This qualitative study explored how reflective journaling about critical thinking (CT) dispositions by RNs in a critical care and emergency department fellowship program influenced development and use of critical thinking dispositions during the first 7 weeks of a critical care/ emergency department fellowship program (Zori, 2016).
Developing strong critical thinking skills and behaviors is essential to the development of clinical judgment in nurses as they engage in nursing practice and assume a key role in transforming the health care system (Benner, Sutphen, Leonard, & Day, 2010). Critical thinking dispositions are the internal behavioral intent to use critical thinking skills. Critical thinking skills and seven dispositions were identified in a seminal study conducted by the American Philosophical Association [APA] (1990). The seven CT dispositions identified in the APA (1990) study (inquisitiveness, systematicity, analyticity, open-mindedness, judicious, truth-seeking and self-confidence in CT) were used in the current study that explored the development and use of CT dispositions of RNs in a fellowship program.
Finding strategies, such as reflective journaling, that foster the development of critical thinking in nursing education has been explored. Strategies that promote the development of critical thinking are necessary in a variety of nursing education programs (Burrell, 2014; Chan, 2013; Martyn, Terwijn, Kek, & Huijser, 2014; Zori, Kohn, Gallo & Friedman, 2013)). Nurse residency programs are considered a best practice for transitioning new nurses to specialty practice (Benner, et al. 2010; Letourneau & Fater, 2015). Using learning strategies such as reflective journaling to foster use of critical thinking for participants while in a residency program could help to foster the development of critical thinking as a basis of clinical judgment in beginning RNs.
Purpose
To explore how using reflective journaling focused on CT dispositions by participants in a critical care/ emergency department fellowship program might influence use of CT dispositions.
Design
This qualitative, descriptive study used content analysis to analyze participant’s journal entries on critical thinking dispositions
Setting
The setting for this research was a large multi-hospital health system in the northeastern United States with a nurse fellowship program of 1 year duration that transitioned nurses to specialty practice in critical care and the emergency department.
Methods
IRB approval was obtained. A convenience sample of all participants in the fellowship program held twice during a calendar year were invited to participate. On the first day of the fellowship program, the researcher presented a 1 hour session on critical thinking dispositions through use of simulated videos and discussion. Participants were invited to participate in the research and informed consent was obtained.
The researcher emailed a weekly prompt with a brief description of one of the CT dispositions for each of the first 7 weeks of the fellowship program. Participants were asked to journal about their experiences with the particular disposition and email it to the researcher. Journal entries were read and then coded by the researcher, initial coding was validated by another researcher with expertise in qualitative methods. Categories were given a descriptor and further reduced resulting in sub-themes for each disposition and then over-arching themes were identified from commonalities of the disposition themes (Krueger & Casey, 2009).
Results
A total of 71 participants agreed to participate on the first day of the fellowship program. The number of journal entries submitted for each of the CT dispositions were: 56 for inquisitiveness, 55 for analyticity; 58 for truth-seeking; 46 for sysematicity; 42 for critical thinking maturity; 43 for open-mindedness; 38 for critical thinking confidence.
Participants in the study were 74.8% female, 51.1% were white; 80.0% had baccalaureate degrees and 74.8% had less than 1 year of RN experience.
Over-arching and Disposition Sub-themes
Over-arching themes: 1. CT Is a process that develops during a period of time
2. Purposefully Using CT dispositions may help prevent negative patient outcomes.
Inquisitiveness 1. Facilitates patient assessment and prevents missed information and errors.
2. Furthers individual learning.
Systematicity 1. Essential to the nursing process, develops over time with experience.
2. Helps with organizing and prioritizing the delivery of patient care.
Open mindedness 1. Prevents judgmental, biased behavior.
2. Promotes teamwork.
Analyticity 1. Works together with inquisitiveness and puts puzzle pieces together.
2. Allows one to recognize patterns and anticipate and prevent complications, thus promoting patient safety.
Truth seeking 1. Requires courage to question and result in better learning.
2. Requires putting biases and preconceived notions aside to focus on the patient.
CT maturity 1. Develops over time and helps make sense of different ways of doing things to reach the same goal.
2. Works with open mindedness and allows for learning through reflection.
CT self-confidence 1. Develops over time with clinical experience and allows one to question things and verbalize it to other team members.
2. Works together with the other dispositions to help make decisions and problem solve.
As an exemplar included here is a journal entry from a nursing fellow describing the importance of inquisitiveness in assessment of patients.
“I was in the Emergency Department when a patient came in complaining about feeling generally unwell. Since this is a complaint that is not taken seriously especially when combined with perfect lab results, it would have been very easy for this patient who was in his 20s to be sent home fairly quickly. I felt there must be a reason that this patient brought himself to the emergency department, and so I sat down with him to have a more in depth conversation about what was happening. After a period of time, the patient started to open up more and started to cry… it turned out he was suicidal. Without being inquisitive the patient would have been discharged too soon … and possibly could have ended his life”.
Another entry reinforcing the notion that inquisitiveness allows one to take ownership of individual learning.
“I found being inquisitive can be intimidating as a new grad. As the week progressed I felt more comfortable asking questions. I realized this is a learning experience and I am the one in the driver’s seat. If I want to get as much out of this experience then I must be as inquisitive as possible”.
Conclusions and Recommendation
Many of the participants in this study described how valuable being proficient in the use of CT dispositions were to their own individual learning and to delivering safe nursing care. Reflective journaling was a strategy that seemed to validate and stress the importance of using CT during the first 7 weeks of a fellowship program. This is consistent with Burrell’s (2014) findings that reflective journaling is a useful strategy that helps the learner connect theory with practice (Burrell, 2014) and Chan’s (2013) findings that reflective journaling positively impacts use of CT.
Further research that explores the internalization of the purposeful use of CT dispositions over time as they progress through their careers would be helpful. Participant satisfaction with journaling as a learning strategy was not explored and would also be helpful in further research.