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CHAPTER 1

THE PROBLEM AND BACKGROUND OF THE STUDY

Introduction

Of the literally dozens of definitions of critical thinking that exist, one of

the most organized efforts to define critical thinking emerged from research done

by Peter Facione and others in the early 1990s. Their agreement work, referred to

as the Delphi report, was accomplished by a group of 46 leading theorists, teachers,

and critical thinking assessment specialists from a variety of academic and business

disciplines. The Delphi panel expert consensus describes critical thinking as a

“process of purposeful self-regulatory judgment that drives problem-solving and

decision-making” (Facione, Giancarlo, & Facione, 2000). This definition implies

that critical thinking is an intentional, self-regulated process that provides a

mechanism for solving problems and making decisions based on reasoning and

logic.

Critical thinking in nursing practice is a discipline-specific, reflective

reasoning process that guides the nurse in generating, implementing and evaluating

approaches for dealing with client care and professional concerns. The practice of

nursing requires the ability to draw upon one’s knowledge base on nursing and

related sciences, perform a myriad of psychomotor skills and interact effectively

with individuals and groups. But in the chaotic, ever-changing, unpredictable,

uncertain world of health care arena of the 21st Century, nurses need additional
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abilities to provide quality care to individuals, families and communities. The

ability to think critically is a skill that nurses need in the practice setting and in

everyday life. Patient assessment, diagnosis, intervention, and evaluation require

critical thinking. In assessment, critical thinking enables students to differentiate

relevant from irrelevant data, identify important cues in the data, identify when

additional data are needed for decision making, and identify patient problems.

Other important skills requiring critical thinking are: generating competing

diagnoses, evaluating each diagnosis to determine what is wrong with the patient,

comparing different interventions that might be possible, deciding on measures to

use in a particular situation, and evaluating the effectiveness of interventions

(Claytor, 1997). Development of critical thinking abilities is likely to improve

accuracy of nurses' diagnoses and for satisfactory client outcomes, complex

decision-making goes hand in hand with critical thinking.

Preparing students to think critically is a goal of many higher education

professionals. Critical thinking has become an increasingly prominent component

of clinical nursing practice and nursing education because it is essential to make

professional judgments that have the potential to affect patients' present and future

quality of life. However, Dorothy del Bueno describes a failure among new nursing

graduates to translate knowledge into practice, a situation that she characterizes as a

crisis. Stating that critical thinking among recent graduates has not improved since

the early 1990s, she identifies possible causes and makes several recommendations
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for nursing education. Our educational system continues to graduate students who

do not reason well (Goodlad & Keating, 1994). Recent studies by Perkins and

associates (Perkins, 1991) have documented the faulty everyday reasoning and poor

argumentation skills used by most people. According to Halpern, even a college

education appears to have a limited effect on graduates’ critical abilities, including

making reasonable interpretations of texts and formulating unbiased and well-

reasoned arguments (Walker & Finney 1999).

There are controversies in the clinical area nowadays that involve a student

nurse. Problems and negligence occur if the student nurse fails to think critically

before making any decision or doing any action or procedure. Example of which is

a student who gives a medication to a patient without understanding the action of

the drug and its effect on the patient, thereby causing the patient to suffer from the

student nurse’s negligence. Another one is the student nurse allegedly punctured a

patient's sciatic nerve while giving an intramuscular injection. The student nurse

had read the patient’s chart and knew the patient had weakness and an unsteady

gait. Nonetheless, the student nurse helped her up from the commode, then walked

away and left the patient standing with her walker in the bathroom, expecting the

patient to walk to the wheelchair on her own to transfer with assistance. The patient

took a step forward, fell backward and was injured.

These are only a few of the negligence done by student nurses while they

are dealing care to their patient. A recent Commonwealth Fund international survey
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of six nations showed that between one-quarter and one-third of patients with

health problems experienced medical, medication, or testing errors. According to

the Institute of Medicine (IOM), more than 98,000 people in the United States of

America (USA) die and more than one million patients suffer injuries each year

(Schifrin, 2001). From the Study of Proctor et.al thirty to 40 percent of every US

dollar spent on healthcare is lost to inappropriate use, poor communication, and

inefficiency. A majority of sentinel events occur in acute care settings, where new

graduate nurses traditionally begin their professional careers. According to the Joint

Commission International Center for Patient Safety, over 70% of sentinel events

reported resulted in a patient’s death and 10% resulted in loss of function

(Timmins, 2006). The inability of a nurse to set priorities and work effectively and

efficiently may delay patient treatment in a critical situation and result in serious

life-threatening consequences.

Student nurses need to be critical thinkers as they are not just doing any job,

but they are handling and taking care of precious lives. The researchers have

chosen the 3rd year nursing students as the respondents in this study because they

want to evaluate the critical thinking skills in the clinical area where they are now

mostly exposed. Critical thinking in the clinical area is essential to skilled nursing

in order to give quality in a variety of traditional and expanding nursing roles. They

also want to reiterate that critical thinking is essential and helpful to decrease the

occurrence of faulty incidence that can be prevented if only one knows how to
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think critically before doing any action. Promoting critical thinking is essential

especially in the field of nursing as it is necessary for the nurses to be critical

thinkers to be able to give quality nursing care and intervention to the patients

while they are still students. Developing this skill while still young will not only

help a nurse on the chosen profession but with everyday life specifically in the

decision making area that should be based on a critical analysis of any given

situation.

The core essence of conducting this study is directed towards obtaining

constructive knowledge that will improve the development of the nursing students’

skills especially in the clinical area. Furthermore, the study aims to evaluate the

critical thinking skills and its application in clinical area of selected level III

students of Siena College Taytay. When identified, necessary recommendations can

be made and presented to enhance the skills of the students and the quality of

education of this institution.

Statement of the Problem

This study aims to evaluate the critical thinking skills and its application in

the clinical area of Selected Level III students on the variables involved.

Furthermore, it seeks to answer the main problem: Why is it important to evaluate

critical thinking in the clinical area among the junior nursing students of Siena

College Taytay?

Specifically, this study aims to answer the following questions:

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1. What is the profile of the respondents in terms of:

1.1. Age

1.2. Sex

1.3. Types of school last attended

2. How do the respondents perceived the application of their critical thinking

skills in the clinical area in terms of:

2.1 Thinking Ahead

2.2 Thinking in Action

2.3 Thinking Back

3 Is there a significant relationship between the respondents’ perception on their

critical thinking skills applied in the clinical area with respect to their

demographic profile?

Theoretical Framework

Since critical thinking is contextual, Alfaro-LeFevre (2008) considered

critical thinking from these three perspectives: Thinking ahead (Assessment),

Thinking in Action (Intervention), and Thinking Back (Evaluation). These

perspectives were linked in nursing process as each of these corresponds to

assessing, intervening and evaluating, which are utilized by the nurses in their

practice. Critical Thinking of a nurse who always encounters emergency situations

while practicing their field would lead to giving the patients good quality of care

better and faster, alleviating the problems, or giving the needs of sick client.
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As discussed above, critical thinking changes depending on the

circumstances. The thinking ahead, thinking in action and thinking back were

considered by Alfaro-LeFevre(2000). Assessing the patient first will lead to think

ahead on what one must do for the anticipated or seen problems. Thinking ahead

were describe as the ability to be proactive and anticipate what might happen and

what one might do to be more prepared before encountering situations. Further

assessment will give more evidence to patient’s disease, what might promote

additional problems, what one can do to prevent or decreased the possibility of the

presence of such anticipated problems. For novices, with limited knowledge and

experience, being proactive is difficult and sometimes restricted to reading

procedure manuals and textbooks to anticipate what might happen.

Next perspective is the Thinking in Action which is related to intervention to

the problem that has occurred to patient. One thinks on the problem while at the

same time do into action what one thinks is right to that situation. This is the ability

to think on your feet - rapid, dynamic reasoning that considers several cues and

priorities at once, making it difficult to describe. Thinking in action is highly

influenced by previous hands-on experience. It is more intuitive and prone to

“kneejerk” responses and decision.

Lastly, Thinking Back has been linked to evaluation which is from the

nursing process. Evaluating the results of the action made will then be reflected

back by the nurse. This will better improve the knowledge as one reflects to what
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might have been wrong if the planned goal was not met. Thinking back is the

ability to think back over and analyze the reasoning process to identify

assumptions, look for flaws and omissions, gain better understanding, and correct

and improve thinking. Experienced clinicians’ double check and reflect on their

thinking in a dynamic way during thinking in action. However, this does not

replace reflective thinking that happens after the fact.

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Figure 1 Theoretical Framework

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Significance of the Study

Every research paper bears new interests and should bring significance to

certain fields of work.

School Administrators: For this Christ-centered institution to produce

knowledgeable, critical-thinking nurses who will base their actions and

interventions according to what is right, just, and fair to human beings.

Faculty members: To enhance their teaching strategies that will improve and

promote critical thinking among the students and gear the students to think

critically by “pushing” and challenging them but still being supportive.

Clinical Instructors: For them to allow the students to think and analyze, lessening

instructions but guiding them in a manner that will allow the students to enhance

their decision making skills that are based on sound judgment. Constructive

criticism is the key for the students to learn more for themselves in the clinical area.

Student Nurses: To help themselves in enhancing their critical thinking skill that is

essential in their everyday lives. To be able to maximize their capabilities in the

clinical area, take advantage of all the knowledge that their clinical professors and

instructors would impart on them, and be able to improve one’s decision-making

skills because they will be handling lives.

Future Researchers: To serve as a future reference to fellow students who would be

conducting the same kind of study but on a different perspective or on another set

of population.
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Scope and Delimitations

This study is conducted to evaluate the critical thinking skills and its

application in the clinical area of selected Level III students of Siena College

Taytay, as perceived by the student respondents during academic year 2008-2009.

The aspects that were looked into were the qualities and profile of the respondents,

and the perception of the respondents on their critical thinking performance in the

clinical area in terms of: thinking ahead, thinking in action, and thinking back.

This study was limited to the critical thinking skills and its application in

the clinical area of the selected Level III nursing students of Siena College Taytay

A.Y. 2008-2009 and will not include the student’s critical thinking skill in the

classroom setting, e.g. during exams, quizzes, participation in class discussion, and

the respondent’s personal reasons.

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Input Output
Process
* Conceptual * Most of the
framework of *Descriptive respondents
Critical Thinking research compromised of
>Questionnaires female whose age
*Profile of the ranges from 19-
respondents in 20 years old,
terms single, and high
school graduates
*Perception of of private
the respondents *Weighted educational
on their critical Mean institutions.
thinking >Percentage
performance in >Ranking * That they
the clinical area “always” use
in terms of: their critical
Thinking Ahead thinking skill in
Thinking in the clinical area.
Action
Thinking Back * There is a
* Pearson relationship
*Significant Correlation between the
relationship Coefficient respondents’
between the perception on
respondents’ * Point – their critical
perception on Biserial thinking skills
their critical Correlation applied in the
thinking skills in Coefficient clinical area with
the clinical area respect to their
with respect to *T - test demographic
their profile but is not
demographic significant
profile. enough to affect
their critical
thinking skill.

Figure 2 Paradigm of the Study

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Hypothesis
Student’s Name: Juan Dela Cruz
Section &perception
There is no significant relationship between the respondents’ Group: BSN4A
on – Group 1

their critical thinking skills applied in the clinical area with respect to their

demographic profile.

Assumption

1. Clinical judgment is the outcome of thinking critically.

2. Teaching is the development of cognition and metacognition and the

belief that critical thinking can be nurtured with active learning.

3. Nurses who think critically may have appropriate knowledge and skilled

judgments in delivering quality patient care.

4. A student who knows how to think critically makes better clinical

judgments than those who have merely memorized facts.

Definition of Terms

To understand the concepts related to the study and for verification of

understanding, the researchers provided a set of operational and conceptual

definition as follows:

Clinical Performance – is the student’s ability to demonstrate the expected

behaviors and skills of a student nurse in the clinical area.

Cognitive – the construction of thought processes which includes remembering,

problem-solving and decision-making.

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Critical Thinking – involves analyzing situation, making judgement, evaluating

information that has formed from the assessment, experience reasoning and

communication.

Knowledge - the fact or condition of knowing something with familiarity gained

through experience or association; acquaintance with or understanding of a science,

art, or technique.

Perception – the ability to see, hear and become aware of something through

senses.

Thinking in Action – thinking ability where one does actions in accordance to

several cues seen and priorities.

Thinking Ahead – is the ability to think in advance when encountering a situation.

Thinking Back – evaluation and analyzing of the acts and decision that has been

done.