strategies

Questioning strategyNurse educators utilized stem/guided questions (King)21

as a tool or device to induce critical thought. Studentswere also given a template of King’s stem questions toassist in generating critical thinking questions (CTQs). Asample of stem questions is reflected in Table 1.

450 E Simpson and M Courtney

© 2008 The AuthorsJournal compilation © 2008 Blackwell Publishing Asia Pty Ltd

Nurse educators used a ‘round-robin’ technique andengaged in thought-provoking questions to confirm stu-dents’ comprehension of the material. For example,‘explain why . . .’ (analysis of significance) and ‘Whatwill happen if . . . ?’ (prediction). Such CTQs inducedhigher-level cognitive processes such as problem solving,analysis of ideas, inference, prediction and evaluation.Students were forced to go beyond the facts to think ofeach focal situation in a variety of ways. These questionsalso energized the participants to interact actively—it wasa way to allow another voice in the classroom, other thanthat of the teacher. Nurse educators provided ‘wait time’for students to respond in order to improve the quantityand quality of their answers. On completion of eachsession, about 5 min was set aside for participants to for-mulate CTQs using the stem guide.

These CTQs were collected, shuffled and redistributedto the class. This method allowed students to answer eachother’s questions, as well as their own and were activelisteners, alert and motivated. The facilitator’s role wasactive and passive: active, when the facilitator wouldspring surprises on any student to answer questionsand passive, when facilitating and clarifying answers asrequired. When students experienced difficulty inresponding, the facilitator paused for a few seconds to givethem time to consider the question. King’s study foundthat when students experienced difficulties they werenot necessarily seeking correct answers, but they weremaking mental connections between concepts that werealready familiar to them.

Videotape presentations of scenarios were used as adevice to support the questioning technique. During thesesessions the facilitator would stop the videotape briefly to

question participants about certain aspects of the scenario.For instance, ‘what is happening here?’ (analysis) and‘What if . . . had happened instead?’ (prediction). Video-tape sessions allowed for group discussions to convene asstudents shared their thoughts and asked more questions.

Educators also formulated questions with correspond-ing answers, which were typed onto flashcards. The classwas divided into teams. One student from a team wasrandomly selected to start a question. Other studentswere required to think and analyse the question. Anopposing team member was selected to give the correctresponse. If this student was unable to respond, themembers within the team were given the opportunity tocollaborate in order to produce the correct response.

When an incorrect response was verbalized, the teamlost a point and the other team(s) was allowed to retrievethe correct answer. This playful approach created arelaxed atmosphere and challenged students to engageactively and think before providing an answer.

Small groups strategySmall group activities were conducted in almost all of thesessions with five students in a workroom. Students wererandomly selected for group work so that they had theopportunity to interact with different individuals. Duringthe group process students utilized the whiteboard orchalkboard to write, create diagrams and flowcharts toexpress their thinking and present their findings to othergroup members. They also formulated CTQs, which theyposed to their peers and discussions ensued.

Nurse educators commented that circulating aroundgroups, listening and observing students provided con-structive feedback about the instructional process becauseit informed the facilitator which concepts needed clarifi-cation or modification. Students commented that thisactivity ‘keeps us interactive, thinking and we are notbored’.

Debate strategyThe debate process was explained and they were encour-aged to ask questions about this activity. The topic fordiscussion was provided before the scheduled debate andthey were randomly selected into two teams. Journalarticles and references were given for background knowl-edge so that they could research the topic. Student judgesand timekeepers were randomly selected and the judgingprocess was explained.

The teams faced each other and the judge and time-keeper sat at the head of the two teams. During a debate,

Table 1 Stem questions adapted from King21

Generic questions Specific thinking skills

induced

What would happen if? Prediction/hypothesis

What are the strengths and

weaknesses of . . . ?

Analysis/inferencing

What is the difference between

. . . and . . . ?

Comparison/contrast

Why is . . . important? Analysis of significance

What is another way to look

at . . . ?

Taking other perspectives

Strategies to enhance nurses’ critical thinking skills 451


the facilitator only assisted when required. When allmembers had the opportunity to respond and argue theirviews, the student judge pronounced the verdict withsupport from the nurse educator if necessary. Followingthe debate, students were encouraged to raise anyissue(s). The educator asked their feelings about thedebate process. Students formulated CTQs, which werecollected. The educator randomly picked questions andencouraged students to respond.

Role-play strategyThe facilitator explained this process and describedthe characters. The facilitator assigned roles for the stu-dents and rearranged the classroom. The actors im-provised their behaviours appropriately to illustrate theexpected actions for the particular scenario. The otherstudents/audience sat in a semi-circle. The facilitator ex-plained the role of the audience as active and interactiveparticipants.

The audience participated and contributed to the dis-cussion and analysis. Students had the opportunity to becreative and actively involved in a learning experience, ina non-threatening situation. Nurse educators were passiveobservers, who interceded as required. At the end of eachrole play, the facilitator debriefed the class by asking ques-tions such as ‘how did this experience make you feel?’.The students were encouraged to ask questions and usedstem guides to generate their own CTQs based on thescenario. These questions were collected and addressed.Clearly, not all of these strategies could be utilized withinthe framework of a single lecture.

RESULTS AND DISCUSSIONDirect participant observation including watching inter-actions and behaviours, listening, asking questions andexamining materials was undertaken by the manager.Additionally, separate focus group interviews wereundertaken with nurse educators as well as students inorder to compare levels of satisfaction with the pro-gramme. Overall, both groups provided very positivefeedback at focus group interviews and are reportedas follows:

Focus group interview: The manager with two nurse edu-cators

Interviewer: Do you think critical thinking can bedeveloped?

N/Educators: Yes, especially when we were given the direc-tion, preparation and the tools to use. For

example, the stem guide question, work-rooms, feedback, adequate resources.

Interviewer: What are your feelings about using criti-cal thinking strategies as a method ofinstruction?

N/Educator: It is an effective way to teach––interactiveand participative.

Interviewer: Why do you like these teaching strategies?N/Educators: Because everyone’s involved, including us

and helps the student to develop an inquir-ing mind.

Interviewer: Which strategy did you like best?N/Educators: All of them—they all had their challenges.

It challenged us too. Remember this is new tous too and it has been a positive learningexperience to be used for the future.

Interviewer: You were observed while you were teaching.How did you feel about this?

N/Educators: We were nervous at first, but the environ-ment was non-threatening as you alwaysgave us timely constructive feedback—praised our efforts. It helped us improve.

Interviewer: Have you noticed any difference in the stu-dents’ performance in the classroom andclinical field?

N/Educator: Indeed! They have moved from being used toa didactic way of learning to being interac-tive. They learned to use a critical thinkingapproach to develop questions, are more dili-gent in asking questions and more confidentin their practice. For example, an unusualdose of medication was ordered for a diabeticpatient. The student reflected on her practiceand the patient’s medical condition. Usingher clinical judgement, she approached thehead nurse for clarification—the medica-tion was reviewed. The head nurse paged meto give me this vital feedback. There areseveral other examples such as this one.

Interviewer: Do you have anything to say?N/Educators: We learnt a lot and will continue to teach

in this manner. We developed ourselves byembracing critical thinking and used thetools and feedback to help us. It is nice toobserve a positive change in the students’behaviour—their interaction and participa-tion which is a result of using critical think-ing strategies.



Focus group interview: the manager with the students

Interviewer: What do you think of critical thinkingstrategies?

Student: Our teaching instruction in the past wasalways memorization and writing, writing,writing! It was hard to write and understandthe content at the same time. This is a muchbetter way of teaching and learning. You’renot just giving us lectures, you are providinginformation by questioning—encouraging usto think and developing our minds.

Interviewer: How do you feel about generating criticalthinking questions?

Student: This is a good idea and the stem guide ques-tions are very helpful. I like it (othersacknowledged). Also when the teacher distrib-utes other peoples’ questions and I don’t knowthe answers, I can learn from other students’answers. I need to have critical thinking skillson the clinical field to make effective clinicaljudgements. I feel more confident now indelivering patient care (nods of approval).

Interviewer writes the four strategies on the board and asksstudents to rate them:

Various members: Group work and questioning, then debateand role play. It is not that we don’t likethe others—we need more practice—keep it—they are fun and we liked it.

Interviewer: Why group work?Student: Because when I have an idea, we can

discuss it together, write on the boardand share our ideas and then present tothe other groups.

Interviewer: Do you have anything to say?Various members: Our teachers were great—they enjoyed it

too. Our Head-Nurses’ also gave us posi-tive feedback. Keep using critical think-ing strategies for other groups.

This programme successfully integrated critical thinkingstrategies into a nursing curriculum in this group ofMiddle Eastern nurses, and classroom learning was trans-formed from memorization to interaction and active par-ticipation. Students were encouraged to solve problem,make clinical judgements based on facts and prioritize carein order to improve patient outcomes.

The students’ ability to formulate CTQs on the contentmaterial and in homework assignments was improved bythe end of the programme. Examples of CTQs by studentsby the end of this programme are reflected as follows:1. What would happen if an elderly person falls anddevelops a fracture? (Prediction/hypothesizing)2. How does ageing affect all the body systems? (Analysisof relationship: cause–effect)3. What strategies can be implemented to deal withdepression? (Application)King21 had similar findings in her study with psychologystudents and reported that teachers can enhance their(students’) use of CTQs by using critical thinking typequestions in their teaching.

The development of faculty members and students wasessential in order to make a change from a passive to aninteractive process. Critical thinking strategies needed tobe integrated into all lesson plans within the curriculum.Resources and devices such as workrooms, videotapes,critical thinking stem questions and so forth should bereadily available for learning to take place.

Furthermore, instructors should have a sound knowl-edge of their curriculum content and adopt an interactiveteaching style, utilizing critical thinking techniques toencourage participation and interaction from the studentsto influence their thinking. Thus, critical thinking‘becomes a daily experience’.18

CONCLUSIONThe educational programme has developed individualswho have transformed from being passive or rote learnersto having inquiring minds. They have socialized into criti-cal thinking and have started on a path that could leadthem to be lifelong learners. Critical thinking in nursingpractice can lead to safe, competent and quality care, aswell as promote professionalism in nursing. Therefore,not only will patients’ outcomes improve but also theactual health-care environment should improve. One pro-gramme cannot function independently to train all MiddleEastern nurses to be critical thinkers. Other programmeshave to be involved to integrate critical thinking into thecurricula nationwide.

RECOMMENDATIONS1. Utilize evidence-based practice and stem guide ques-tions to assist and encourage the formulation of CTQs.2. Support the needs of nurse educators in order for themto effectively implement teaching strategies to foster criti-cal thinking skills.

Strategies to enhance nurses’ critical thinking skills 453


3. Adopt creative approaches to: (i) transform studentsinto interactive participants; and (ii) open students’ mindsand broaden and stimulate higher-level thinking andproblem-solving abilities.

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2 National League for Nursing. Criteria and Guidelines forthe Education of Baccalaureate and Higher Degree Programs inNursing. New York: National League for Nursing, 1992.

3 Joint Commission for Accreditation for Healthcare Organi-sations (JCAHO). Accreditation Manual for Hospitals.Oakbrook, IL, USA: The Joint Commission, 1993.

4 Garrison DR. Critical thinking and adult education: Aconceptual model for developing critical thinking in adultlearners. International Journal in Life Long Education 1991;11 (4): 287–303.

5 Blair JA. Some challenges for critical thinking. In: HoaglandJ (ed.). Conference on Critical Thinking: Christopher NewportCollege. Newport, VA, USA: Christopher Newport CollegePress, 1985.

6 Brookfield SD. Developing Critical Thinkers. Milton Keynes,UK: Open University Press, 1987.

7 Kramer MK. Concept clarification and critical thinking:Integrated processes. Journal of Nursing Education 1993; 32(9): 406–414.

8 Facione NC, Facione PA. Holistic Critical ThinkingRubric. Millbrae, CA, USA: The California Academic Press,1994.

9 Kurfiss JG. Critical Thinking Theory, Research, Practice andPossibilities. ASHE-ERIC Higher Education Report No.2.Washington DC, USA: Association for Study for HigherEducation, 1988.

10 McPeck J. Critical Thinking in Education. New York: StMartin’s Press, 1981.

11 Paul R. The critical thinking movement. National Forum1985; 65 (1): 32.

12 Schank M. Wanted: Nurses with critical thinking skills.Journal of Continuing Education in Nursing 1990; 21 (2):86–89.

13 Royal College of Nursing, Australia. Position Statement:Quality in Nursing Practice. February. Deakin, ACT,Australia: Royal College of Nursing (RCNA), 1997.

14 Miller M, Malcolm N. Critical thinking in the nursing cur-riculum. Nursing and Health Care 1990; 11 (12): 67–73.

15 Paul R. Critical Thinking. Rohnert Park, CA, USA: SonomaState University, 1990.

16 Bittner NB, Tobin D. Critical thinking: Strategies forclinical practice. Journal for Nurses in Staff Development 1998;14 (6): 267–272.

17 Case B. Critical thinking: Challenging assumptions andimagining alternatives. Dimensions of Critical Care Nursing1995; 14 (5): 275–279.

18 Elliott D. Promoting critical thinking in the classroom.Nurse Educator 1996; 21 (2): 49–52.

19 Oermann MH. Evaluating critical thinking in clinical prac-tice. Nurse Education 1997; 22 (5): 25–28.

20 Schell K. Promoting student questioning. Nurse Education1998; 23 (950): 8–12.

21 King A. Designing the instructional process to enhancecritical thinking across the curriculum. Teaching of Psychology1995; 22 (1): 13–17.



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