28 Dias Critical Thinking

 
S-1 Thinking Independently

Principle: Critical thinking is independent thinking, thinking for oneself. Many of our beliefs are acquired at an early age, when we have a strong tendency to form beliefs for irrational reasons (because we want to believe, because we are praised or rewarded for believing). Critical thinkers use critical skills and insights to reveal and reject beliefs that are irrational.

In forming new beliefs, critical thinkers do not passively accept the beliefs of others; rather, they try to figure things out for themselves, reject unjustified authorities, and recognize the contributions of genuine authorities. They thoughtfully form principles of thought and action; they do not mindlessly accept those presented to them. Nor are they unduly influenced by the language of another.

If they find that a set of categories or distinctions is more appropriate than that used by another, they will use it. Recognizing that categories serve human purposes, they use those categories which best serve their purpose at the time. They are not limited by accepted ways of doing things. They evaluate both goals and how to achieve them. They do not accept as true, or reject as false, beliefs they do not understand. They are not easily manipulated.

Independent thinkers strive to incorporate all known relevant knowledge and insight into their thought and behavior. They strive to determine for themselves when information is relevant, when to apply a concept, or when to make use of a skill. They are self-monitoring: they catch their own mistakes; they don't need to be told what to do every step of the way.

S-2 Developing Insight Into Egocentricity or Sociocentricity

Principle: Egocentricity means confusing what we see and think with reality. When under the influence of egocentricity, we think that the way we see things is exactly the way things are. Egocentricity manifests itself as an inability or unwillingness to consider others' points of view, a refusal to accept ideas or facts which would prevent us from getting what we want (or think we want).

In its extreme forms, it is characterized by a need to be right about everything, a lack of interest in consistency and clarity, an all or nothing attitude ("I am 100% right; you are 100% wrong."), and a lack of self-consciousness of one's own thought processes. The egocentric individual is more concerned with the appearance of truth, fairness, and fairmindedness, than with actually being correct, fair, or fairminded. Egocentricity is the opposite of critical thought. It is common in adults as well as in children.

As people are socialized, egocentricity partly evolves into sociocentricity. Egocentric tendencies extend to their groups. The individual goes from "I am right!" to "We are right!" To put this another way, people find that they can often best satisfy their egocentric desires through a group.

"Group think" results when people egocentrically attach themselves to a group. One can see this in both children and adults: My daddy is better than your daddy! My school (religion, country, race, etc.) is better than yours. Uncritical thinkers often confuse loyalty with always supporting and agreeing, even when the other person or the group is wrong.

If egocentricity and sociocentricity are the disease, self-awareness is the cure. We need to become aware of our own tendency to confuse our view with "The Truth". People can often recognize when someone else is egocentric. Most of us can identify the sociocentricity of members of opposing groups. Yet when we ourselves are thinking egocentrically or sociocentrically, it seems right to us (at least at the time).

Our belief in our own rightness is easier to maintain because we ignore the faults in our thinking. We automatically hide our egocentricity from ourselves. We fail to notice when our behavior contradicts our self-image. We base our reasoning on false assumptions we are unaware of making. We fail to make relevant distinctions (of which we are otherwise aware and able to make) when making them prevents us from getting what we want. We deny or conveniently "forget" facts that do not support our conclusions. We often misunderstand or distort what others say.

The solution, then, is to reflect on our reasoning and behavior; to make our beliefs explicit, critique them, and, when they are false, stop making them; to apply the same concepts in the same ways to ourselves and others; to consider every relevant fact, and to make our conclusions consistent with the evidence; and to listen carefully and openmindedly to others.

We can change egocentric tendencies when we see them for what they are: irrational and unjust. The development of children's awareness of their egocentric and sociocentric patterns of thought is a crucial part of education in critical thinking. This development will be modest at first but can grow considerably over time.

S-3 Exercising Fairmindedness

Principle: To think critically, we must be able to consider the strengths and weaknesses of opposing points of view; to imaginatively put ourselves in the place of others in order to genuinely understand them; to overcome our egocentric tendency to identify truth with our immediate perceptions or long-standing thought or belief.

This trait is linked to the ability to accurately reconstruct the viewpoints and reasoning of others and to reason from premises, assumptions, and ideas other than our own. This trait also requires the willingness to remember occasions when we were wrong in the past despite an intense conviction that we were right, as well as the ability to imagine our being similarly deceived in a case at hand. Critical thinkers realize the unfairness of judging unfamiliar ideas until they fully understand them.

The world consists of many societies and peoples with many different points of view and ways of thinking. To develop as reasonable persons, we need to enter into and think within the frameworks and ideas of different peoples and societies.

We cannot truly understand the world if we think about it only from one viewpoint, as Americans, as Italians, or as Soviets. Furthermore, critical thinkers recognize that their behavior affects others, and so consider their behavior from the perspective of those others.

S-4 Exploring Thoughts Underlying Feelings and Feelings Underlying Thoughts

Principle: Although it is common to separate thought and feeling as though they were independent, opposing forces in the human mind, the truth is that virtually all human feelings are based on some level of thought and virtually all thought generative of some level of feeling. To think with self-understanding and insight, we must come to terms with the intimate connections between thought and feeling, reason and emotion.

Critical thinkers realize that their feelings are their response (but not the only possible, or even necessarily the most reasonable response) to a situation. They know that their feelings would be different if they had a different understanding or interpretation of the situation.

They recognize that thoughts and feelings, far from being different kinds of "things", are two aspects of their responses. Uncritical thinkers see little or no relationship between their feelings and their thoughts, and so escape responsibility for their thoughts, feelings, and actions. Their own feelings often seem unintelligible to them.

When we feel sad or depressed, it is often because we are interpreting our situation in an overly negative or pessimistic light. We may be forgetting to consider positive aspects of our lives.

We can better understand our feelings by asking ourselves, "How have I come to feel this way? How am I looking at the situation? To what conclusion have I come? What is my evidence? What assumptions am I making? What inferences am I making? Are they sound inferences? Do my conclusions make sense? Are there other ways to interpret this situation?"

We can learn to seek patterns in our assumptions, and so begin to see the unity behind our separate emotions. Understanding ourselves is the first step toward self-control and self-improvement. This self-understanding requires that we understand our feelings and emotions in relation to our thoughts, ideas, and interpretations of the world.

S-5 Developing Intellectual Humility and Suspending Judgment

Principle: Critical thinkers recognize the limits of their knowledge. They are sensitive to circumstances in which their native egocentricity is likely to function self-deceptively; they are sensitive to bias, prejudice, and limitations of their views. Intellectual humility is based on the recognition that one should not claim more than one actually knows. It does not imply spinelessness or submissiveness.

It implies the lack of intellectual pretentiousness, arrogance, or conceit. It implies insight into the foundations of one's beliefs: knowing what evidence one has, how one has come to believe, what further evidence one might look for or examine. Thus, critical thinkers distinguish what they know from what they don't know. They are not afraid of saying "I don't know" when they are not in a position to be sure.

They can make this distinction because they habitually ask themselves, "How could one know whether or not this is true?" To say "In this case I must suspend judgment until I find out x and y", does not make them anxious or uncomfortable. They are willing to rethink conclusions in the light of new knowledge. They qualify their claims appropriately.

In exposing children to concepts within a field of knowledge, we can help them see how all concepts depend on other, more basic concepts and how each field is based on fundamental assumptions which need to be examined, understood, and justified. The class should often explore the connections between specific details and basic concepts or principles. We can help children discover experiences in their own lives which help support or justify what a text says. We should always be willing to entertain student doubts about what a text says. Judgment

S-6 Developing Intellectual Courage

Principle: To think independently and fairly, one must feel the need to face and fairly deal with unpopular ideas, beliefs, or viewpoints. The courage to do so arises when we see that ideas considered dangerous or absurd are sometimes rationally justified (in whole or in part) and that conclusions or beliefs inculcated in us are sometimes false or misleading.

To determine for ourselves which is which, we must not passively and uncritically accept what we have "learned". We need courage to admit the truth in some ideas considered dangerous and absurd, and the distortion or falsity in some ideas strongly held in our social group. It will take courage to be true to our own thinking, for honestly questioning our deeply held beliefs can be difficult and sometimes frightening, and the penalties for non-conformity are often severe. Judgment

S-7 Developing Intellectual Good Faith or Integrity

Principle: Critical thinkers recognize the need to be true to their own thought, to be consistent in the intellectual standards they apply, to hold themselves to the same rigorous standards of evidence and proof to which they hold others, to practice what they advocate for others, and to honestly admit discrepancies and inconsistencies in their own thought and action. They believe most strongly what has been justified by their own thought and analyzed experience.

They have a commitment to bringing the self they are and the self they want to be together. People in general are often inconsistent in their application of standards once their ego is involved positively or negatively. For instance, when people like us, we tend to over-estimate their positive characteristics; when they dislike us, we tend to underrate them

S-8 Developing Intellectual Perseverance

Principle: Becoming a more critical thinker is not easy. It takes time and effort. Critical thinking is reflective and recursive; that is, we often think back to previous problems to re-consider or re-analyze them. Critical thinkers are willing to pursue intellectual insights and truths in spite of difficulties, obstacles, and frustrations.

They recognize the need to struggle with confusion and unsettled questions over time in order to achieve deeper understanding and insight. They recognize that significant change requires patience and hard work. Important issues often require extended thought, research, struggle. Considering a new view takes time. Yet people are often impatient to "get on with it" when they most need to slow down and think carefully.

People rarely define issues or problems clearly; concepts are often left vague; related issues are not sorted out, etc. When people don't understand a problem or situation, their reactions and solutions often compound the original problem. Children need to gain insight into the need for intellectual perseverance.

S-9 Developing Confidence in Reason

Principle: The rational person recognizes the power of reason and the value of disciplining thinking in accordance with rational standards. Virtually all of the progress that has been made in science and human knowledge testifies to this power, and so to the reasonability of having confidence in reason.

To develop this faith in reason is to come to see that ultimately one's own higher interests and those of humankind at large will best be served by giving the freest play to reason, by encouraging people to come to their own conclusions through a process of developing their own rational faculties.

It is to reject force and trickery as standard ways of changing another's mind. It is to believe that, with proper encouragement and cultivation, people can develop the ability to think for themselves, to form reasonable points of view, draw reasonable conclusions, think clearly and logically, persuade each other by reason and, ultimately, become reasonable persons, despite the deep-seated obstacles in the native character of the human mind and in society as we know it.

This confidence is essential to building a democracy in which people come to genuine rule, rather than being manipulated by the mass media, special interests, or by the inner prejudices, fears, and irrationalities that so easily and commonly dominate human minds.

You should note that the act of faith we are recommending is not blind faith, but should be tested in everyday experiences and academic work. In other words, we should have confidence in reason because reason works. Confidence in reason does not deny the reality of intuition; rather, it provides a way of distinguishing intuition from prejudice. When we know the source of our thinking and keep our minds open to new reason and evidence, we will be more likely to correct our prejudiced thought.

At the heart of this principle of faith in reason is the desire to make sense of the world and the expectation that sense can be made. Texts often don't make sense to children, sometimes because what they say doesn't make sense, more often because children aren't given time to make sense out of what they are told.

Being continually called upon to "master" what seems nonsensical undermines the feeling that one can make sense of the world. Many children, rushed through mountains of material, give up on this early. ("If I try to make sense of this, I'll never finish. Trying to really understand just slows me down. Nobody expects me to make sense of this; they just want me to do it.")

S-10 Refining Generalizations and Avoiding Oversimplifications

Principle: It is natural to seek to simplify problems and experiences to make them easier to deal with. Everyone does this. However, the uncritical thinker often oversimplifies and as a result misrepresents problems and experiences.

What should be recognized as complex, intricate, ambiguous, or subtle is viewed as simple, elementary, clear, and obvious. For example, it is typically an oversimplification to view people or groups as all good or all bad, actions as always right or always wrong, one contributing factor as the cause, etc., and yet such beliefs are common.

Critical thinkers try to find simplifying patterns and solutions, but not by misrepresentation or distortion. Seeing the difference between useful simplifications and misleading oversimplifications is important to critical thinking.

Critical thinkers scrutinize generalizations, probe for possible exceptions, and then use appropriate qualifications. Critical thinkers are not only clear, but also exact and precise. One of the strongest tendencies of the egocentric, uncritical mind is to see things in terms of black and white, "all right" and "all wrong". Hence, beliefs which should be held with varying degrees of certainty are held as certain. Critical thinkers are sensitive to this problem.

They understand the important relationship of evidence to belief and so qualify their statements accordingly. The tentativeness of many of their beliefs is characterized by the appropriate use of such qualifiers as 'highly likely', 'probably', 'not very likely', 'highly unlikely', 'often', 'usually', 'seldom', 'I doubt', 'I suspect', 'most', 'many', and 'some'.

S-11 Comparing Analogous Situations: Transferring Insights to New Contexts

Principle: An idea's power is limited by our ability to use it. Critical thinkers' ability to use ideas mindfully enhances their ability to transfer ideas critically. They practice using ideas and insights by appropriately applying them to new situations. This allows them to organize materials and experiences in different ways, to compare and contrast alternative labels, to integrate their understanding of different situations, and to find useful ways to think about new situations.

Every time we use an insight or principle, we increase our understanding of both the insight and the situation to which we have applied it. True education provides for more than one way to organize material. For example, history can be organized in our minds by geography, chronology, or by such phenomena as repeated patterns, common situations, analogous "stories", and so on. The truly educated person is not trapped by one organizing principle, but can take knowledge apart and put it together many different ways. Each way of organizing knowledge has some benefit.

S-12 Developing One's Perspective: Creating or Exploring Beliefs, Arguments, or Theories

Principle: The world is not given to us sliced up into categories with pre-assigned labels on them. There are always many ways to "divide up" and so experience the world. How we do so is essential to our thinking and behavior. Uncritical thinkers assume that their perspective on things is the only correct one. Selfish critical thinkers manipulate the perspectives of others to gain advantage for themselves.

Fairminded critical thinkers learn to recognize that their own ways of thinking and that of all other perspectives are some combination of insight and error. They learn to develop their points of view through a critical analysis of their experience.

They learn to question commonly accepted ways of understanding things and avoid uncritically accepting the viewpoints of their peers or society. They know what their perspectives are and can talk insightfully about them. To do this, they must create and explore their own beliefs, their own reasoning, and their own theories.

S-13 Clarifying Issues, Conclusions, or Beliefs

Principle: The more completely, clearly, and accurately an issue or statement is formulated, the easier and more helpful the discussion of its settlement or verification. Given a clear statement of an issue, and prior to evaluating conclusions or solutions, it is important to recognize what is required to settle it. And before we can agree or disagree with a claim, we must understand it clearly.

It makes no sense to say "I don't know what you mean, but I deny it, whatever it is." Critical thinkers recognize problematic claims, concepts, and standards of evaluation, making sure that understanding precedes judgment. They routinely distinguish facts from interpretations, opinions, judgments, or theories. They can then raise those questions most appropriate to understanding and evaluating each.

S-14 Clarifying and Analyzing The Meanings of Words or Phrases

Principle: Critical, independent thinking requires clarity of thought. A clear thinker understands concepts and knows what kind of evidence is required to justify applying a word or phrase to a situation. The ability to supply a definition is not proof of understanding. One must be able to supply clear, obvious examples and use the concept appropriately. In contrast, for an unclear thinker, words float through the mind unattached to clear, specific, concrete cases. Distinct concepts are confused.

Often the only criterion for the application of a term is that the case in question "seems like" an example. Irrelevant associations are confused with what are necessary parts of the concept (e.g., "Love involves flowers and candlelight.") Unclear thinkers lack independence of thought because they lack the ability to analyze a concept, and so critique its use.

INTRODUCTION

Nursing has been transforming its epistemological assumptions in the course of its history, in search of the definition of its object of study; which is a process marked by an essentially positivist and biomedical view of health care. The discomfort generated by this vision leads to the agglutination of the constructivist foundations of the social sciences. This movement was influenced by the diverse philosophical streams that attributed a more complex look to face the challenges in the area of health. A clear example of this is the Critical Theory, which defends critical thinking (CT) as a mechanism for the emancipation of the human being,1 and consequently an emancipated care. There are several theoretical bases2-3 that guide the use of CT in nursing and other areas, such as education. Besides sustaining the concept, theses bases direct their development, which can be in a dynamic and procedural way or in a punctual way, as a skill with clinical purposes. Since 1992, Brazilian and Ibero-American nursing, in tune with the Pan American Federation of Nursing Professionals (FEPPEN) and the Pan American Health Organization (PAHO), reiterates the need to incorporate critical and reflective thinking into the teaching of nursing. This demand emerges from the need to provide humanized and qualified care to the population. Alongside this, the importance of preparing teachers for teaching through interactive pedagogical strategies is emphasized. The purpose of these guidelines is to improve the quality of education and care and advance the discipline.4

As a result of these guidelines, several authors5-7 have investigated CT since the 1990s. In the last decade, in particular, there has been a remarkable number of publications discussing the theme in nursing.8-11 However, the literature indicates the need to clarify the concept of CT in nursing, as well as the theoretical bases that support it.8 This challenge led us to propose the identification of the theoretical bases that underpin the concepts of critical thinking in Ibero-American nursing in the last ten years, as the objective of this study.

METHOD

Integrative review was chosen as the method to reach the study objective, as it corresponds to a broad methodological strategy that allows the search, critical evaluation and synthesis of relevant evidence on a particular theme.12

The first stage consisted of the identification of the topic and the selection of the research question: “what are the theoretical bases of CT used by Ibero-American nursing in the last ten years?” In the second stage, criteria for inclusion and exclusion of studies were established. Inclusion criteria included: publications that were available online in full, with free access, in Portuguese, English or Spanish, with a qualitative approach, published between 2006 and 2015, by nursing authors from Ibero-American countries, which discussed or presented the concept of CT or its central concepts or support reflexive practice and critical conscience. Exclusion criteria was considered as: other publications (abstracts, book chapters, theses, dissertations, editorials), articles repeated or published by authors from other areas and by non-Ibero-American countries. Articles that did not meet the objective of the study were also excluded (publications that did not address the topic CT and did not present the concepts mentioned above).

The research was performed in December of 2015 in the Public Medline (PubMed), Scientific Electronic Library Online (SciELO) and Bibliographic Database on Health Care in Latin America (CUIDEN) databases.

The descriptor “nursing” associated with the word “critical thinking” (with Boolean operator “and”) was used for the article research, which were used in English for PubMed and, in Spanish, for SciELO and CUIDEN. The advanced form was used In PubMed and CUIDEN; The simple form was used in the SciELO due to the limitation of publications in the first option.

1654 publications were located from the digital search in the period from 2006 to 2015, 1489 in PubMed, 122 in CUIDEN, 41 in SciELO and two identified by references. 1623 studies from this total were discarded that did not meet the inclusion or exclusion criteria previously established (Figure 1). In the present integrative review, 32 studies were analyzed (15 located in PubMed, 11 in CUIDEN and seven in SciELO), all of them being articles from periodicals. For this selection process, the recommendations from the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) were used.13

Figure 1 Flowchart of selection of publications for the integrative review, based on the PRISMA model 

The third step included defining the information to be extracted through the elaboration of an instrument, containing title, country and year of publication, objective, study type, concept, theoretical basis and main results.

The fourth stage was characterized by the filling out and the evaluation of the instrument with the data from the selected publications, which was carried out by two researchers. The fifth stage composed of the discussion and interpretation of the obtained results, followed by the sixth stage, which included the presentation of the evidences found.

RESULTS

The majority of the 32 analyzed publications originated from Brazil (17), followed by Spain (6), Mexico (4), Chile (3), Cuba (1) and Costa Rica (1) (Figure 2). As for the type of study, theoretical reflection predominated (15), followed by literature review (8), exploratory study (5) and experience report (4). In relation to the year of publication, there was no regularity, observing an average of three publications per year, ranging from one to six.

Figure 2 Characterization of the publications regarding the country, study type and year of publication 

The review of the studies indicates that there are several definitions, and there is no universally accepted theoretical and conceptual framework for CT in nursing. However, it was possible to identify the prevalence of nine thinkers as theoretical bases of this concept, which reveal two distinct conceptions of CT and, therefore, were organized into two groups, called “group A” and “group B” (Figure 3). Among the 32 publications included in this review, 17 used the thinkers from group A and 15 employed the thinkers from Group B in the construction of the definitions of CT (Figure 3).

Figure 3 Authors, year of publication and theoretical bases used in the 32 studies included in the qualitative synthesis of the present study 

Group A consists of five thinkers: 1) Rosalinda Alfaro-Lefevre, a studious critical thinking nurse, with clinical reasoning and clinical judgment in the nursing process, mentioned in nine articles;7 2) Peter A. Facione, editor of the Critical Thinking Report for the American Philosophical Association, quoted in five studies;5 3) Scheffer and Rubenfeld, who constituted an international panel of specialist nurses using the Delphi technique, quoted by six publications;14 4) Richard Paul, president of the American National Council of Excellence in Critical Thinking, which follows the same line of reasoning, was referenced by four articles.6

The Group B consists of four thinkers: John Dewey, philosopher, psychologist, and educator of the United States of the first half of the twentieth century, considered to be the forerunner in the reflexive thought movement in education, quoted in six publications:15 Donald Schön, American philosopher, who constructed the so-called epistemology of practice, mentioned by eight articles; philosopher Paulo Freire, a very influential Brazilian educator in Ibero-American nursing, was referred to in three studies;17 Jürgen Habermas, a German philosopher and sociologist, considered one of the advocates of Critical Theory, was quoted in four publications.18

As can be seen in figure 4, the five thinkers of Group A, who represent 53% of the publications, relate the CT to the notion of skills, competencies and evaluation of nursing care performance. The focus of most of the studies guided by these authors was related to the evaluation of the abilities of the academic / nurse in developing and applying the clinical reasoning. Group B, cited by 47% of the publications, follows another line of reasoning, and is also formed by four thinkers. In a more dynamic approach, these references point to fundamental factors for the construction of the CT, such as subjectivity, uniqueness and reciprocity of dialogic relations, as well as the stimulus for reflection, which allow the gradual revelation of reality and empowerment to take decisions. These authors exhibited the concept of CT or other central concepts in their construction, such as reflective thinking, reflective practice, critical awareness, autonomy, and communicative action.

Figure 4 Distribution of publications according to the theoretical bases of the critical thinking concept 

Many used more than one theoretical basis (see Figure 2) and so the number of cases in figure 4 is greater than the number of articles evaluated (n>32).

21 out of the 32 papers used only one theoretical basis, seven used two, three referenced two bases and only one paper was based on four theoretical bases, therefore, thinkers are cited 45 times in the articles (Figures 3 and 4). Besides this theoretical-conceptual framework, the studies highlighted instruments for measuring CT, and several teaching strategies, such as conceptual mapping, case study, reflection diaries and simulation.

Table 1 presents the synthesis of the theoretical bases, concepts, publications and applications of critical thinking in Ibero-American nursing.

Table 1 Theoretical bases, concepts, publications and applications of critical thinking in Ibero American nursing, 2006-2015 

GroupTheoretical bases and conceptsPublicationsApplications of concepts in nursing
AAlfaro-Lefevre
Critical Thinking
Crosseti et al., 2014;19 Crossetti et al., 2009;20 Zuriguel Pérez et al., 2014;21 Bittencourt et al., 2013;22 Díaz, et al., 2010;23 Pegueroles, 2009;24 Morán-Peña, 2007;25 Serrano et al., 2006;26 Lima et al., 2007271) Tools for measuring CT skills (California Critical Thinking Disposition Inventory, California Critical Thinking Skills Test, Ennis Weir Critical Thinking Essa Test, Watson-Glaser Critical Thinking Assessment Handbook
2) Teaching strategies (nursing process, conceptual maps, case study, clinical case, model for the teaching of integrated critical thinking in nursing (EPCIE), evidence-based nursing)
Peter Facione
Critical Thinking
Bertacchini et al., 2015;9 Vacek, 2009;10 Crosseti et al., 2014;19 Bittencourt et al., 2013;22 Morán-Peña, 2007;25 Bittencourt et al., 201328
Scheffer e Rubenfeld
Critical Thinking
Crosseti et al., 2014;19 Bittencourt et al., 2013;22 Bittencourt et al 2013;28 Bittencourt et al., 2011;29 Cerullo et al., 2010;30 Isaacs, 201031
Richard Paul
Critical Thinking
Crosseti et al., 2014;19 Bittencourt et al., 2013;28 Becerril et al., 201532
BJohn Dewey
Reflective Thinking
Piña-Jiménez et al., 2015;33 Ferreira et al., 2013;34 Valente et al., 2007;35 Valente et al., 2009;36 Mitre et al., 2008;37 Barrios et al., 2012381) Methodological theoretical reference (dialectical structural model of care).
2) Conceptual framework (sociocritical nursing, care, health, health education).
3) Teaching strategies (problem-based learning, problem-solving, portfolio, reflective diary, simulation, in-service learning).
Donald Schön
Prática reflexiva
Reflective Practise
Piña-Jiménez et al., 2015;33 Ferreira et al., 2013,34 Valente et al., 2007;35 Valente et al., 2009;36Solano et al., 2013;39 Burgatti et al., 2013;40 Fandos, 2008;41 Moya et al., 200642
Paulo Freire
Critical Awareness
Autonomy
Mitre et al., 2008;37 Martins et al., 2012;43 Alvim et al., 200744
Jürgen Habermas
Critical Thinking
Communicative action
Mosqueda-Díaz et al., 2014;1 Minguez et al., 2014;11 Solano et al., 2013;39Elizondo et al., 201345

DISCUSSION

In 1988 and 1989, the Committee on Pre-College Philosophy of the American Philosophical Association (APA) formed a group of 46 experts regarding the evaluation and teaching of CT, Facione, who wrote the Delphi Report was among these experts. In this report, consensuses were reached regarding skills, aptitudes, evaluation and implementation of CT programs in education, as well as the definition of the term itself and a consensus on the ideal critical thinker.5

For Facione, the CT is an intentional and self-regulating judgment, resulting from interpretation, analysis, evaluation and inference, as well as explanation of the evidence, conceptual, methodological, and contextual or criteria considerations on which the judgment was based

From the Delphi Report, evaluation methods such as the California Critical Thinking Disposition Inventory and the California Critical Thinking Skills Test were created whose main purposes are to measure a student’s tendency to think critically (considering elements such as openness of thought, analytical spirit, systematization, self-confidence, curiosity and maturity in judgment) and to measure CT skills (based on questions such as analysis, evaluation, inference and reasoning).

Several studies from this review9,21,30 recommend the use of several CT measurement instruments (Table 1). Despite being validated and used by educational institutions, their adequacy is questioned in order to reach an understanding of the dialectic nature of nursing care, which requires a broad interpretation of the health-disease process and of the human being in its entirety.

In 1987, based on discussions at the International Conference on Critical Thinking and Education Reform, Paul and a group of thinkers formulated a concept of CT as an intellectually disciplined, agile and competent process of conceptualizing, applying, analyzing, synthesizing, and evaluate the information collected or generated by observation, experience, reflection, reasoning or communication.6

Some CT scholars, including Paul, were a reference for conducting research,19 developed with emergency nurses, who applied a case study in order to analyze the structural elements of the CT of these professionals. The results revealed that the priority elements for clinical decision making are technical-scientific knowledge, patient assessment, clinical experience, clinical reasoning and ethics. The study emphasizes that CT is an essential skill to enhance clinical reasoning, which can be developed and improved by students and nursing professionals in order to evaluate behaviors and implement accurate and safe care.

With the conceptual contribution of Paul, Facione, Scheffer and Rubenfeld, a study28 applied a validated case study to nursing students aiming at the identification of a priority nursing diagnosis (based on Nanda-I Taxonomy) and CT skills in the diagnostic nursing process. The analysis revealed technical-scientific knowledge, logical reasoning, clinical experience, knowledge about the patient, application of standards, discernment and contextual perspective as CT skills in the diagnostic process in nursing analysis.

In order to define CT in nursing, Scheffer and Rubenfeld coordinated a Delphi study in the 1990s which composed of 95 professionals. The consensus of these scholars identified several elements that critical thinkers in nursing practice do, such as mental habits (affective component) of trust, contextual perspective, creativity, flexibility, curiosity, intellectual integrity, intuition, understanding, perseverance and analysis reflection; (cognitive component) , application of standards, discernment, search for information, logical reasoning, prediction and transformation of knowledge.

The theoretical support of Scheffer and Rubenfeld sustained the construction of a model for the Ensino do Pensamento Crítico Integrado a Enfermagem / Teaching of Integrated Critical Thinking in Nursing (EPCIE), which has been incorporated into teaching since 1990. The investigation of this teaching experience found that the model assists in the development of CT patterns, such as argument analysis, evaluation of information sources, identification of hypotheses, clinical judgment, diagnostic reasoning and decision making.31

The conceptual map is another didactic strategy suggested by some authors10,20,22,28 to aid in decision making. It is a diagram that seeks to classify concepts, to relate and hierarchize them. This tool instigates the ability to analyze, synthesize, have flexibility, curiosity, and participation.20

A study22 evaluated conceptual maps developed by students for the understanding of research projects. The constructed maps were evidenced as a strategy for knowledge organization, which established coherence between concepts, significant relationships, clarity of ideas and logical relation between the stages of a research project.

Along the same lines, Alfaro-Lefevre, president of Teaching Smart/Learning Easy (Florida), defines CT as a careful, deliberate and results-focused reasoning motivated by patient needs. Understood as a problem-solving method that guides decision-making, CT provides the basis for accurate and disciplined judgment in work situations, essential for the nursing process.7

A study of this review25 raised the importance of CT in the implementation of the nursing process, emphasizing that all its phases require diverse CT skills, such as diagnostic reasoning, clinical inferences and decision making. Another research23 related CT with evidence-based nursing (EBN), a method that leads to evidence-based decision-making emanating from research, systematized clinical experience, and user needs. The authors support EBE as a didactic strategy that allows them to train professionals with critical and reflexive thinking skills.

The theoretical bases of CT described so far, present in 17 publications, explicitly or implicitly refer to the need to acquire habits, skills and competences, which can be improved through teaching strategies and evaluated by measurement instruments, for the purpose to qualify clinical reasoning and clinical judgment in nursing. This evidence raises questions about the limitation of these strategies and instruments to develop and evaluate social and political skills and competences, such as ethics, autonomy, reflection and criticism.

A minor portion of the publications of this review (15 studies) adopted the foundations of John Dewey, Donald A. Schön, Paulo Freire, and Jürgen Habermas as the theoretical basis of CT, which follow a chain of thought distinct from previous authors, as they incorporate elements inherent in complexity of the human being in the formulation of their theories.

John Dewey advocates democracy and freedom of thought as tools for people’s emotional and intellectual evolution. He has a broad conception of man in his environment and proposes a new type of teaching, centered on the student and practical experience, with the “learning by doing” approach.15

For Dewey, reflective thinking requires quitting inertia and experiencing a state of restlessness and mental disturbance. It is a systematic dialogue of the subject with himself, in an exercise that involves the confrontation with a difficulty, the formulation of the problem, making a hypothesis and the elaborated reasoning.15

Dewey was the theoretical basis of a study38 that emphasized service learning as a methodology that favors the construction of CT. The author defends the benefits of this methodology for teaching activities (reflection, critical thinking, problem solving) and personal development (self-knowledge).

Another teaching strategy reported was simulation, a tool that supports the training process, focusing on practical activity and reflection, considering the students’ experience. By these characteristics, the simulation can result in a significant process in the life of the learner.33

John Dewey’s contributions to learning by doing were later taken up by Schön, who incorporated the idea of reflective professional training and reincorporated the idea of practical knowledge and service learning. Schön explains that reflexive practice, developed through the processes of knowledge in action and reflection in action, leads to the use of knowledge to describe, analyze and evaluate previous interventions, which lead to future solutions and actions.16

Several authors33-36,39-42 based themselves on Schön to defend a formation in which the teacher needs to create practical situations of learning, to manage the heterogeneity and to foment the reflexive practice and CT. These authors cite some teaching strategies that can enhance practical knowledge and learning in action, such as: portfolio, field diary, written narratives40 and reflective daily.41

The resurgence of reflexive practice in American teacher education based on Schön, inspired the thinking of other intellectuals in the world, such as Freire’s in Brazil and Habermas’s in Europe.

Paulo Freire is considered a theoretical and pedagogical basis for teaching. His thinking sees education as a practice of freedom, that is to say, a democratic exercise, critical, reflexive and dialogic, nurtured by social interaction.46 Freire does not define CT, but weaves a reference that justifies it. The author assumes that critical consciousness is not constituted at the intellectualist level, but in praxis, which continually demands action accompanied by reflection on reality.46 Thus, critical consciousness is instigated through problematization, a process in which the person experiences and instigates their curiosity, realizing their potentiality and creating conditions to discover themselves as subjects of their own knowledge.17

The purpose of this process is awareness, a dialectical process in which there is articulation between action and reflection for the emancipation of the subjects, that is to say, for the individual to be able to assume their ontological and social condition in order to contribute to the transformation of reality. Autonomy, as a consequence of this process, is the evolution of the being and the instrument of struggle for a more humanized world.17

Some researchers of this revision37,43-44 defend the construction of critical and problematizing health education based on Freirian ideas, which is born and nourished in the dialogue between educators and students. It is in this conception of education that the use of innovative methods, inscribed in the dialectic of action-reflection-action, grows. A study37 discussed the main methodological changes in the training process of health professionals, emphasizing the potential of active methodologies, which are based on the principle of autonomy and use the problematization as a teaching-learning strategy.

The author37 emphasizes that the active methodology has allowed the articulation between the university, the service and the community. Two instruments have been recognized as activators of teaching and health service integration: problem-based teaching and curricular organization based on problem-based learning.

Another theoretical basis of CT that follows this line of reasoning is that of Habermas. His thinking encompasses several themes - law, politics, history, ethics - with which he seeks to highlight the possibilities of rational-critical communication and emancipation, repressed in modern institutions.18 Habermas created the Theory of Communicative Action, in which he clarifies that language, in its communicative use, postulates a close connection between speech and action and enables a full interaction between human beings. Communicative action is based on linguistic interaction, centered on significant aspects of the actors’ lives. It is a form of social action, free of coercion, in which participants engage in equal conditions to express or produce personal opinions and to draw up subjective agreements.2 The purpose of the interaction established in a communicative action is the development of CT, which refers to a continuous process of reflection on life, resulting in the emancipation of the actors.2

Habermas was used as the theoretical basis in a study performed in Spain, which highlights the CT as a new horizon for nursing. The authors argue the need to go beyond the CT model aimed at clinical practice and approach a critical and reflexive thinking model oriented toward citizen emancipation.11 This model is based on the sociocritical paradigm that establishes a dynamic horizon of care, which means identifying social inequalities in health and transforming them through communication between the professional context and the daily life of people.47

A theoretical and methodological framework of sociocritical nursing, which includes a network of concepts and a model of data analysis, was mentioned in a publication,11 of which one of the authors is a creator. Siles,3 an advocate of sociocritical nursing, was based on Habermas to epistemologically explain the nature of this, linking the historical, social and cultural dimensions to the biological dimension of care. This way of interpreting care implies the need to consider not only the world of facts and behavior (phenomena observable on the “surface” of society), but also those factors that remain hidden under the surface of the explicit manifesto, which determine the choice of one or another way of life.

Regardless of the thinking strain that supports the concept of CT, it is understood that this is an essential element for the planning of nursing actions. The understanding of CT as a skill and application in clinical practice - as outlined by the theoretical basis of Group A - is a determining factor in the construction of nursing diagnoses. The logic of this trend of thinkers is that the exercise of critical thinking can be trained in order to improve clinical reasoning about the health-disease process.

The concept of CT based on the thinkers in Group B supports the understanding of nursing as a social profession, committed to the subjectivity of the human being and its health needs.3 From this understanding, the nurse has the potential to care for the citizens with a sense of emancipation. It means care that includes the experiences and conceptions of the citizen’s health in order to collectively build a care plan. It is a vision that goes beyond clinical practices and promotes care for life, for the citizen to interpret his needs and seek solutions, and to face the contradictions of society and to actively participate in his history.

CONCLUSION

This integrative literature review has revealed that in the last ten years, Ibero-American nursing has been dedicated to understanding CT and including it as a competence in vocational training. It was found that there is no uniformity in the adoption of a theoretical basis of CT. However, two conceptions of CT differ between thinkers, who were organized into two groups: Alfaro-Lefevre, Peter Facione, Scheffer and Rubenfeld and Richard Paul (Group A) and John Dewey, Donald Schön, Paulo Freire and Jürgen Habermas (Group B).

Group A, referred to in 17 publications, understands CT as having the ability for clinical reasoning, which is present in several nursing care actions and decisions: in the diagnosis of the phenomena, in the choice of appropriate interventions and in the evaluation of the results obtained. The thinkers of Group B weave a network of fundamental concepts for the construction of CT. The definitions of reflexive thinking, reflexive practice, critical awareness, autonomy and communicative action support the concept of CT as a cooperative process of disposition for mutual understanding between people. The purpose of this process is the development of critical awareness and the exercise of citizen autonomy.

The challenge for the future of nursing research is to adopt a paradigm that will serve as a basis for formulating a universal definition of the concept and resulting teaching strategies. Considering that the subject of nursing care is the human is included in a sociocultural and historical context, the orientation of this study is to include the perspective of Group B - Dewey, Schön, Freire and Habermas - in the nursing curriculum and practice, as these thinkers weave a network of concepts and a dynamic theoretical framework in relation to CT.

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