Curriculum infused with critical thinking ethos has become preferred in nursing education today (Colln-Appling & Giuliano, 2017; Noone & Seery, 2018). Critical thinking-based curricula adopt learning outcomes, instructional methods, and assessment approaches that are grounded on the concept of critical thinking. Consequently, students who experience such curricula are more likely to provide safe patient care (Paul, 2014), to engage in autonomous, and meaningful and self-reflective thinking (Dunne, 2015).
Meanwhile, in Ghana, limited resources in nursing schools may inhibit the experiences that the students require to develop critical thinking skills. For example, studies have identified lack of qualified educators (Bell et al., 2013), infrastructural and logistical constraints (Salifu et., 2018), the use of inappropriate instructional methods, large class sizes, and absenteeism (Wilmot et al., 2013) as some of the challenges affecting nursing education.
However, a critical thinking framework could provide the needed drive to foster the development of critical thinking skills of students. More importantly, a “framework can be used to move students toward a more active-learning environment which, ultimately, is more enjoyable and effective for teachers and students alike” (Duron et al., 2006, p.160). Yet, in Ghana, there is no known framework to drive the facilitation of critical thinking skills in the context of a developing country. Therefore, the purpose of this study was to develop a nuanced curriculum framework to facilitate critical thinking skills of students in a nursing educational institution in Ghana.
Methods:
Cooperative inquiry was used as an overarching research design in a Ghanaian nursing school (case study). Ethical approval was obtained from the Health Research Ethics Committee of Stellenbosch University and the university in which the study was conducted (name withheld to ensure the anonymity of participants). Consistent with ethos of the cooperative inquiry research method, 11 participants comprising 3 educators, 2 preceptors, 5 students, and the principal researcher were purposively selected to obtain preliminary data with the view of developing the framework. These 11 participants engaged in 7 phases of data collection, analysis, and reflection using the O’Leary’s cycle of action research as described in Koshy (2010) below:
Phase 1. Data were collected on the instructional practices/activities of the selected school from September 2017 to March 2018. These datasets were to help the 11 participants to understand current practices and provide the baseline data for the development of a framework.
Phase 2. The analysed data were presented to the 11 participants at a meeting held in March 2018. Vital factors regarding instructional practices that may enhance and/or inhibit the acquisition of critical thinking skills of students were identified. These included 1) educators’ factors, 2) students’ factors, 3) university-wide factors (infrastructure), and 3) continuous quality improvement.
Phase 3. Following the reflection on the data, the 11 participants through the Nominal Group Technique facilitated by the principal researcher identified concepts, and processes that should be included in the structure of the curriculum framework. Consequently, a draft framework was designed.
Phase 4. Through a structured interview, 3 educators and 6 students evaluated the draft framework to determine its applicability.
Phase 5. The students and educators’ evaluations regarding the draft framework were analyzed thematically. The draft framework was evaluated as applicable by all participants (3 applicable, 6 very applicable). The reasons for their verdict included the following: the framework was simple, realistic, and comprehensive (essential factors included).
Phase 6. The results of the evaluation of the framework were reflected on by the 11 participants and appropriate revision carried out.
Phase 7. A revised framework was designed to reflect the views of the evaluators of the draft framework. Some concepts/processes (outcome setting, advocacy, system review) were further explicated. Through Nominal Group Technique, ethical (behavior) was suggested and added to the definition of caring professional relationship.
Results:
The results from the cooperative inquiry culminated in a design of a framework with six (6) interconnected concepts recommending approaches that are required to drive the development of critical thinking of students. These include: 1) caring professional relationship; 2) facilitator; 3) learner; 4) learning environment; 5) outcome setting, review system, and advocacy; and 6) contextual dynamics/factors. The concepts are described below.
Caring professional relationship. Caring professional relationship denotes an authentic, supportive, responsive, empathetic, learner-directed, mutually respectful, ethical, accountable, and democratic learning engagement which focuses on helping a learner experience meaningful learning experience toward the development of critical thinking skills.
Facilitator. The facilitator leads and facilitates the teaching-learning process. The facilitator becomes a role model in terms of how he/she collaborates and communicates with the learner, and models critical thinking in his/her teaching. The facilitator should possess positive attitude toward learners, hold a sets of scholarships/experiences in teaching (active teaching approaches and questioning techniques), clinical and theoretical nursing knowledge base, and have enthusiasm/passion for the nursing profession and helping learners in their learning.
Learner. The learner should be encouraged not to see him/herself as a receptacle in which content/information is dumped. But rather as a rational individual who can make a determination for him/herself regarding truth. Therefore, he/she should adopt learning practices that helps to examine/reflect on information for self-determination and lifelong learning.
Learning environment. The caring professional relationship between the learner and facilitator occurs in a conducive learning environment that promotes critical thinking. This environment has two components: the hard and soft. The hard environment involves appropriate library resources, learning space and technology. Institutional support is required for the provision of appropriate technology, learning space, and library resources for meaningful learning experience. The soft environment involves the intangible safe, non-threatening, empathetic and democratic atmosphere or mood that is created to encourage the learner to share his/her views freely.
Outcome setting, review system, and advocacy. Processes for outcome setting, system review and advocacy should be established in order to ensure continuous feedbacks, review and improvement of the critical thinking curriculum. Outcomes that are set should be measurable, realistic, and attainable which allows for continuous evaluation and improvement. On the basis of this review, particularly educators should engage in advocacy to effect changes as may be necessary for helping students acquire critical thinking skills. These components (outcome setting, system review and advocacy) must be the driving principles of the critical thinking-based curriculum governance.
Contextual dynamics. A curriculum does not exist in a vacuum. It must be designed and operated within a specific context. The learning process and the extent to which one could address critical thinking skills are influenced by contextual factors or dynamics. These contextual factors or dynamics are at the periphery of the frame and provide the boundaries within which a curriculum could operate. These include the program of study, the global/national trends and policies, and legal/regulatory framework.
Conclusion:
Critical thinking is required to help nurses function appropriately in their expanded roles occasioned by the ever-changing complex health environment. A critical thinking-based framework may provide the impetus required to drive the development of critical thinking skills of nursing students. Therefore, it is envisaged that the adoption of this framework will help educators refine their instructional practices/activities to assist students develop their critical thinking skills. Likewise, the framework could direct continuous educational programs for nurse educators, monitoring and evaluation with the view of improving standard setting, and teaching-learning experiences of students. Furthermore, this study contributes to the global discussion regarding critical thinking of nursing students from a Sub-Saharan African perspective which has mostly been absent.