Critical Thinking Dispositions of Nursing Students in Asian and Non-Asian Countries: A Literature Review
Mahvash Salsali,1Mansooreh Tajvidi,2 and Shahrzad Ghiyasvandian1
1School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
2School of Nursing and Midwifery, Tehran University of Medical Sciences, International Campus, Tehran, Iran
Correspondence: Mansooreh Tajvidi, BSN, MSN, PhD student, PhD Department, School of Nursing and Midwifery, Tehran University of Medical Sciences International Campus. Postal Code: 1419733171. E-mail: moc.oohay@idivjat_heroosnam
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Received 2013 Jul 30; Accepted 2013 Aug 27.
Critical thinking disposition represents an inclination of a person to use possessed skills in relation to critical thinking. The trend of critical thinking has been described as inner motivation to solve problems and make decisions by thinking. In nursing as a practical profession, the concept of critical thinking dispositions is important component in helping to manage complex health situations and to deal with patient issues effectively. Willingness to think critically is a prerequisite for safe and subtly performance. The results of studies show critical thinking dispositions of nursing students in Asian countries are different from non-Asian countries. Aim of this literature review was to compare critical thinking dispositions of nursing students in Asian and non-Asian countries. Literature review was done in English and Persian databases. The results showed of the 795 articles published in English and Persian language that studied critical thinking, 73 ones studied critical thinking skills and dispositions in nursing education, and relationship between teaching methods and critical thinking skills and dispositions in nursing education of different countries. Fifteen of seventy three articles assessed critical thinking dispositions in nursing students. Limited studies showed that the Asian nursing students had mostly undermining score of the critical thinking dispositions, while non-Asian countries tend to positive scores. The reasons for these differences could be due to issues such as environmental, educational methods and cultural differences. However, future studies should measure critical thinking disposition by discipline-based tools.
Keywords: critical thinking, disposition, nursing student, literature review
Literature on critical thinking shows that there is little agreement about the concept of critical thinking. Dewey (1910), from a philosophical view, proposed that critical thinking involves probing, discriminating and testing ideas as well as exploring various options on an issue. Paul (1992) described critical thinking as the ‘art of thinking about your thinking while you are thinking in order to make your thinking better; more clear, more accurate and more defensible’ (p. 11). In another study by Paul (1993), three essential elements—thought, intellectual standards, and affective traits—were identified as central to the critical thinking process. Ennis (1987) and Halpern (1998) defined the term critical thinking as represents a set of cognitive skills and dispositions which are conducive to decision making and problem solving in different situations. Watson and Glaser (1980) defined critical thinking as a composite of attitudes, knowledge, and skills. According to Facione, Facione, and Sanchez (1994), a critical thinking disposition represents an inclination of a person to use possessed skills in relation to critical thinking. The trend of critical thinking has been described as inner motivation to solve problems and make decisions by thinking (Huan & Vickie, 2008). According to American Society of Philosophy (1990) that has proposed a precise consensus on the definition of critical thinking which comprises emotional and cognitive components, ‘critical thinking is purposeful, self-regulatory judgment which results in interpretation, analysis, evaluation and inference as well as explanation of the evidential conceptual, methodological, criteriological or contextual considerations upon which that judgment was based. The ideal critical thinker is habitually inquisitive, well informed, trustful of reason, open-minded, flexible, fair minded in evaluation, honest in facing personal biases, prudent in making judgements, willing to reconsider, clear about issues, orderly in complex matters, diligent in seeking relevant information, reasonable in the selection of criteria, focused in inquiry, and persistent in seeking results which are as precise as the subject and the circumstances of inquiry permit’ (p. 3). The good critical thinker must foster critical thinking dispositions, as well as the development of critical thinking skills (Paul, 1992; Facione et al., 1994; Norris, 1995).
In nursing as a practical profession, where rapid changes occurred and decision-making is imperative, the concept of critical thinking is important portion in helping to manage complex health situations and to counter patient problems effectively (Distler, 2007; Beckie, Lowry, & Barnett, 2001; Yeh & Chen, 2003; Hwang and et al., 2010). Intending to think critically is a prerequisite for safe and subtle performance (Alfaro-LeFevre, 1999). Overall, emotional tendency toward critical thinking is a pivotal component for cognitive skills. Emphasis on cognitive skills alone without emotional attitude probably conduces the tendency to educate nurses to be closed mind, inflexible and prejudicial (American Philosophical Association, 1990). Despite the importance of critical thinking dispositions in nursing students and the necessity of its existence to reach the critical thinking performance, few studies have been conducted in this area. While critical thinking in nursing has been studied for almost 25 years, literature on critical thinking dispositions has only been within the past 10 years (Stewart, 2005). There is little research directly examining differences in critical thinking between Asian students and their non-Asian counterparts (Lun, Fischer, & Ward, 2010). Ten Dam and Volman (2004) observed, research which addresses the role of culture in relation to critical thinking is currently limited. Since the results of studies show critical thinking dispositions of students in Asian countries are different from other countries, this hypothesis would suggest that critical thinking dispositions is associated with cultural and contextual issues. (Profetto-McGrath, 2003; Ip et al., 2000; Tiwari, Avery, & Lai, 2003). Therefore the purpose of this review is the comparison of critical thinking dispositions between nursing students in Asian and non-Asian countries.
In this review, the following questions are answered: 1. What is the level of the critical thinking dispositions of nursing students in Asian countries in the literature? 2. What is the level of the critical thinking dispositions of nursing students in non-Asian countries in the literature? 3. Are there differences between critical thinking dispositions in Asian and non-Asian countries?
All major electronic sources of relevant information were systematically searched to identify peer-reviewed English and Iranian language abstracts or papers published between 1990 and 2012. To identify all relevant studies for the review, the search strategy comprised searches of the following: CINAHL database, Proquest, Pub-Med, Medline, Science Direct, OVID and Iranian Journal Full-text Databases including SID, Iran medex and Magiran; Internet source (www.google.com) using the key words: ‘critical thinking’, ‘nursing’, ‘students’ ‘nursing students’ and ‘critical thinking dispositions’. Initially 717 English articles and 78 Persian articles were found. However, several were discarded as they did not specifically address critical thinking dispositions in nursing students. The inclusion criteria were (1) articles that were related to critical thinking dispositions in nursing students (2) articles that used California Critical Thinking Disposition Inventory (CCTDI) to measure critical thinking dispositions in nursing students. A variety of instruments have been used to study critical thinking in nursing education. Facione and Facione (1992) developed the California critical thinking disposition inventory (CCTDI) that was used to measure critical thinking dispositions. California Critical Thinking Disposition Inventory contains 75 items with a Likert scale ranging from completely agree to completely disagree scoring. Maximum and minimum values of 70 and 420 are obtained from this test. Strong and stable disposition (over 350), positive (between 280 and 350), undermining (between 210 and 280) and negative (below 210) are classified. The questions included seven subscales: truth-seeking (12 items), open-mindedness (12 items), analyticity (11 items), systematicity (10 items), critical thinking and self-confidence (10 items), inquisitiveness (10 items) and maturity (10 items). Total points from the seven sub-scales determine an individual’s critical thinking disposition. Therefore authors studied abstracts of 717 English articles and 78 Persian articles. English and Persian language studies were separately classified and reviewed. In the final stage, critical thinking dispositions in nursing students was compared in Asian and non-Asian countries.
Of the 795 articles published in English and Persian language, 73 articles studied critical thinking skills and dispositions in nursing education, and relationship between teaching methods and critical thinking skills and dispositions in countries such as Iran, Korea, Turkey, China, Japan, Hong Kong, Jordan, Norway, United State, Canada, and Australia. Fifteen of seventy three articles assessed critical thinking dispositions in nursing students (Table 1). Studies showed differences in total scores of California Critical Thinking Disposition Inventory. Review of these articles showed only four of Iranian articles studied critical thinking dispositions in nursing students. The two of them have been conducted by the same authors in the same place. The results of these studies showed a low level of critical thinking disposition in nursing students that indicate undermining score (210-280) and no one had a positive or stable critical thinking disposition (>280) (Barkhordary, Jalalmanesh, & Mahmoodi, 2009, 2011). Also according to the results of Ranjbar and Esmaili (2006), students’ critical thinking disposition was negative (<210). Gharib (2006) examined critical thinking dispositions of nursing students in Iran University of Medical Sciences, results showed that the mean score of critical thinking disposition was 278.6 that indicated undermining attitudes toward critical thinking. Review of studies in other countries shows that the dimension of the critical thinking disposition has been given more attention than Iran. Furthermore, some studies compared critical thinking disposition of nursing students in Asian and non-Asian countries. Candan, Gonca and Aklime (2008) concluded Turkish students’ critical thinking disposition scores were 255.8 ± 23.7 (undermining attitude). Students’ critical thinking disposition scores in Hong Kong has been reported 264.70±24.01 indicating the undermining attitude of the students towards critical thinking (Ip et al., 2000). Comparison of Australian and Hong Kong students’ critical thinking disposition scores showed that Hong Kong students’ score was 268.36 (undermining attitude) and Australian students’ score was 287.73 (positive attitude) (Tiwari et al., 2003).
Critical thinking disposition of nursing students in Asian and non-Asian countries
Suliman and Halebi (2007) studied critical thinking disposition in nursing students in Jordan. The mean total score of critical thinking disposition in their study was 284.93 (positive attitude). Kyungrim, Duk, Sujin and Myoung (2006) studied critical thinking skills and dispositions in Korean nursing students in associate, bachelor’s and master’s programs that results showed the average score was 263 (undermining attitude). Huan and Vicki (2008) studied the critical thinking disposition and learning styles of baccalaureate nursing students in China, results showed that score of critical thinking disposition in Chinese students was 272.82 (undermining attitude). McGrath (2003) studied disposition of critical thinking in the Canadian nursing students. Results showed score of Canadian students’ critical thinking disposition was between 280 and 350 (positive attitude). Findings of Giancarlo and Facione’ (2001) study showed critical thinking disposition in American students was 301 (positive attitude). Wangensteen et al. (2010) studied critical thinking disposition in newly graduated nursing students in Norway; results showed that almost 80 percent of students had positive attitude toward critical thinking (score was 300.3).
Furthermore some studies showed differences in some subscales of California Critical Thinking Disposition Inventory. For example Min-Ling Yeh Chen and CIA Sing Chen (2003) compared disposition of critical thinking between Chinese and American graduate nursing students; results showed Chinese students had trends to an open-mindness, analysicity, self confidence and inquisitiveness. American students had trends to open-minded, analysicity, self confidence, inquisitiveness, systematicity and maturity. There were significant differences between the two groups in subscales of truth seeking, open-mindness and maturity. American students had a higher score of critical thinking disposition subscales than Chinese students. Authors tend to express that one reason for this difference in some subscales of critical thinking disposition comes from the cultural differences between the two groups.
According to Huan and Vicki (2008) in China, results showed between scores of critical thinking disposition subscales that were reported, truth seeking subscale score was lowest. Similar results have been noticed in other studies (Ip et al., 2000; Li & Guo, 2004). Results of study in Norwegian nursing students showed the highest score in subscale of inquisitiveness and lowest score in truth seeking (Wangensteen et al., 2010). The results of these studies show that it is essential to investigate the reasons for different nursing students’ critical thinking disposition in different countries.
In this literature review, nursing students’ critical thinking dispositions in Asian and non-Asian countries were reviewed and compared. Limited studies showed that the critical thinking dispositions of Asian nursing students are mostly undermining. Some Asian countries such as Iran, China, Japan and Hong Kong reflect a low critical thinking disposition scores of their students (Huan & Vickie, 2008, Ip et al., 2000; Tiwari et al., 2003); while non-Asian countries tend to score highly in critical thinking dispositions in nursing students. The reasons for the low critical thinking disposition in most of studies in the Asian countries could be due to issues such as environmental, educational methods and cultural differences (Min-Ling Yeh Chen & CIA Sing Chen, 2003; Profetto-McGrath, 2003). Brown (1998) suggested that critical thinking is specific to a certain kind of culture. This may explain the observed differences in scores. Academics often affirm that Asian students do not naturally take part in critical thinking because they do not obviously contribute in classroom discussions (Paton, 2005).
In a culture that does not value critical questioning and having inconsistent viewpoints, for example in the Chinese culture (Gabrenya & Hwang 1996), students may easily lose opportunities to practise how to express conflicting views and when to delay judgment or come to a closure. Most likely the low critical thinking disposition scores of Asian nursing students are due to the application of traditional methods in nursing education, which shows the need to revise the nursing curriculum. Tiwari et al. (2003) attributed higher scores of the critical thinking disposition in Australian nursing students than those of Chinese students to the active educational model used in the Australian school and to cultural differences. Critical thinking in nursing students develops through active educational programs. Pang et al. (2004) have argued that nursing is conceptualized differently by Eastern and Western nurses. For example Chinese nursing is grounded in a cultural understanding of health. It is feasible that differences in modes of thinking between nursing students in the East and West are responsible for the difference in scores.
Furthermore, as already mentioned, studies show that nursing students in Asian countries and non- Asian countries have differences in subscales of critical thinking disposition. Most studies have reported score of truth seeking subscale in students are low. Colucciello (1997) proposed that a lower score of truth seeking could be due to traditional teaching and learning strategies where the extensive information was presented in the lectures, students are expected to learn rather than seeking information or asking questions. Huan and Vickie (2008) express Chinese students are not encouraged to ask teachers questions because teachers fear that they cannot answer questions from students and be shamed. It is another reason for the low scores of truth seeking in Chinese students. The low score in open-mindness in some studies may be due to students that could not tolerate divergent views because they are not encouraged to ask questions of the instructor or other students. Low scores on the Order-taking and analysis can also show the weakness of organized reasoning and focus on problem solving (Huan & Vickie, 2008). In general, review of studies shows that current nursing programs will not lead to a shift in critical thinking (Stephanie et al., 2005). This has raised the need to revise these programs.
Finally, the reviewed studies have applied a general tool, regardless of cultural and linguistic differences to measure critical thinking dispositions in nursing students. It could be the other reason for inconsistency in the results of studies. Many researchers have acknowledged this issue as well (Huan & Vickie, 2008; Yeh, 2003; Shin et al., 2006); Profetto-McGrath, 2003; Ip et al., 2000; Tiwari et al., 2003). There is a need to develop a discipline-specific tool designed to measure nurses’ critical thinking (Hartley & Aukamp, 1994). California Critical Thinking Disposition Inventory may be appropriated to Western social customs and beliefs that Eastern nurses cannot fully understand it.
According to present study, there are the diverse and often contradictory results about critical thinking dispositions of nursing students in Asian and non-Asian countries. In some cases, it has been expressed critical thinking disposition in Asian countries is lower than in other countries. It should be noted the most studies in critical thinking disposition of nursing students were descriptive studies without analyzing causes of low critical thinking disposition. Therefore following these few articles, we could not conclude that all nursing students in Asian countries have low disposition toward critical thinking. It is suggested to compare the trend of critical thinking of nursing students in different countries according to different cultural backgrounds. However, future studies should measure critical thinking disposition by discipline-based tools.
This paper has been derived from PhD thesis. Tehran University of Medical Sciences International Campus supported financially it.
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As human beings, we make thousands of decisions every day. Every time we go to the shop to buy bread we must decide whether we would prefer white bread, brown bread, small or large loaf, barrel or sliced, etc. The same goes for the ‘simple’ task of ordering a coffee. For example, if you enter Starbucks, it’s been estimated that there are over 19,000 possible beverages available to you (Vohs et al., 2014). Indeed, we are immersed in increasingly complex and differentiated environments -- decisions are ever-present and surround us as we make our way in the world.
Of course, some decisions are more important than others. Perhaps ordering coffee at Starbucks and selecting bread at the shop are not seen as incredibly important by many people and, naturally, we often depend on prior choices or habitual responses to guide our choices in these situations. But what about decisions we care about, decisions that we recognise as important and that require some deliberation? Repeating habitual responses or ‘going with our gut’ in those situations will not suffice – we must pause for reflection and think critically – we must think about our decisions in these situations. Although it is not always clear what is needed to support good critical thinking, scholars have suggested that there may be a number of core personal dispositions that support good critical thinking. But what are these critical thinking dispositions?
Critical thinking (CT) is commonly defined as a metacognitive process, consisting of a number of cognitive skills (e.g. analysis, evaluation and inference) and a variety of personal dispositions (e.g. open-mindedness, inquisitiveness and scepticism), that, when used appropriately, increases the chances of producing a logical solution to a problem or a valid conclusion to an argument (Dwyer, 2011; Dwyer, Hogan & Stewart, 2012; 2014). However, most definitions of critical thinking (CT), and most interventions designed to increase CT, are grounded in academic or expert definitions of CT skills; and there has been very little emphasis on CT dispositions in the research conducted to date. Furthermore, students and educators are rarely, if ever, asked to describe their perspectives on what constitutes CT or key CT dispositions. As such, critical thinking dispositions have not yet been clearly conceptualised in research literature; and what little is agreed upon when it comes to such disposition is generally derived from the opinions of academics.
So what do students and educators describe as the key dispositions of good critical thinkers? We recently conducted research to address this question, as part of our ongoing efforts to develop and validate a new Critical Thinking Dispositions Scale. Using a collective intelligence methodology, Interactive Management, we examined the way students and educators conceptualise CT dispositions.
Interactive Management (IM) is a computer-assisted process that allows a group to build a structural model describing relations among elements in a system. In the current study, these elements were CT dispositions, and the relations of interest were the ways in which these dispositions support one another in a positive system of influence. Interactive Management is a five-step systems thinking methodology that is used to aid groups in developing outcomes that integrate contributions from individuals with diverse views, backgrounds and perspectives, via: (1) generating and clarifying ideas; (2) voting, ranking and selecting elements for structuring; (3) structuring elements by answering a series of questions in the form: “Does CT disposition A facilitate CT disposition B?’’; (4) evaluating a graphical representation of group logic; and (5) interpreting and evaluating discourse and reasoning to further understand the nature of the collective intelligence. In our study on critical thinking dispositions, three groups comprising a total of thirty-one students and ten educators took part in the collective intelligence workshops. Across these three workshops, a total of 32 CT dispositions were identified and organised into 13 categories (see figure 1).
Figure 1. Key Dispositions of Good Critical Thinkers
An analysis of the systems thinking of participants revealed that key CT dispositions including inquisitiveness, open-mindedness and self-efficacy had the strongest positive, supporting influence on other CT dispositions in the set; whereas, reflection and resourcefulness were seen as highly dependent on other dispositions (i.e., supported positively by other dispositions in the set). Drawing upon the logic of these systems structures, and ordering the full set of critical thinking dispositions by reference to their relative influence in the system, revealed the following ordered set:
- Inquisitiveness: An inclination to be curious; desire to fully understand something, discover the answer to a problem and accept that the full answer may not yet be known; a desire to understand a task and its associated requirements, available options and limits.
- Open-Mindedness: An inclination to be cognitively flexible, open to divergent or conflicting views; detaching from one’s own beliefs to consider diverse points of view without bias or self-interest; to be open to feedback, accepting positive feedback, criticism or constructive feedback with thoughtful consideration; an openness to amending existing knowledge in light of new ideas and experiences; and a willingness to explore new, alternative or ‘unusual’ ideas.
- Self-efficacy: The tendency to be confident and trust in one’s own reasoned judgments; acknowledging one’s sense of self while considering problems and arguments (i.e. situating reasoned judgements within one’s own life experiences, knowledge, biases, culture and environment); to believe in one’s ability to receive and internalize feedback positively and constructively; to be self-efficacious in leading others in the rational resolution of problems; and belief that good reasoning is the key to living a rational life and to a creating a more just world.
- Attentiveness: Willingness to focus and concentrate; to be aware of surroundings, context, consequences and potential obstacles; to have the ‘full picture’.
- Intrinsic Goal Orientation: Inclined to be enthusiastic towards a goal, task, topic of focus and, if not the topic itself, enthusiasm for the process of learning new things; to search for answers as a result of internal motivation, rather than an external, extrinsic reward system.
- Perseverance: To be resilient and to be motivated to persist at working through complex tasks and the associated frustration and difficulty inherent in such tasks, without giving up; motivation to get the job done correctly; a desire to progress.
- Organization: An inclination to be orderly, systematic and diligent with information, resources and time when determining and maintaining focus on a task, problem or question, whilst simultaneously considering the total situation and being able to present the resulting information in a holistic, organized fashion, for purposes of achieving specified goals.
- Truth-Seeking: A desire for knowledge and truth; to seek and offer both reasons and objections in an effort to inform and to be well-informed; a willingness to challenge popular beliefs and social norms by asking questions (of oneself and others); to be honest and objective about pursuing the truth even if the findings do not support one’s self-interest or pre-conceived beliefs or opinions; and willingness to change one’s mind about an idea as a result of the desire for truth.
- Creativity: A tendency to visualize and generate ideas; and to ‘think outside the box’ (i.e. think differently than usual)
- Skepticism: An inclination to challenge ideas and question conclusions in light of the evidence presented; to withhold judgment prior to engaging with the evidence; to take a position and be able to change position when the evidence and reasons are sufficient; and to look at findings from various perspectives.
- Reflection: An inclination to reflect on one’s behavior, attitudes, opinions, and motivations; to distinguish what is known and what is not; to approach decision-making with an awareness of limited knowledge or uncertainty, recognition that some problems are ill-structured, some situations permit more than one plausible conclusion or solution, and judgments must often be made based on analysis, evaluation, standards, contexts and evidence that preclude certainty.
- Resourcefulness: The willingness to utilize existing resources to resolve problems; search for additional resources in order to resolve problems; to switch between solution processes and knowledge to seek new ways/information to solve a problem; to make the best of the resources available; to adapt and/or improve if something goes wrong; and to think about how and why something went wrong.
Another way to understand this logic of supporting influence, or the relation between critical thinking dispositions, is by reference to the total influence map in figure 2, where dispositions to the left are collectively seen to influence disposition to the right. This figure represents a meta-analysis of the systems thinking across the three workshops, and highlights dispositions that influence or support other dispositions in the system.
Figure 2. Influence Map Describing Supporting Relations between CT Dispositions
Interestingly, one CT disposition, clarity, although highlighted as important during the idea generation stage (i.e., Step 1 above), did not receive a sufficient number of votes when it came to selecting ideas for structuring (i.e., Step 3 above). However, we believe it is important to highlight the significance of clarity, which was defined by our participants as the inclination to seek intelligibility, transparency, lucidity and precision, from oneself and others, and to be clear with respect to the intended meaning of what is communicated.
We appreciate that more work needs to be done to further understand the dynamics of critical thinking dispositions in action. We are currently working to develop critical thinking educational programmes that support the cultivation of key CT skills and dispositions. The understanding obtained through our collective intelligence research has also informed the development or a new Critical Thinking Dispositions Scale, which we are currently working to validate. We believe a new Critical Thinking Dispositions Scale is needed to empower students and educators who wish to reflect upon their critical thinking dispositions and negotiate new learning experiences that promote the development of CT skill and dispositions in academic settings. If you would like to contribute to our scale development work, we would be delighted if you could take our survey.
Link to Sona version of survey for NUI, Galway Students:
A direct link to survey is available upon request to email@example.com
Chris Dwyer (LinkedIn, ResearchGate), Michael Hogan (Web), Owen Harney (ResearchGate), Caroline Kavanagh, Sarah Quinn.
Dwyer, C.P., Hogan, M.J., Harney, O. & Kavanagh, C. (2016). Facilitating a student-educator conceptual model of dispositions towards critical thinking through interactive management. Educational Technology & Research (Submitted).
Dwyer, C.P. & Hogan, M.J. (2014). An integrated critical thinking framework for the 21st century. Thinking Skills & Creativity, 12, 43-52.
Dwyer, C.P., Hogan, M.J., & Stewart, I. (2012). An evaluation of argument mapping as a method of enhancing critical thinking performance in e-learning environments. Metacognition and Learning, 7, 219-244.
Dwyer, C.P., Hogan, M.J., & Stewart, I. (2011). The promotion of critical thinking skills through argument mapping. In C.P. Horvart & J.M. Forte (Eds.), Critical Thinking, 97-122. Nova Science Publishers, New York.
Vohs, K. D., Baumeister, R. F., Schmeichel, B. J., Twenge, J. M., Nelson, N. M., & Tice, D. M. (2014). Making choices impairs subsequent self-control: a limited-resource account of decision making, self-regulation, and active initiative.
Source: Michael Hogan, Chris Dwyer, Sarah Quinn
Source: Michael Hogan, Chris Dwyer, Sarah Quinn