JAN O R IG I NALR E S EAR C H

Evaluation of a reflective learning intervention to improve critical

thinking in novice nurses
1 2
Susan Gross Forneris & Cynthia Peden-McAlpine

Accepted for publication 5 September 2006

1
Susan Gross Forneris PhD RN CRRN CCM FORNERIS S . G . & PEDEN - MCALPINE C . (2007) Evaluation of a reflective learning
Assistant Professor intervention to improve critical thinking in novice nurses. Journal of Advanced Nursing
Department of Nursing, College of St 57(4), 410–421
Catherine, St Paul, Minnesota, USA doi: 10.1111/j.1365-2648.2006.04120.x
2
Cynthia Peden-McAlpine PhD RN APRN
BC
Abstract
Associate Professor Title. Evaluation of a reflective learning intervention to improve critical thinking in
School of Nursing, University of Minnesota, novice nurses
Minneapolis, Minnesota, USA Aim. This paper reports a study to determine if a reflective contextual learning
intervention would improve novice nurses’ critical thinking skills during the first 6
Correspondence to Susan Gross Forneris: e- months of their practice.
mail: [email protected]
Background. Nursing research evaluating the development of critical thinking in novice
nursing practice is limited. The continual struggle by nurse educators to improve critical
thinking demonstrates the need for innovative educational inter-ventions that assist in the
development of critical thinking as novice nurses enter into practice.

Method. This small case study was conducted in the United States of America in 2004
with six student/preceptor dyads. The contextual learning intervention was the case
through which the novice nurses’ critical thinking were analysed using Stake’s phases of
data analysis. Specific questions (i.e. novice nurses’ use of reflection, context, dialogue,
time) guided the analysis. Repeating patterns were coded and isolated and later
collapsed/enhanced as the analysis moved forward.
Findings. Three main themes describe the novice nurses’ development of critical
thinking: (1) influence of anxiety and power on critical thinking; putting pieces together;
(2) questioning as critical thinking: sequential thinking to contextual thinking; and (3)
emergence of the intentional critical thinker.
Conclusion. Used as a reflective practicum, contextual learning can be a model of
clinical learning in nursing education that develops the contextual, reflective nature of
critical thinking.

Keywords: case study, critical thinking, narrative, nursing education, reflective

practice, research in practice

their need for support in the clinical setting to incorporate critical

Introduction
thinking along with clinical skill acquisition (Benner 1984,
The literature suggests that nursing practice and patient outcomes Benner et al. 1996). While nursing students are involved in
are improved by nurses’ critical thinking. This has implications academic clinical experiences, many of the experiences are
for the practice of novice nurses as it highlights limited. As novice nurses make the transition

410 2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd
JAN: ORIGINAL RESEARCH Improving critical thinking

into actual clinical practice, their critical thinking and real life enhances the ability to be critical in our thinking (to
understanding have been described as acontextual, using rule- uncover hidden realties).
governed thinking to solve practice problems. Achieving Stemming from their work, the nursing literature con-tains
competence in an area of practice is described as a 2–3-year many discussions on reflection that outline frame-works for
process (Benner 1984). Without developed critical thinking reflective practice (Boyd & Fales 1983, Jarvis
skills, nursing care at best may be suboptimal and affect patient 1992, Atkins & Murphy 1993, Darbyshire 1993, Green-
outcomes. wood 1993, 1998, Burnard 1995, Johns 1995, Baker
Nursing research has to date been poor at defining or 1996). These accounts make two important contributions.
evaluating the effects of critical thinking in practice, and First, they recognize the lack of consistency surrounding the
specifically how critical thinking is developed in novice nursing definition and use of the concept of reflection, emphasizing that
practice to enhance practical performance. Nursing educators reflection is more than just thoughtful practice or pondering
continue to struggle to find innovative teaching methodologies to thought. They establish a baseline understanding of reflection as
improve critical thinking in novice nurses (Facione et al. 1994, a thinking process of creating and clarifying the meaning of an
Colucciello 1997, 1999, Krichbaum experience. Second, they recognize that nursing education has
et al. 1997, McGovern & Valiga 1997, O’Sullivan et al. failed to study reflection systematically in order to further define
1997, Sedlak 1997, Girot 2000, Chau et al. 2001, Daly and operationalize the concept.
2001, Staib 2003). Educational methodologies that incor-
porate the use of context in a reflective, dialogical approach over Findings from much of the research on reflective thinking in
time hold much promise for improving a dynamic process of the nursing education and practice literature do not illustrate how
critical thinking in practice. This paper is to report a study to reflective thinking is developed to actually change practice.
evaluate a contextual learning intervention (CLI) aimed at However, previous research by Hartrick (2000) and Peden-
improving novice nurses’ critical thinking in practice. McAlpine et al. (2005) provided evidence
that reflective practice transformed how nurses practice family
nursing.
Hartrick (2000) used a qualitative reflective process guided by
Background
the principles of critical theory that facilitated an eight member
The majority of nursing research on critical thinking portrays it multidisciplinary team’s development of family health promoting
as a composite of traits, dispositions, and/or skills (Watson & practices. The findings suggested that practicing nurses enhanced
Glaser 1964, Ennis 1985, Norris 1985, Facione et al. their skills in family health promotion so that they shifted the
1994, Paul & Heaslip 1995). Other theoretical views portray focus from care of the individual to the family within the context
it as a process of thinking to understand the many complex-ities of their lives.
of context to determine what is meaningful and relevant Freire Peden-McAlpine et al. (2005) reported the findings of a
1970, Argyris & Scho¨n 1974, Scho¨n 1983, 1987, phenomenological study evaluating the outcomes of a reflective
Tennyson & Breuer 1997, Brookfield 2000, Mezirow 2000). practice intervention that taught eight paediatric critical care
Reflection is a key mechanism in this process of critical thinking. nurses how to incorporate family sensitive care into their
Grounded in these theoretical views, critical thinking is defined practice. The findings supported the fact that, through reflective
as a process of reflective thinking that goes beyond logical practice, the nurses began to transform their practice by
reasoning to evaluate the rationality and justification for actions recognizing the family as the unit of care and incorporating the
within context. It is a thinking process focused not on family into their practice.
achievement of the answers, but on achievement of a coherence The significance of these two studies is that reflection,
of understanding within the context of a situation. combined with narrative and dialogue, helped to transform
nursing practice by bridging the gap between the theoretical
Reflective thinking as critical thinking became popular ideals of nursing care and the realities of daily care-giving
through the work of Schon and Argyris (Argyris & Scho¨n 1974, practices. These studies suggest how reflective thinking can be
Scho¨n 1983, 1987, Argyris 1992. Scho¨n’s (1987) work developed in nursing practice and education. Because of the lack
emphasized that thinking in practice differs from thinking in of studies incorporating effective reflective strategies to enhance
structured learning situations as real world problems provide nursing practice, we carried out a qualitative case study to
unique complexities that do not present themselves in structured explore the use of reflection and narrative through a CLI to
formats. Argyris and Scho¨n (1974) give insight into the notion improve novice nurses’ critical thinking in practice.
that reflective thinking within the context of

2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd 411
S.G. Forneris and C. Peden-McAlpine
 A qualitative instrumental case study design was used, with
Theoretical underpinnings of the CLI
the CLI identified as the case. A case is viewed by Stake (1995)
The CLI is derived from the philosophical and theoretical work as an entity of interest that we seek to understand. A case is a
of educational theorists Freire, Scho¨n, Argyris, Mezirow, bounded system and, as such, a programme and a programme
Brookfield and Tennyson. These theorists all share similar intervention may be consid-ered a case. Through case study
perspectives on thinking in practice to achieve a coherent design, the patterns and complex interrelationships of the
understanding by developing learners’ ability to discern what is attributes of critical thinking were examined within a specific
relevant and meaningful, given the context of the situation, and bounded context
thereby to move beyond the simple application of facts and rules – contextual learning. This case study approach was defined as
to achieve situational understanding and transform practice instrumental because a case (i.e. CLI) was being studied for the
(Freire 1970, Argyris & Scho¨n 1974, Scho¨n 1983, 1987, purpose of understanding something else (i.e. novice nurses’
Brookfield 1993, 1995, 2000, Tennyson & Breuer 1997, critical thinking). Intense study of the CLI was crucial in
Mezirow 1978, 1990, 2000). Using the work of these theorists, understanding the novice nurses’ critical thinking.
four attributes of critical thinking were derived that support the
CLI: reflection, context, dialogue and time. A more detailed
discussion of the work of each theorist and the attributes of
Participants
critical thinking is given in Forneris (2004) and Forneris and
Peden-McAline (2006). The setting for the case study was an acute care facility in a
major metropolitan area in the north-western United States of
America (USA) with an established nursing orientation
The study
programme that incorporated nurse preceptors. Novice nurses
were defined as baccalaureate-prepared, newly employed (e.g.
Aim
within 1 month) Registered Nurses assigned to patient care
The aim of this study was to determine if a reflective CLI would responsibilities and having less than or equal to 1 month of
improve novice nurses’ critical thinking skills during the first 6 professional nursing experience. Nurse preceptors were defined
months of their practice, as evidenced by the nature of their as nurse colleagues educated and assigned by the acute care
dialogue, writing and respondent interviews. facility to orient the novice nurses during their first 6 months of
practice. Nurses meeting the criteria for inclusion were invited to
participate in the case study during a standard introductory
Study design
employee/orientation meeting within their facility. The principal
The CLI was implemented over a 6-month period in 2004 as part investigator (SGF) gave an oral introduction describing the
of a standard nursing orientation programme for novice nurses to research project and an outline of the CLI. Interested participants
improve critical thinking during their transition from education to were given a written introduction and consent form, and follow-
professional nursing practice. CLI case study participants kept up telephone calls were made by the investigator to answer
journals and attended small group components outside of the questions and provide further clarification on risks
standard orientation (see Table 1).

Table 1 Contextual learning intervention overview

Educational components Time frame Description
Narrative reflective journaling Ongoing 6 months Mechanism to engage the novice nurse in a reflective thinking
process as they recalled and documented their narrative
stories
Individual interviews Prior to intervention, at 3 months Mechanism to individually coach the novice nurse supporting
and again at 6 months their critical thinking process
Preceptor coaching First 3 months Use of preceptors to engage the novice nurse in contextual
learning on a daily basis to help the novice nurse incorporate
critical thinking into their daily practice experiences
Leader facilitated discussion Biweekly · 4 months; Monthly · Use of narrative (stories) in small groups to coach the novice
groups 2 months nurses to understand what is encompassed in critical thinking
in practice and understand how it is incorporated into their
practice
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JAN: ORIGINAL RESEARCH Improving critical thinking

and benefits. The preceptors of interested novice nurses were Contextual learning intervention
then contacted by the investigator and given a written letter of
introduction and consent form. The novice nurses and preceptors The CLI encompasses four interrelated components:
must have consented in dyads and were then enroled into the (a) narrative reflective journaling; (b) individual interviews;
case study. A total of 20 novice nurses meeting the criteria for (c) preceptor coaching; and (d) leader-facilitated discussion
inclusion were invited to participate; eight expressed an interest groups (see Figure 1).
in participating and were enroled in the study with their The components incorporate the attributes of critical thinking
preceptors. Two novice nurses left the study within two weeks of within the context of real life practice through the use of
enrolment, citing personal conflicts in devoting the necessary narrative (stories). The learner is coached to reflect on and
time to the study. The remaining six dyads completed the study organize thinking around context to gain an understand-ing of
and thus com-prised the case study sample. While Stake does not critical thinking in practice and develop critical thinking skills
give parameters for sample size in case study, Morse (1989) and (e.g. using the attributes of reflection, context, dialogue and
Sandelowski (1995) recommend a sample size of six to ten for time). The design and theoretical framework underpinning the
narrative text analysis. CLI is described in more detail in Forneris and Peden-McAline
(2006).
The novice nurse group median age was 25 years of age Contextual learning was implemented over the course of 6
representing both private and public 4-year nursing pro-grammes months to improve novice nurses’ critical thinking in practice as
across several states of the USA. Their experience with reflection part of their orientation into professional practice (see Table 1).
involved mostly journaling of academic clinical experiences with The investigator facilitated all the components of the intervention
little involvement in group dia-logue around reflection. The to ensure consistency in presentation with the novice nurses and
nurse preceptor group median age was 35 years of age. preceptors.
Preceptor’s level of education was representative of both 2-year
and baccalaureate prepar-ation, with median years of practice Narrative reflective journaling
experience at 14 years representing varied backgrounds (i.e. As part of the CLI, novice nurses used narrative reflective
ICU, general medical surgical, cardiac, orthopaedics and journaling to relay their experiences as new graduate nurses.
oncology). All of the preceptors had experience in precepting Adapted from Brookfield’s (1990) critical incident technique,
new graduate nurses receiving instruction by the investigator on they were asked to recall an aspect of their work in the past week
the CLI to engage the attributes of critical thinking in practice. It that had resulted in a feeling of accomplishment, sat-isfaction
was determined that the case study sample was repre-sentative of and/or resulted in feelings of discouragement or frustration. They
the novice nurses and preceptors employed throughout the were asked to write and reflect about this experience in the form
hospital through comparison with demo-graphics. of a story (narrative), using guided questions adapted from the
nursing literature and critical thinking attributes (Heinrich 1992,
Cameron & Mitchell

ilitat edDis cus

sio
r ac

te
F n
Gr
a o
u
e
torC p
L
recep oachi s

dividualInt
P ng

ervie

In eR
eflective Jo urws
rr
a
tiv
n ali n

g
a

N
Reflection
 Time Context

Dialogue

Figure 1 Contextual learning intervention.

2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd 413
S.G. Forneris and C. Peden-McAlpine

1993, Baker & Diekelmann 1994, Johns 1994, Bowles 1995, or the barriers to critical thinking development. Most
Paterson 1995, Baker 1996, Andrews et al. 2001, Aranda & importantly, the dialogue created an opportunity for sharing and
Street 2001, Diekelmann et al. 2003, Ironside 2003a, Forneris challenging of multiple perspectives to gain a wider vi-sion of
2004). The novice nurses then shared these narra-tives through the contextual elements involved in the stories.
story-telling during the leader-facilitated dis-cussion group
sessions and individual interviews.
Data collection

Individual interviews Data on the novice nurses’ critical thinking were collected
Using the novice nurses’ personal narratives, the investigator through the individual interviews, discussion groups and
engaged in reflection and individual dialogue with each novice narrative reflective journaling at varying intervals over the 6-
nurse about their stories and reflections coaching each nurse in month case study period in 2004 (see Table 1). All interviews and
the use of the attributes. The use of real life practice situations leader-facilitated discussion groups were tape recorded and
gave an opportunity for the novice nurses to ana-lyse thinking transcribed for textual analysis.
over time, draw on past knowledge, reflect on assumptions,
elaborate on that knowledge and, through coaching during the
Ethical considerations
interview, to construct new knowledge.
The appropriate human subject protection committees at the
Preceptor coaching university and clinical facility approved the study before
Nurse preceptors involved in the study were taught by the recruiting the nurses and preceptors, who were told that all
investigator how to coach novice nurses in dialogue, use information would be kept strictly confidential and that names
reflection, and use past experiences and past knowledge to would not be associated with any information given. Each nurse
understand the context of care situations and enhance critical and nurse preceptor signed a consent form. All identifying names
thinking in practice. Through an intentional, guided, reflect-ive, and places were removed during transcrip-tion and the transcripts
coaching process of dialogue and questioning, preceptors were numerically coded.
challenged the context of the nurses’ thinking framework.
Preceptors’ questions assisted the novice nurses to determine
Data analysis
significant aspects of the context of care situations, taking into
consideration patterns, perceptions, attitudes, values, etc. Case study analysis differs from general qualitative analysis in
(Myrick & Yonge 2002, Ironside 2003b). The teaching that the investigator is taking apart impressions and
involved preceptors in attending two small group-training understanding the case by piecing data together to illuminate
sessions, one prior to their work with the novice nurses and patterns, relationships and relevant meanings (Stake 1995).
another at the completion of the case study to discuss their The data analysis for this case study was guided by specific
experiences with the CLI. To assess the consistency of their questions (i.e. use of reflection, context, dialogue and time)
training, the preceptor group sessions were tape recorded, focused on understanding the impact of the CLI on the nature of
transcribed and analysed for consistency using textual ana-lysis. the novice nurses’ critical thinking. Using Stake’s (1995) phases
There appeared to be no inconsistencies in preceptor guidance. of data analysis (see Table 2), data were analysed as they were
The findings and discussion of this process will be reported in a collected. Patterns that repeated were coded and isolated and
separate paper. later collapsed or enhanced as the collection and analysis moved
forward.
Leader-facilitated discussion groups
Similar to individual interviews, leader-facilitated discussion
Rigour
groups gave an opportunity for the investigator to conduct a
group dialogue with the novice nurses about their stories and Rigour was evidenced and maintained in this case study by
reflections. They were asked in advance to think about their closely following an accepted format for collection of data and
experiences over a specific period of time and, using reflection method of analysis, as described. The investigator consulted a
guidelines, to give examples in the form of stories. The nar- case study method expert for each 2-month time interval to
ratives of their practice experiences were then shared through assure consensus of themes and patterns and congruence of
storytelling, after which they were guided in a reflective dialogue meaning as it related to the critical thinking processes; this
incorporating the attributes of critical thinking. This reflective provided another check on the trustworthiness of the analysis
dialogue helped to illuminate their critical thinking (Sandelowski 1991, 1994, Stake 1995). The

414 2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd
JAN: ORIGINAL RESEARCH Improving critical thinking

Table 2 Data analysis

Specific aim: To determine if contextual learning would enhance novice nurses’ critical thinking skills over time during the first 6 months of their
practice as evidenced by the nature of their dialogue, writing and respondent interviews.

Analysis Analysis activities

Phase 1 – Description: Data were reviewed and a general • Reading and rereading the data in its entirety
description of the critical thinking process used by the novice • Note commonalities and discrepancies between the novice nurses’
nurse over a 6-month period of time was outlined. thinking processes
• Compile a general description of the progression of the critical
thinking process used by the novice nurses over time
Phase 2 – Categorical aggregation: Data were categorized and • Reading and rereading the data in its entirety
specific exemplars compiled to illuminate the critical thinking • Isolating critical incidents where the novice nurse incorporated
process and to examine how dialogue, reflection, context and dialogue, reflection, context and time into the critical thinking
time were incorporated into the thinking process over a process
6-month period of time • Interpreting the meaning of how dialogue, context, time, and
reflection were incorporated in the critical thinking process and how
it changed over a 6-month period of time
• Compile exemplars identifying how the critically reflective process
was incorporated into practice
Phase 3 – Establishing patterns: Categories were analysed • Reading and rereading the data of the critical incidents and
further to establish patterns or themes and the consistency of comparing similarities and differences on examples of critical
those patterns or themes across data. Patterns could be known thinking processes
in advance and served as a template for the analysis: • Coding segments of meaningful data representing critical thinking
(i.e. Questioning of personal assumptions; Knowledge processes into common categories
regurgitated or connected to context; Action plans identified • Recoding the data into common categories and naming the
based on new meaning; Previous knowledge connected to ‘patterns’ based on researcher consensus
current experiences, etc.) • Writing the thematic description of the critical thinking process
utilized by the novice nurse during the reflective mentored
educational intervention over a 6-month period of time and
illustrating the description with exemplars from data
Phase 4 – Naturalistic generalizations: Findings were • Review of the findings generated from the first three phases and the
interpreted relative to what was learned from the case analysis transcripts from interviews and focus groups, and journal entries
and were generalized for the purpose of making • Interpreting the findings in light of using contextual learning and
recommendations for use or adaptation of contextual learning making generalizations regarding enhancing novice nurses’ critical
in practice. thinking
• Making recommendations for use or adaptation of the reflective
mentored educational intervention in novice nurse orientation
programs

researcher provided written exemplars of the findings to the description of critical thinking used, categorical aggrega-tion
demonstrate how the interpretation of findings was reached. The (i.e. how the novice nurses incorporated the attributes in their
qualitative process was visible and auditable through the dialogue and writing) and themes (see Figure. 2–4). Naturalistic
documentation of underlying assumptions, thoughts, and insights generalizations will be reported in a separate paper. Exemplars
that become apparent during observations and analysis, illustrating the themes for each time period are discussed below.
especially in identifying patterns and interpreting the meaning of To illustrate the change in critical thinking over time, the
the critical thinking processes of the novice nurses. This left an exemplars presented come from one novice nurse’s experience;
audit trail so that the interpretation could be reconstructed by however, this progression is representative of all six participants.
readers or another researcher (Sande-lowski 1995).

Theme for time period 1: Influence of anxiety and power on

Findings critical thinking; putting pieces together

The CLI was analysed over a 6-month timeframe broken down During time period 1 (see Figure 2), the novice nurses
into 2-month intervals, creating three separate time periods. experienced anxiety; however, this anxiety resulted from more
Using Stake’s phases of analysis, the findings portray than just being new. Specifically, experienced nursing

2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd 415
S.G. Forneris and C. Peden-McAlpine

Focus of Contextual Learning Intervention

To gain an understanding of critical thinking

Description of Critical Thinking

Trying to find the pieces and Reflection
put them together Recognizing patterns,
connection knowledge,
recognizing assumptions

Use of past experience Overview of

Time and knowledge practice Context
expectations

Sharing experienced nurses’

stories to structure knowledge

Dialogue

Categorical Aggregation

Themes – Time Period One

Influence of anxiety on critical thinking

Influence of power on critical thinking
Figure 2 Summary of findings for months 1
Putting the pieces together
and 2

Focus of Contextual Learning Intervention

To develop critical thinking skills

Description of Critical Thinking

Reflection
Productive pattern of
questioning Thinking out loud to validate knowledge base, thinking beyond the
assumptions to implications

The use of past The patient care

Time experience to discern situation and patient Context
change over time patterns

Questioning to clarify and target

context; to validate thinking and
nursing action; move away from
assumptions
Dialogue

Categorical Aggregation

Themes – Time Period Two

Questioning as critical thinking; beginning

as linear thinking process – moving to a
contextual thinking process Figure 3 Summary of findings for months 3
and 4

staff created a socialization process that discounted the novice of doing things’. Power was manifested by the preceptor and the
nurses’ existing knowledge and gave little opportunity to preceptor’s expectations for performance. As a result, the novice
dialogue. Discussions with preceptors focused on ‘our way nurses questioned their own knowledge and beliefs.

416 2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd
JAN: ORIGINAL RESEARCH Improving critical thinking

Focus of Contextual Learning Intervention

To evaluate critical thinking

Description of Critical Thinking

Pattern of being intentional Reflection

and reflective Thinking intentionally to take

the appropriate right action

The use of past A broader patient

Time experience to discern Context

change over time care view

Questioning thinking and nursing

action to enhance their
effectivenesss as a member of
the care team

Dialogue
Categorical Aggregation

Themes – Time Period Three

Emergence of self as the

Figure 4 Summary of findings for months 5 intentional critical
and 6 thinker

Their anxiety increased as they attempted to filter the influences Theme for time period 2: Questioning as critical thinking:
of the hospital culture: sequential thinking to contextual thinking
Novice Nurse 5: ‘On Thursday we post-opted an older woman…she was The novice nurses moved along a continuum from a sequential,
in a great deal of pain that first day following surgery and we were rules-oriented thinking style (e.g. based on unit policies,
having a difficult time controlling it as well as her nausea…We had tried preceptor directives) to a more contextual style of thinking (e.g.
crackers, soda, and other non-pharmaceutical interven-tions, but nothing incorporating past experiences, knowledge and patterns in light
was working…I had entertained the idea of an antiemetic, but had of the care situation). During time period 2 (see Figure 3), the
deferred to my preceptor and doubted my assessment. Mistakenly, I intervention focused on dialogue that encouraged them to ask
waited for my preceptor to suggest an intervention that never questions in a reflective and critical manner. Questioning
materialized…the next nurse said the patient should have been given prompted reflection on the context of the patient care situation,
something, meaning an antiemetic…no one should suffer like that. I engaging them to move from thinking focused on rules to
didn’t even ask why or run it by my preceptor…I really have to work context. Thinking out loud as a form of questioning, the novice
hard to get out from under my preceptor…I do have to learn to trust my nurses verbalized sources of knowledge, past experience,
own judgment and intuition. patterns; and identified plans for action (e.g. ‘I’m thinking this…
the reason might be…and I am considering that…would this be
in line with what you might be thinking?’). The dialogue became
In this exemplar, the novice nurse reflects on her assump-tions
a form of critical questioning (e.g. verbalizing and questioning
that her preceptor should have identified an alternat-ive care
sources of knowledge, past experience, assumptions, biases,
plan. Through reflection, the novice nurse is able to put the
plans for action, etc.) helping to challenge their thinking and
pieces together to establish an appropriate course of action.
those of others:
However, her lack of trust in her knowledge base and the
influence of her preceptor influ-enced her critical thinking and
the nursing action. As the first 2-month time period progressed, Novice Nurse 5: Well, I feel like I’m being able to pull bits and pieces
the influence of anxiety and power seemed to lessen, and the from what my preceptor told me…I had been checking on this patient
novice nurses began to emerge with more confidence in their every hour, writing down everything and then…I went in to do the one
own critical thinking. check on [my patient] and she was just gasping for air…I thought, OK,
she’s really having trouble here so right away I put on

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S.G. Forneris and C. Peden-McAlpine

the oxygen. I thought, you know, that was pretty good ‘cause it really felt
Discussion
automatic. And mostly it was the anxiety on her face…I could tell it
was…even though wheezing and stuff was kind of normal for her, this The case study analysis illustrates that the CLI, as an educational
was not in her realm of what it should have been. Her O 2 sats looked intervention, assisted in the development of critical thinking
fine…but I was starting to kind of process that and I was looking at all within the context of practice. Analysis of narratives from the
those things…and she calmed down. novice nurses’ experiences while engaged in the intervention
demonstrated visible changes in their critical thinking over time.
The novice nurse is faced with the experience of managing a
The attribute of context began with rules and expectations and
patient with difficulty breathing. Her thinking is initially focused
was later characterized by the novice nurses’ consideration of the
on writing everything down as directed by her preceptor as she
broader patient care view (e.g. knowledge, assumptions,
questions her knowledge and reasoning. She then begins to
expectations, impact of the hospital culture, patients’ views and
question her thinking, ultimately considering other contextual
opinions). The use of context helped to organize and broaden the
elements (e.g. anxiety on her patient’s face and different pattern
knowledge base. (Benner’s (1984) and (Benner et al.’s (1996)
of breathing). Her actions are influenced by these additional
work with novice nurses highlights their clinical practice as
contextual elements. Her reflective questioning helped to
acontextual, using rule-governed behaviour to solve problems of
highlight the important contextual elements and her sense that
practice. This has the potential to influence successful
things were not quite right, and this ultimately affected the
performance of nursing care. Given the natural course of
patient’s breathing and anxiety.
experience in practice, most novice nurses develop their critical
thinking and achieve competence in an area within 2–3 years
(Benner 1984). However, the CLI provided a learning structure
Theme for time period 3: Emergence of the intentional
that was focused on context, stimulating the novice nurses to
critical thinker
engage in an intentional, reflective, dialogue with themselves and
During time period 3 (see Figure 4), the novice nurses were their colleagues and connecting them to the contextual realities
intentional about the use of critical questioning as a way to of care situations to expedite the development of critical thinking
articulate their thinking. This resulted in more intentional in practice and their journey toward com-petence.
reflection on context, which guided their thinking during
practice:
Benner et al. (1996) work with novice and advanced beginner
Novice Nurse 5: What slowly has emerged for me is more thought of
nurses also describes them being limited to aspects of care
how can I be an advocate for this person and how can I move them to
situations that they can see and understand. Under-standing how
where they want to be, whether that’s emotional or…once I go in and
pieces fit the whole picture has been documen-ted as beyond
meet the person…see what’s going on. Just as simple as, I had a lady
their skill. Their focus is on applying their knowledge in practice
yesterday and today…there were some issues that were holding her back
situations. However, merely applying knowledge limits
and she was back peddling. A big one was constipation…[I] worked for
development of critical thinking because there is no opportunity
two days … and she said, ’Now I feel so much better’. Simple things like
to differentiate how knowledge may change given context.
that, and you don’t realize the bigger picture…I don’t think it’s stressed
Scho¨n (1983, 1987) contends that thinking in practice involves a
enough…I think our group [unit] gets pretty complacent…I look at it and
reorganization of context moving beyond the application of
say, ‘What can I do different from what the nurse before me has done to
knowledge to construct knowledge. Tennyson and Rasch (1988),
make them progress a little bit more with just the simple things?’
Tennyson 1990, 1992 and Tennyson & Breuer 1997) work on
cognitivism also focuses on construction of knowledge through
The novice nurse was intentional about reflecting on the the use of context to create contextual knowledge. When the
contextual elements of this care situation (e.g. bigger care novice nurses were coached to integrate the attributes into their
picture, patient’s sense of progress). Critical thinking in practice thinking to manage complexities, they began moving from
was illustrated by listening closely taking into consid-eration the simply organizing and applying their knowledge to con-structing
contextual information [e.g. patient’s pattern (back-peddling), new knowledge based on context. The CLI provided a
complacency of coworkers] surrounding the healthcare situation. developmental structure that moved beyond the application of
This ultimately affected the novice nurses’ actions. During the knowledge to thinking that identified the individual contextual
last 2 months of the intervention, they had moved to an elements and integrated these elements to create a framework of
intentional reflective process of thinking that resulted in nursing contextual knowledge.
actions based on context.

418 2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd
JAN: ORIGINAL RESEARCH Improving critical thinking

reflective practicums suggest that they are successful in

What is already known about this topic
operationalizing abstract theoretical principles into daily care-
• The nursing literature contains numerous accounts of giving practices and transforming nursing practice by generating
discussions on reflection that outline frameworks for a deeper understanding of patient needs. Similarly, findings from
reflective practice. the CLI as a reflective practicum illustrate how coaching novice
• These attempt to establish a baseline understanding of nurses to make connections between past experiences and new,
reflection as a thinking process of creating and clarify-ing unfamiliar, unstructured practice situ-ations facilitated the
the meaning of an experience and recognize that nursing connection between thinking and doing in the context of real life
education has failed to study reflection sys-tematically in practice. Coaching in the context of real life practice expedited
order to further define and operationalize the concept. novice nurse thinking further along a continuum from thinking as
separate facts to organizing their thinking as a process of critical
• The clinical practice of novice nurses is acontextual, using thinking in practice.
rule-governed behaviour to solve problems does not
facilitate use of critical thinking. Finally, our findings raise questions of power relations and the
influence of the dominant culture of the healthcare system. The
role of the preceptor and the hospital culture had a significant
What this paper adds impact on thinking, as illustrated in the novice nurses’ stories.
• The contextual learning intervention can be used to develop Power within the hospital culture initially reinforced the novice
critical thinking to change nursing practice. nurses’ rule-governed behaviour. These findings raise questions
• The benefits of using a reflective practice intervention to as to whether the goal of orientation is to foster critical thinking
create a process of critical thinking were use of discre- or to orient nurses to survive within a hospital culture. The role
tionary judgment and achieving understanding within the of preceptor needs careful consideration in relation to the nature
context of care. of the hospital culture and its expectations and goals for
• The contextual learning intervention can be incorpor-ated orientation.
into both nursing education and professional development
programmes to expedite the development of critical Study limitations
thinking and competence in novice nurses.
The study was an intensive examination of an intervention in one
particular institution. Other institutions may yield different
The study also demonstrates the importance of dialogue in results because of differences in the cultural milieu. The findings
developing a process of critical thinking in practice, support-ing are limited to generalizing the concept of critical thinking in
the work of Diekelmann and colleagues on narrative pedagogy practice to contextually similar novice nurse settings. They create
(Diekelmann 1995, 2001, Andrews et al. 2001, a new understanding of the design and evaluation of a reflective
Diekelmann et al. 2003, Ironside 2003a,b). Diekelmann educational intervention on critical thinking, but generalization
et al.’s (2003) work suggests that dialogue around our everyday to other contexts is not possible without further study. Further
experiences gets at how we are thinking. Our case study findings research needs to be done to continue investigating this type of
suggest that, by sharing narratives on practice experiences, reflective practicum on thinking in novice nurses and/or nursing
novice nurses were not only able to explore their own thinking students.
but also to gain perspective from others. This helped them
engage in critical questioning focused on context. Thinking out Conclusion
loud (contextual questioning) was more than articulating
thoughts and enabled the development of unique practice Critical thinking in practice is more than articulating content
frameworks as opposed to merely applying the culture’s practice knowledge – it is an intentional thinking process of under-
framework. standing within context. This should be an expectation for
The findings of the study also support the effectiveness of nursing educational programmes. Nursing education should
reflective practicums, as highlighted in the nursing literature focus on facilitating critical dialogue (i.e. encouraging students
(Hartrick 2000, Peden-McAlpine et al. 2005). Scho¨n’s (1983, to challenge perceptions, asking questions beyond expository or
1987) work on reflective practicums incorporates learning within declarative knowledge) making visible the nature of thinking to
the context of practice. Findings from other nursing studies broaden perspectives and reframe thoughts and insights. Used as
(Hartrick 2000, Peden-McAlpine et al. 2005) using a reflective practicum, the CLI

2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd 419
S.G. Forneris and C. Peden-McAlpine

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