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Introduction

Nurses need critical thinking in order to be safe, competent, skillful practitioners in their profession. The pace of knowledge development demands that nurses be critical thinkers. This article proposes the Critical Thinking Model for Nursing Judgment, which defines the concept of critical thinking as the first step toward analysis and utilization within nursing and nursing education.

Despite the interest in developing critical thinking among nurses and nursing students, few nursing studies have attempted to use a nursing critical thinking theoretical/ conceptual framework. Frameworks were applied from other disciplines to nursing education (Berger, 1984; Bowers & McCarthy, 1993; Gross, Takazawa, & Rose, 1987; Jones & Brown, 1991). Miller and Malcolm (1990) alone have adapted and developed a critical thinking framework in nursing curricula evaluation. Nursing lacks a critical thinking framework that is domain-specific and encompasses all areas of nursing. The Miller and Malcolm framework contains the general components of attitude, knowledge, skill, and levels of critical thinking. The Critical Thinking Model for Nursing Judgment builds upon the concepts of Miller and Malcolm, but expands to include components of nursing experience, competencies, and standards.

The National League for Nursing (NLN) recognizes the inclusion of critical thinking as a specific criterion for the accreditation of baccalaureate programs. The criterion states: "The curriculum emphasizes the development of critical thinking and of progressively independent decisionmaking*1 (NLN, 1989). Therefore, faculty need an understandable, workable, yet comprehensive definition of critical thinking. In addition, staff developers must meet hospital accreditation standards requiring critical thinking as part of clinical competencies and, therefore, are faced with similar concerns.

Since nursing is faced with facilitating and measuring the critical thinking process in direct relationship to nursing, a domain-specific critical thinking definition is necessary. Many definitions of critical thinking exist (Ennis, 1962, 1985; Pacione, 1984; Glaser, 1941; Kurfiss, 1988; McPeck, 1981; Paul, 1993; Siegel, 1980). However, there is a lack of agreement on the meaning of the concept; it is neither clearly understood nor systematically applied. The current definitions originate principally from philosophy and education and may not always be relevant to a practice discipline such as nursing. The lack of consensus and its relevancy to nursing impedes nurse educators who struggle with professional curricula and accreditation expectations te define and measure critical thinking in their curricula.

In nursing education, critical thinking has been narrowly defined as a rational-linear problem-solving activity that reflects the nursing process (Jones & Brown, 1991). Critical thinking has also been described simply as the scientific process (Kemp, 1985; Malek, 1986). Yet, it is a mistake to define critical thinking in nursing only as problem solving, scientific methodology, or nursing process because it may encompass the interaction of all of these and more.

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Based on a broader, multidimensional focus within nursing and adapted from Ennis (1985) and Kurfiss (1988), our proposed model defines critical thinking as follows: "The critical thinking process is reflective and reasonable thinking about nursing problems without a single solution and is focused on deciding what to believe and do." The definition provides the foundation for the model (see Figure).

The impetus to create the Critical Thinking Model for Nursing Judgment stemmed from an interest in incorporating critical thinking into a new undergraduate curriculum. The model was initially influenced by Miller and Malcolm's (1990) adaptation of Glaser's (1941) definition and research on critical thinking. Glaser suggested that attitudes, knowledge, and skills influence critical thinking. Miller and Malcolm illustrated the interaction of attitudes, knowledge, and skills in the resulting levels of critical thinking attained in nursing curricula. Primary goals in the construction of the model were (a) to build upon the works of Glaser and Miller and Malcolm, (b) to expand the model to include other components of critical thinking believed to be domain-specific or related to nursing, and (c) to broaden the audience beyond nurse educators and nursing students to include the entire discipline of nursing.

Development of the Model

Early versions of the Critical Thinking Model for Nursing Judgment were presented to focus groups for critique of face validity. In order to be meaningful, the model must be relevant to nursing education and to practicing nurses in a variety of clinical settings; therefore, the focus groups provided feedback on clarity and relevance.

The first focus group of three nursing educators interested in critical thinking met with the authors. This group worked principally on components of the model, creating a taxonomy of the multiple terms and phrases in the current literature relative to critical thinking in nursing and in other disciplines. Specifically, this group attempted to clarify what specific competencies were unique to nursing and to clarify the relationships among terms such as the scientific process, hypothesis generation, problem solving, decision making, diagnostic reasoning, clinical inferences, clinical decision making, and nursing process. The authors synthesized their comments for a new draft of the model.

The new draft was presented to 30 practicing registered nurses enrolled in a graduate-level nursing education program. These nurses focused principally on the levels of critical thinking and validated the levels with examples from their clinical specialties. They made design suggestions, reaffirmed the existing component section of the model, and added experience as a new component. Following another series of refinements integrating these changes, a graphic design consultant made suggestions regarding the visual representation. Finally, the initial group of nursing educators gave input for minor changes and validated this final version of the model.

Critical Thinking and Nursing Judgment

The model defines the outcome of critical thinking as nursing judgment (discipline-specific clinical judgment). That is, the outcome is the clinical judgment of nurses relevant to nursing problems in a variety of settings.

Nursing judgment entails decisions formed in direct, semi-direct, and indirect nursing care roles. As examples of these roles, staff nurses make decisions about patient care (direct), directors of nursing in agencies make decisions about distribution of nursing resources (semidirect), and nurse educators make curricular decisions (indirect).

In contrast, clinical judgment has been defined exclusively in direct care situations. In the literature, clinical judgment is discussed more than nursing judgment (Kintgen- Andrews, 1991; Westfall, Tanner, Putzier, & Padrick, 1986). Tanner (1983) defines clinical judgment as including (a) decisions regarding what to observe in the patient situation, (b) inferential decisions, deriving meaning from data observed, and (c) decisions regarding actions that should be taken that will be of optimal benefit to the patient. Research studies have been unable to show consistently a significant relationship between clinical judgment and critical thinking. Many research studies have reported that no identifiable relationship exists between clinical judgment and critical thinking (Brooks & Shepherd, 1990; Frederickson & Mayer, 1977; Pardue, 1987). However, this may be due to the lack of refinement in design and instrumentation rather than a lack of relationship between critical thinking and clinical judgment.

The authors believe that this model provides a foundation from which relationships between variables such as critical thinking and clinical judgment can be tested and validated. The five components of critical thinking for nursing judgment are specific knowledge, experience, competencies, attitudes, and standards in nursing (see Table).

Specific Knowledge

The first component is specific knowledge and was based on one of Glaaer's (1941) three composites of knowledge, attitudes, and skills. Glaser stated that knowledge is required in critical thinking. Others have documented the importance of domain-specific knowledge to successful clinical reasoning (Elstein, Shulman, & Sprafka, 1990). A specific knowledge base in nursing provides the data for the various critical thinking processes. One cannot identify appropriate actions for unexpected clinical symptoms, for example, without understanding the physiology involved. Knowledge based on courses in the sciences, humanities, and nursing is necessary to think about nursing problems. The urgent need for critical thinking processes within schools and clinical settings must not obscure the basic requirement that nurses be able to access the necessary knowledge base on which to build critical thinking.

Experience

The second component is experience. Development of critical thinking can be limited by the lack of practical experience and opportunity to actually make decisions. Benner (1984) states that practical knowledge in an applied discipline is only developed through clinical experience. Tanner, Benner, Chesla, and Gordon (1993) describe the importance of experiential knowledge, as separate from formalized knowledge, as the "know-how that allows for the instantaneous recognition of patterns and intuitive responses" in expert judgment (p. 274). Studies of other practice disciplines also demonstrate the importance of experience (Dreyfus & Dreyfus, 1986; Schon, 1983).

The expert nurse understands the context of the situation, recognizes cues, and interprets them as relevant or irrelevant (Benner, 1984). Understanding of a complex situation only comee through experience with analysis of similar and contrasting situations. Furthermore, real world experiences provide a potent strategy to decrease simplistic thinking (Kurfiss, 1988).

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Competencies

The third component is competencies and originates from Glaser's (1941) composite ability, skill. However, this model uses the word competencies to emphasize that these are cognitive rather than psychomotor processes. The competencies are of three types, based on feedback UOm the focus group and the review of literature. The three types of competencies are: (1) general critical thinking competencies, (2) specific critical thinking competencies in clinical situations, and (3) specific critical thinking competency in nursing. The examples within the areas of general critical thinking competencies, specific critical thinking competencies in clinical situations, and specific critical thinking competency in nursing involve elements common to each other.

General critical thinking competencies are not unique to nursing per se, but are used in other disciplines and nonclinical situations. Examples of general critical thinking competencies are scientific process, hypothesis generation, problem solving, and decision making. The literature is replete with multiple definitions of these sometimes overlapping competencies (Brooks & Shepherd, 1990; del Bueno, 1983; Fredrickson & Mayer, 1977; Hughes & Young, 1992; Jenkins, 1985; Kurfiss, 1988; Nehring, Durham, & Macek, 1986; Pardue, 1987; Schaefer, 1974; Tanner, 1983; Wilkinson, 1992).

The next category of critical thinking competencies is found in clinical situations, both in nursing and other clinical disciplines. These processes are used by physicians and allied health professions as well as nurses. This category of clinical critical thinking competencies includes examples such as diagnostic reasoning, clinical inferences, and clinical decision making (Elstein, Shulman, & Sprafka, 1978; Tanner, Padrick, Westfall, & Putzier, 1987; Thiele, Baldwin, Hyde, Sloan, & Strandquist, 1986; Westfall et al., 1986).

The final category is the critical thinking competency specific to nursing - the nursing process. The model suggests that the nursing process is not an allencompassing competency, but only one of the competencies of critical thinking. The format for the nursing process is unique to the discipline of nursing, just as other subject areas have disciplined ways of thinking. The nursing process provides a systematic, rational method of planning, providing, and evaluating nursing care using higher order thinking processes (Kozier, Erb, & Biais, 1992). This particular format provides a common language and process by which nurses "think through" clients' clinical problems. It provides a systematic and structural framework for nursing care (Miller & Malcolm, 1990).

In the nursing literature, some authors say that the nursing process constrains the process of critical thinking. Jones and Brown (1991) suggest that the nursing process may impede the profession's development as a legitimate science since it may not include the complex thinking processes involved in nursing practice. Miller and Malcolm (1990) criticize the nursing process for deemphasizing the contextual basis for nursing practice. Similarly, Alien, Bowers, and Diekelmann (1989) suggest that the nursing process represents an outline to organize information gathered elsewhere, "rather than a process by which to make discoveries and learn to manage that previously obtained information" (p. 9).

These three areas of competencies are not mutually exclusive, but interact to support and reinforce one another. For example, using the nursing process involves problem solving and decision making (Malek, 1986; Nehring et al., 1986; Pardue, 1987; Schaefer, 1974). Diagnostic reasoning and clinical inference are influenced by data acquisition, diagnostic accuracy, decision making, and hypothesis generation (Elstein et al., 1978; Tanner et al., 1987; Thîele et al., 1986; Westfall et al., 1986).

Attitudes for Critical Thinking

The fourth component of critical thinking is attitudes. This component was adapted from Glaser (1941) and the attitudinal traits were adapted from the work done by Paul (1993). Paul calls these "traits of the mind* and reminds us that they are central rather than peripheral aspects of a critical thinker. He says that if one does not persevere at reasoning, or is not fair in weighing evidence for an opposing viewpoint, or does not value curiosity or discipline, critical thinking is not possible. Similarly, independence, confidence, and responsibility are essential to arrive at one's own judgment (Paul, 1993). He mentions that integrity and humility help to acknowledge the limitations of personal knowledge or viewpoint. Creativity and risk taking may well be necessary to generate alternative and innovative viewpoints. Therefore, the ability to think critically in this model includes confidence, independence, fairness, responsibility, risk taking, discipline, perseverance, creativity, curiousity, integrity, and humility.

Standards

The fifth component, standards, includes two parts: intellectual standards and professional standards. The model adopts Paul's (1993) intellectual standards and expands this section to include professional standards specific to nursing. Paul states that critical thinking must meet universal intellectual standards. Paul says that in comparing and evaluating the critical thinking ability of individuals, one should apply the following intellectual standards: clarity, precision, specificity, accuracy, relevancy, plausibility, consistency, logicality, depth, broadness, completeness, significance, adequacy, and fairness.

The professional standards section is necessary for critical thinking in nursing. It sets precedence in requiring nurses to use critical thinking for the good of individuals or groups rather than to cause harm or undermine the situation. The professional standards section includes ethical criteria for nursing judgment (i.e., ANA's Code for Nurses with Interpretive Statements), criteria for evaluation (i.e., NLN accreditation or JCAHO accreditation), and criteria for professional responsibility (i.e., Nurse Practice Act or ANA Standards of Practice).

Levels of Critical Thinking in Nursing

The model identifies three levels of critical thinking in nursing: basic, complex, and commitment. These are adapted from Perry's (1970) "positions" of the ability to think critically, which describe a scheme for intellectual and ethical development. Perry's scheme may be seen in three parts, each consisting of three "positions."

In the first part, the self sees answers as dichotomous (dualism) and assumes that the authorities have the right answers for every problem. Also included in the first part are the multiplicity positions in which diversity of opinions and values among the authorities is acceptable.

In the second part, relativism, the self continues to recognize the diversity of individual outlook and perception, but the self rather than the authority is the prime mover of this process. The self has the ability to detach, analyze, and examine alternatives systematically.

In the third part, commitment, the self anticipates the necessity of personal choices in a relativistic world after the relative merits of the alternatives have been examined. In our model, the basic level is adapted from Perry's (1970) dualism position, the complex level from Perry's multiplicity and relativism positions, and the commitment level from Perry's commitment positions.

Basic

At this level, answers to complex problems are right or wrong, and one right answer usually exists for each complex problem. This level is an early step in the development of reasoning ability in each particular area of nursing. Unfamiliar content, inexperience, inadequate competencies, inappropriate attitudes, and nonutilization of standards can restrict personal ability to move to higher levels, although the goal is to think on a higher level than basic.

Complex

At this level, the nurse's best answer to a problem may be, "It depends." Nurses at this level realize that alternative, perhaps conflicting, solutions exist, each with benefits and costs. Unique aspects of the client and the context matter in weighing alternative answers. A common example of the need for complex thinking is the consideration of deviation from standard protocols or rules when complex client situations have to be taken into account. Nurses at this level may find that there is not one normal pattern; rather, accurate assessment may depend on salient situational features. At this level there may be more than one solution, but the nurse has not made a commitment to any one solution.

Commitment

At the complex level, one may be aware of the complexities of alternative solutions, yet defer from commitment to any one of the solutions. At the commitment level, however, the nurse chooses an action or belief based on the alternatives identified at the complex level.

However, an action may be delayed until a later time. For example, initially, a staff nurse may override a learned racial bias to accept a belief from a more egalitarian position. This belief will eventually result in the nurse's advocacy for improved access to health care for people of all races. If that chosen action is unsuccessful, alternative solutions are considered and utilized.

Although there are times when a nurse functions at the basic level, the goal is to reach the commitment level. Like Perry's (1970) positions of critical thinking, the levels of critical thinking in this model reflect a developmental approach. The model suggests that critical thinking ability moves up and down the hierarchy of levels, depending on the nurse, but commitment is the ultimate goal.

Assumptions

The nursing environment provides the context that constrains or facilitates critical thinking. Nurses are faced with increased workloads, and nursing students are often reinforced for memorizing and retaining factual information. In such environments, nurses and nursing students are impeded in developing their critical thinking abilities. Characteristics of a work or learning environment conducive to critical thinking are flexibility, creativity, support for change, and risk taking. If a climate of intellectual openness and integrity in the classroom or agency is lacking, critical thinking can be stifled at the outset (Paul, 1984). Similarly, environments that demand perfection or reinforce the status quo constrain the critical thinking climate necessary among colleagues for excellent nursing judgment. If new ideas are not exchanged and sometimes accepted, then why think through a troublesome nursing situation or an outdated protocol?

In addition to environment, individual characteristics influence one's critical thinking ability. Age, culture, gender, ethnicity, socioeconomic status, intelligence, and level of development may affect the components of critical thinking, which in turn influence one's level of critical thinking.

Summary

Today's increasingly complex health care environment creates an urgency for professionals to be able to solve complex problems. The Model of Critical Thinking for Nursing Judgment provides a definition and conceptualization of this process based on the literature and critique from nurses and nurse educators. The model includes five components of critical thinking: specific knowledge base, experience, competencies, attitudes, and standards. These components influence the three levels of critical thinking: basic, complex, and commitment.

The model underscores the view that the nursing process alone is not an adequate conceptualization of critical thinking. Other processes are needed for nursing judgment. Nursing educators and staff developers must ask themselves whether nursing programs are socializing nurses to think at a basic level. The hierarchy of levels reminds us that the objective in complex nursing situations is the commitment level, rather than being satisfied with simple answers to complicated situations.

The model may provide a basis for future research and educational strategies. The components and levels can be used by researchers to develop reliable and valid instruments, operationalize definitions, and examine relationships within the model. In addition, the model will provide nurse educators with a framework for developing teaching strategies and assessing students' potential for critical thinking. Finally, this conceptualization lays a foundation for nurses and nurse educators to promote critical thinking abilities within nursing. Further discussion of the model is essential to facilitate the understanding of the critical thinking process.