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Journal of Advanced Nursing, 1999, 29(3), 577±583 Integrative literature reviews and meta-analyses
Catching the wave: understanding
the concept of critical thinking
Judy E. Boychuk Duchscher RN BSN FCCM MNc
Graduate Student in the Masters of Nursing Programme,
University of Saskatchewan, Saskatoon, Saskatchewan, Canada
Accepted for publication 19 February 1998
BOYCHUK DUCHSCHER J.E. (1999) Journal of Advanced Nursing 29(3), 577±583
Catching the wave: understanding the concept of critical thinking
As a practice-orientated profession, nursing is clearly guided by theoretical
concepts. Concept clari®cation attempts to show speakers and readers how they
can liberate themselves from the judgement limitations imposed by rigid,
unexamined beliefs, by exposing differences in the interpretation of language
and how that interpretation creates meaning. Critical thinking is one way nurses
apply the process of inquiry. As a method of assessing, planning, implementing,
evaluating and reconstructing nursing care, a critical thinking approach
encourages nurses to challenge established theory and practice. Existing
literature on critical thinking is confusing in its description of the process, and
ambiguous in drawing relationships between critical thinking and the language
currently used to illustrate the process of nursing. This paper examines
elements and components of critical thinking as they relate to the language of
nursing: problem solving, decision making, clinical judgement, re¯ection, and
the nursing process. The purpose of this analysis is to illuminate the meaning
and clarify the intent of critical thinking application to nursing practice. The
paper begins by brie¯y outlining the historical aspects of critical social theory,
suggesting that the foundational tenets of critical theory have in¯uenced the
development of critical thinking. The paper also critically compares the
language used to describe critical thinking and that language that has tradi-
tionally de®ned nursing.
Keywords: critical thinking, critical theory, nursing practice, concept
clari®cation, problem solving, clinical judgement, decision making
readers from the judgement limitations imposed by rigid,
TOWARD A CLARIFICATION
unexamined beliefs.
OF CRITICAL THINKING
This paper will brie¯y outline the historical aspects of
As a practice-orientated profession, nursing is clearly critical social theory, suggesting that the tenets of this
guided by theoretical concepts. The clari®cation of con- theory have in¯uenced the development of theory related
cepts is widely recognized to be an important factor in the to critical thinking. The paper will provide a critical
development of nursing theory (Kramer 1993). The central comparison between the language used to describe critical
challenge of concept clari®cation is to understand how thinking and the language that de®nes nursing. The goal is
words create meaning, thereby liberating speakers and to illuminate the meaning and clarify the intent of critical
thinking application to nursing practice.
Critical thinking is one way nurses apply the process of
Correspondence: Judy E. Boychuk Duchscher, 216 Cumberland Avenue
South, Saskatoon, Saskatchewan, Canada S7N 1L9. inquiry. As a method of assessing, planning, implement-
Ó 1999 Blackwell Science Ltd 577
J.E. Boychuk Duchscher
ing, evaluating and reconstructing nursing care, a critical Mezirow (1981 p. 6) coined the term `perspective
thinking approach encourages nurses to challenge estab- transformation' to denote the acquisition of a `critical
lished theory and practice. Existing literature on critical consciousness' (Mezirow 1981 p. 13). This disposition is
thinking is confusing in its description of the process, and realized by critically analysing perceptions, cultural as-
ambiguous in drawing relationships between critical sumptions, and social expectations that dictate how
thinking and the language currently used to illustrate the human beings relate to their world. Re¯ection is a key
process of nursing. Elements and components of critical element in this process (Rogers 1989). The emphasis is on
thinking will be examined as they relate to the language of facilitation of self-understanding so that the person be-
nursing: problem solving, decision making, clinical judge- comes aware of institutionally, culturally or socially
ment, re¯ection, and the nursing process. embedded ideologies that have been unknowingly or
unwillingly internalized. Continued re¯ection exposes a
`false consciousness' (Grundy 1987 p. 19) and serves to
CRITICAL SOCIAL THEORY
emancipate the individual. Critical thinking, though not
In the early 20th century, the Institute of Social Research in the sole means, provides a framework for the practice of
Germany, later known as the Frankfurt School, was critical social theory.
concentrating its efforts on developing a theory to address
the unsuccessful integration of capitalism and socialism
in Eastern Europe. Philosophers of the Frankfurt School, CRITICAL THINKING
most notably Max Horkheimer, Herbert Marcuse, Theodor
Adorno and Jurgen Habermas, were looking into a new Critical thinking has been described in the literature as: a
pathway for social development (Holter 1988). Critical skill applied to the nursing process (Jones & Brown 1991,
social theory laid a foundation for the interdisciplinary Case 1994), a variant of the scienti®c method utilized in
study of questions about the conditions that in¯uence clinical practice (Shank Pless & Clayton 1993), contextual
society, the meaning and internalization of cultural mores, formal reasoning undertaken with critical inquiry (Schu-
and the relationship between individuals and their social macher & Severson 1996), a process orientated
environments (Held 1980). The purpose of this applied educational ideal (Jones & Brown 1993), a necessary tool
theory was to identify and to challenge the assumptions of for socially responsible nursing practice (Tanner 1996),
oppression existing within social structures; the goal was and a free, rational and autonomous mind (Paul 1990,
emancipation (Wilson Thomas 1995). Jones & Brown 1991). Facione & Facione (1996 p. 345)
At the heart of critical social theory was its criticism provided an interesting description of `critical spirit' as a
of ideology. Critical social theorists believed that insis- style or set of attitudes that de®ne one's personal dispo-
tence on rational thought mediated strictly through sition to value and apply critical thinking in the person's
scienti®c objectivity invalidated the perceptions and life work. These researchers contend that `ideally, critical
experiences of human beings. As a knowledge generat- thinking becomes a habit of mind, a part of one's charac-
ing force, human subjectivity had been too long ignored. ter' (Facione & Facione 1996 p. 129).
Critical social theory epistemology maintained that The emergence of critical thinking in nursing originated
knowledge as truth was socially constructed and that from an identi®ed need to address social, economic,
life was valuable only in its meaning, a meaning that environmental and international health challenges (Ray
was derived from the lived experiences of persons 1992). In 1987, the consideration of critical thinking as a
(Campbell & Bunting 1991). nursing concept started to take hold, driven largely by the
Integral to critical social theory and its approach to American Philosophical Association's Delphi Research
knowledge is an awareness of language. Language is a Project. This collaborative effort by 46 cross-disciplinary
powerful in¯uence in the interpretation of context; dom- theoreticians across North America culminated in a 1990
inant group supported power imbalances act as concealed publication that outlined a conceptual de®nition of the
inhibitors of free discourse; rationality and embedded ideal or paradigm critical thinker:
social constraints operate intentionally to restrict discus-
sion therefore repressing a democratic approach to prob- The ideal critical thinker is habitually inquisitive, well informed,
lem resolution (Allen 1985). Examples of power trustful of reason, open minded, ¯exible, fair minded in evalu-
imbalances interposed through language can be found in ation, honest in facing personal biases, prudent in making
the use of nursing practice terms such as non-compliant or judgments, willing to reconsider, clear about issues, orderly in
dysfunctional. The use of such terms can serve to control complex matters, diligent in seeking relevant information, rea-
by virtue of their interpretation; to be labelled dysfunc- sonable in the selection of criteria, focused in inquiry, and
tional or non-compliant is, generally, to be invalidated persistent in seeking results which are as precise as the subject
and disempowered. One is left to question the intent by and the circumstances of inquiry permit
virtue of the outcome. (Facione 1990 p. 2)
578 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(3), 577±583
Integrative literature reviews and meta-analyses Understanding critical thinking
Though certainly ideal in its depiction, this de®nition violations in critical thinking as results of either the
spirited a new emphasis on critical thinking in North process or the underlying applied beliefs and assump-
American educational curricula. tions. The components of communicative action and
Subsequent to this de®nition, standards of nursing re¯ection inherent in critical social theory are vital for
accreditation were instated through the National League exploring reason in critical thinking.
of Nursing (NLN) Council of Baccalaureate and Higher Brook®eld (1987) believed that we would know a
Degree Programmes. Critical thinking, communication critical thinker when we saw one. He characterized
and therapeutic nursing interventions became requisites critical thinkers as people: engaging in productive and
for nursing education. The Vision for Nursing Education, positive activity, viewing their thinking as a process rather
published in 1993, delineated the need for changes in than an outcome, varying in their manifestations of critical
nursing education that re¯ected the importance of the thinking according to context, experiencing triggers of
student/teacher relationship in the development of caring critical thinking as positive or negative, and feeling
and humanitarian graduate nurses (L. Crawford, personal comfortable with the emotive as well as the rational
communication, 23 October 1996). Critical thinking was elements of the critical thinking process. One immutable
designated as `the process of purposeful, self regulatory interpretation of the concept of critical thinking through-
judgment; an interactive, re¯ective, reasoning process' out the literature and congruent with the foundational
(Facione et al. 1994 p. 345). The Canadian Association of tenets of critical social theory, is its emancipatory poten-
University Schools of Nursing (CAUSN) and the Canadian tial (Ray 1992, Ford & Profetto McGrath 1994, Porter 1994,
Nurses Association (CNA) recently expressed their inte- Henderson 1995, Conger & Mezza 1996). To Apps (1985 p.
rest in exploring the development of critical thinking as a 151), `emancipatory learning is that which frees people
construct for nursing education, research and practice (W. from personal, institutional, or environmental forces that
McBride, personal communication, 14 August 1997, B. prevent them from seeing new directions, from gaining
Mullington, personal communication, 14 August 1997). A control of their lives, their society and their world'.
new era of nursing is being initiated by the conventional A second concept integral to critical thinking is the
acknowledgement of critical thought as essential to ratio- dialectical thinking mentioned earlier (Paul 1990). Dia-
nal and accountable practice. lectical thinking focuses on understanding and resolving
contradictions (Brook®eld 1987). This author suggests that
a circular association of judgement re¯ection reconsider-
Elements of the critical thinking process
ation is compatible with the binary dialogical dialectical
In applying critical thought to the practice of nursing, it is thinking approach. Critical thinking, said Brook®eld
necessary to understand the principles and components of (1987), involves our recognition of the assumptions un-
the critical thinking process. Kintgen Andrews (1991) derlying our beliefs and behaviours, which returns us to
provided interesting insight into the complexities of crit- the key component of critical thinking re¯ection.
ical thinking. She addressed metacognition, de®ned as
thinking about your thinking, as differentiating between
Components of critical thinking
mediocrity and excellence in one's disposition to think
critically. Berger (1984) described creative thinking as Brook®eld (1987) identi®ed four key components to crit-
incorporating both rationality and imagination in the ical thinking; these elements appear insistently in the
thoughtful examination of possibilities. Ability in dia- literature. Identifying and challenging assumptions is
logical reasoning and dialectical thinking incorporates central to critical thinking. Once assumptions are ex-
many perspectives in the holistic development of one's posed, they can be examined for accuracy and validity.
sense of rationality. Dialogical reasoning, also referred to as Second, the importance of context to critical thinking is
multilogical thinking, is the extended exchange of frames of crucial. Recognizing that action in practice is never
reference between two or more persons. Concurrently, the context free, critical thinkers have a heightened awareness
practice of dialectical thinking plots two or more opposing of how assimilated assumptions shape their perceptions,
points of view in competition with each other. Support for understandings and interpretations of the world.
each view, and the raising and countering of objections, is Exploring and imagining alternatives is the third com-
integral to the process (Paul 1996). A dialectical debate is ponent in Brook®eld's (1987) analysis of critical thinking.
conceded when one's position is reconstructed through the Critical thinkers are continually trying to uncover new
integration and incorporation of opposing views. The and different ways of perceiving their world. They appre-
outcome of dialectical thinking and dialogical reasoning ciate that context is circumscribed by inherent environ-
is communicative action; the consensual development of a mental norms which are open to scrutiny. Brook®eld
more accurate interpretation of meaning. (1987 p. 18) described this as `com[ing] to realize that
Norris (1985) emphasized the necessary knowledge for every belief we hold, every behaviour we cherish as
successful critical thinking. He concerned himself with normal, every social or economic arrangement we perceive
Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(3), 577±583 579
J.E. Boychuk Duchscher
as ®xed and unalterable can be and is regarded by other[s] within the de®nitive nature of problem solving as a
as bizarre, inexplicable, and wholly irrational'. concept (Friere 1970). In critical thinking, one may reach a
Finally, imagining and exploring leads the critical reasoned conclusion only to have it return to the practi-
thinker to re¯ective scepticism. Scepticism born of com- tioner for re-evaluation of the original problem posed.
municative action and re¯ection cautions one in the This circular association referred to earlier as judgment
acceptance of universal truths. Unique knowledge gener- re¯ection reconsideration is vital for the generation of new
ated in the perpetual search for new understandings makes knowledge. Further explication of this idea will follow in
all previously set knowledge boundaries vulnerable. a discussion of the nursing process.
CRITICAL THINKING IN NURSING Decision making
Nursing, as both art and science, is predicated upon the Once an individual is comfortable with the knowledge
human experience. As such, it is complex and seldom that universal truths are open to speculation, decision
amenable to the application of singular solutions. Nursing making and clinical judgement as rigid structural dimen-
should have little adherence to linear thinking. This sions become less circumscribed. The development of
section will explore the relationship of critical thinking to excellent reasoning skill takes time and a willingness to
problem solving, decision making, clinical nursing judg- explore alternatives; critical thinking provides a clarifying
ment and the nursing process. framework within which the search for alternatives is both
supported and anticipated.
Decision making and problem solving connote different
Problem solving
meanings with respect to critical thinking. Although
As Bevis (1993 p. 104) observes, `problem solvingF F F [in]F F F problem solving presupposes absolute solutions, decision
nursingF F F is a framework for solving problems; it may or making provides a basis for intervention that is predicated
may not have critical thinking as an element'. By de®ni- on softer justi®ed conclusions; as such it is more congru-
tion, problem solving is solution or product orientated, in ent with the basis of critical thought. Bandman & Band-
con¯ict with the process orientation of critical thinking. man (1995 p. 103) believed that `all thoughts and actions
Traditional empiricist behaviourist methods of teaching culminate in some kind of a decision. Even ``no decision''
can reinforce graduates whose thinking is limited by an is a decision, because, in effect, it supports the existing
adherence to the structure and linearity of problem state of affairs'. It would seem that the difference in
solving. Linearity, as used in the context of traditional decision making, as opposed to problem solving, within
nursing education, connotes straight line thinking; it is the perspective of critical thinking lies in accepting the
implied that there is a right or wrong answer, or that the equivocal nature of de®nitiveness. Nurses face a current
answer is the truth, and therefore absolute. This is in challenge to facilitate the shift from critical thinking as
contrast to a critical approach to thinking, in which the problem solving to critical thinking as a process of
process of consideration re¯ection reconsideration is re¯ective decision making. That process is mediated
engaged. Creative, non-traditional alternatives for clinical through dialectical thinking and dialogical interaction,
problems often threaten the security and assured correct- grounded in critical inquiry.
ness of the traditional outcome orientation of the behav-
iourist paradigm. Developing an environment that
Clinical judgement
celebrates the uncertainty inherent within established
methodologies, and one that encourages the consideration Clinical judgement rooted in the critical thinking process
of multiple perspectives outside of what is already known, assumes `an understanding that knowledge is limited,
endorses new knowledge, provides for intellectual ¯exi- beliefs change, and conclusions are temporary' (Jones &
bility, yet maintains a safety net of established care Brown 1993 p. 72). Tanner (1987 p. 154) de®ned clinical
standards. As Alfaro LeFevre (1995 p. 11) claimed, `in judgement as:
many ways, critical thinking is like an ``upgraded version''
a series of decisions made by the nurse, in interaction with the
of the problem solving method'.
client regarding (a) the type of observations to be made in the
Questioning is an important tool used by the critical
client situation, (b) the evaluation of the data observed and
thinker in problem solving processes (Miller & Malcolm
derivation of meaning (diagnosis), and (c) nursing actions that
1990). Questioning identi®es central issues, examines
should be taken with or on behalf of the client.
reasoning, inquires into the clarity or ambiguity of the
language de®ning the problem, places emphasis on the This de®nition resembles the nursing process itself,
exploration of value con¯icts, and facilitates the challeng- with the exception of an emphasis on interactive dis-
ing of assumptions. Through the inherent problem posing course with the client as fundamental to the development
elements of critical thinking, we can expose discrepancies of nursing interventions.
580 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(3), 577±583
Integrative literature reviews and meta-analyses Understanding critical thinking
Research studies have not demonstrated a consistently tiate the process-driven, phenomenological knowledge
signi®cant relationship between clinical nursing judge- generated by nursing practice.
ment and critical thinking (Frederickson & Mayer 1977, Taken within the context of its original intent, the
Pardue 1987, Brooks & Shepherd 1990, Kataoka et al. nursing process is scienti®c and product driven; its
1994). However, this indetermination may result from lack objective is to provide a rational linear approach to
of re®nement in design and instrumentation, rather than problem solving (Howenstein et al. 1996). Initiation of
from any lack of relationship between critical thinking the process is problem orientated and the goal is to
and clinical judgement (Howell Adams et al. 1996, Rane uncover the best solution by applying a comprehensive set
Szostak & Fisher Robertson 1996). Clari®cation of the of steps.
terms critical thinking and clinical judgement, as well as In 1991, Jones and Brown undertook a study to expand
an evaluation of the reliability and applicability of the their understanding of perceptions about critical thinking
measurement tools used in nursing will require further in the discipline of nursing. A total of 470 surveys were
investigation. distributed to deans or directors of each identi®ed NLN
accredited baccalaureate and higher degree programme in
the United States. The survey asked respondents to
identify those concepts they perceived to be associated
The nursing process
with critical thinking. Data were analysed on a 51% return
Reviewing literature on critical thinking makes one privy rate. Respondents `believed critical thinking to beF F F a
to debates about the congruency of the nursing process logical, reductionistic, rule driven decision making pro-
and the concept of critical thinking. Although they are not cess, similar in character to the nursing process' (Jones &
all inclusive, several perspectives will be presented here. Brown 1991 p. 532). Jones & Brown (1991) found that their
The National Council for Excellence in Critical Thinking respondents had interpreted the concept in ways too
Instruction (Paul 1996 p. 65) de®ned critical thinking as: narrowly de®ned and contradictory. They concluded their
results by stating, `nurse educators in this sample were
the intellectually disciplined process of actively and skillfully
unclear about the mechanisms or operations of critical
conceptualizing, applying, analysing, synthesizing and evaluat-
thinking' (Jones & Brown 1991 p. 532). Based on their
ing information gathered from or generated by observation,
research, Jones & Brown (1993) suggested that nursing
experience, re¯ection, reasoning, or communication, as a guide
education has interpreted the nursing process as synon-
to belief and action.
ymous with critical thinking. They contested this assump-
Evident in this de®nition are the assessment, planning, tion, arguing that critical thinking `is a superordinate
implementation, and evaluation components of the nurs- concept under which problem solving and the nursing
ing process, embedded in methodology that fosters the process are subsumed' (Jones & Brown 1993 p. 72). They
principles of critical thinking. Key elements that empha- criticized the persistence of linear thinking, maintaining
size a critical approach to the process of nursing can be that `movement from a question through a series of
inferred from this de®nition: it validates experiences as operations to a ®nal absolute answer' (Jones & Brown
emancipatory, and points out the importance of re¯ection 1993 p. 533) is founded on rational technical methodol-
and communicative action as operational guides to nurs- ogy. Such methodology remains inadequate for preparing
ing intervention. nurses to confront the future challenges of a changing
Watson and Glaser's (1964) identi®cation of critical healthcare system.
thinking abilities also parallels the steps of the nursing Based upon this reductionistic, but undeniably embed-
process: (1) de®ning a problem (assessment), (2) selecting ded approach to the discipline of nursing, what can be
pertinent information for problem solving (planning), salvaged? Conger & Mezza (1996) provided interesting
(3) recognizing stated and unstated assumptions (plan- insight in their development of a critical thinking model.
ning), (4) formulating or selecting relevant hypotheses This model built on Ford & Profetto McGrath's (1994)
(nursing diagnosis), (5) identifying valid conclusions and visual exemplar of critical thinking as nursing praxis and
validity judgement of inferences (evaluation) (Brooks & provided a nursing structure grounded in Grundy's (1987
Shepherd 1990). In 1980, Watson and Glaser developed an p. 59) `curriculum as praxis' ideology. Their approach
instrument, entitled the Watson Glaser Critical Thinking integrated critical thinking into the framework of the
Appraisal (WGCTA) tool, to measure critical thinking nursing process, placing emphasis on re¯ection as in-
ability. The majority of empirical evidence on critical forming nursing action and empowering individuals for
thinking has been generated from this tool. However, change: `The process is cyclical because the resulting
questions have arisen regarding its reliability and validity action is directed by re¯ection, and re¯ection is further
for measuring critical thinking in nursing. Perhaps there is informed by action' (Conger & Mezza 1996 p. 11). The
a connection between the design of the tool based on a emphasis placed on re¯ection in critical thinking by
product-driven nursing process and its failure to substan- Conger & Mezza (1996) is widely accepted. The image of
Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(3), 577±583 581
J.E. Boychuk Duchscher
re¯ection as informing practice has enriched our know- re¯ection, dialogue and dialectical thinking Ð are the
ledge of the nursing process and is worthy of further means through which potentially oppressive ideologies
discussion. for both client and nurse can be challenged. The result is a
reconstruction of relationships and roles, and an optimiz-
ing of health care delivery through partnership.
REFLECTION IN NURSING PRACTICE Clari®cation of critical thinking as a concept is both a
good beginning and an essential step towards its future
Re¯ective practice in nursing is one of the most exciting
application and evaluation in nursing practice. This
notions to emanate from the literature on critical thinking.
author believes that nursing scholarship, along with its
Although re¯ection has always inherently and intuitively
educational and clinical practices, can be enhanced by
been applied in nursing practice, re¯ection as a research
further research on critical thinking and re¯ection as
topic has only recently emerged (Stockhausen 1991).
learning tools.
Learning through practice and re¯ective processes was
Based on the spirit of critical thinking discussed earlier
expounded upon by Kolb (1984) in his experiential
in this paper, the author poses questions that suggest areas
learning theory. The theory suggested that learning,
for further study:
change and growth are facilitated by cyclical processes
involving direct experience, re¯ection, and abstract con-
What obstacles are inherent in the process of critical
cept formation. Schon (1983) and Benner (1984) empha-
thinking?
sized the link between theory and practice provided by
Would a discipline speci®c critical thinking measure-
critical re¯ection. Stockhausen (1991) presented an entic-
ment instrument capture the true essence of nursing
ing clinical learning spiral to outline and describe a
care?
method of teaching that facilitates re¯ective nursing
Could further analysis of expert nursing practice illu-
practice. Her constructive re¯ective reconstructive phases
minate the critical thinking process in nursing?
closely parallel the judgement re¯ection reconsideration
What is clinical judgement, and why has it not been
cycle previously explored in this paper.
clearly linked to critical thinking in nursing?
Van Manen (1990, 1991) suggested a thought provoking
What is/are the reason(s) for the negligible volume of
and illuminating approach to re¯ection as informing
qualitative research being generated from nurses on the
practice. He proposed four kinds of re¯ection: (1) antic-
topic of critical thinking?
ipatory re¯ection in which consideration is given to
various approaches to patient care during the preliminary
Clearly, the process of critical thinking generates new
nursing assessment, (2) active re¯ection, or `thinking on
possibilities for the development of nursing knowledge.
your feet', (3) mindfulness, or intentional involvement in
Concept clari®cation is a step in the journey towards an
our immediate practice situations, and (4) recollective
understanding of this process.
re¯ection, or the evaluative component of post-event
re¯ection. The premise here Ð strongly supported in
critical social theory and evident within the tenets of
critical thinking Ð is that learning is both facilitated by
Acknowledgements
and dependent upon, active, committed involvement in The author gratefully acknowledges Dr Gail Laing RN PhD
the process of one's practice. Experiences lacking in for her support and encouragement in the preparation of
re¯ection remain unexamined; the full potential for expe- this manuscript and Dr Karen Wright for her continued
riential learning goes unrealized. mentorship throughout my graduate programme.
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