Nurse Education Today 34 (2014) 67–72

Contents lists available at ScienceDirect

Nurse Education Today

journal homepage: www.elsevier.com/nedt

The effect of reflective writing interventions on the critical thinking

skills and dispositions of baccalaureate nursing students
Jessica Naber a,⁎, Tami H. Wyatt b, 1
a
219 Mason Hall, Murray, KY 42071, United States
b
University of Tennessee Knoxville, 1200 Volunteer Boulevard, Knoxville, TN 37996-4180, United States

a r t i c l e i n f o s u m m a r y

Article history: Background: The importance of critical thinking is well-documented by the American Association of Colleges
Accepted 4 April 2013 of Nursing and the National League for Nursing. Reflective writing is often used to increase understanding
and analytical ability. The lack of empirical evidence about the effect of reflective writing interventions on
Keywords: critical thinking supports the examination of this concept.
Problem solving Objectives: Study objectives were:
Nursing students
Writing
Richard Paul
• To test the effectiveness of a novel reflective writing intervention, based on Paul's (1993) model of critical
California Critical Thinking Skills Test thinking, for improving critical thinking skills and dispositions in nursing students.
California Critical Thinking • To determine the common characteristics of high-scoring participants.
Dispositions Inventory Test • To determine relationships between scores and institution, gender, age, ethnicity, or experience.

Design: This study used an experimental, pretest–posttest design.

Settings: The setting was two schools of nursing at universities in the southern United States.
Participants: The convenience sample included 70 fourth-semester students in baccalaureate nursing programs.
Methods: Randomly assigned control and experimental groups completed the California Critical Thinking Skills
Test (CCTST) and the California Critical Thinking Dispositions Inventory Test (CCTDI). The experimental group
completed six reflective writing assignments. Both groups completed the two tests again.
Results: Results showed that the experimental group had a significant increase (p = 0.03) on the truthseeking
subscale of the CCTDI when compared to the control group. The experimental group's scores increased on four
CCTST subscales and were higher than the control group's on three CCTST subscales.
Conclusions: The results of this study make it imperative for nursing schools to consider including reflective
writing—especially assignments based on Paul's (1993) model—in nursing courses. If future studies, testing
over longer periods of time, show significant increases in critical thinking, those interventions could be incorpo-
rated into nursing curriculum and change the way nurse educators evaluate students.
© 2013 Elsevier Ltd. All rights reserved.

Introduction it's appropriate to seek alternative treatments. The American Association

Critical thinking is generally thought of as a process of analyzing,
synthesizing, and/or evaluating information (Paul and Scriven, 1987).
For decades, the concept of critical thinking has been recognized as an
essential outcome for students at all levels and in all disciplines (Reed
and Kromrey, 2001). Critical thinking is an important concept in nursing
curricula because practicing nurses need these skills to complete nursing
actions that directly affect patient outcomes. These actions include
analyzing each patient's situation, weighing possible nursing measures,
considering patients' feelings and circumstances, and recognizing when
⁎ Corresponding author. Tel.: +1 502 541 3011; fax: +1 270 809 6662.
E-mail addresses: jnaber@murraystate.edu (J. Naber), twyatt@utk.edu (T.H. Wyatt).
1
Tel.: +1 865 974 6804; fax: +1 865 974 3569.
of Colleges of Nursing (AACN) (2008) has emphasized the importance of
graduating nurses who can apply critical thinking in all practice situa-
tions in order to improve patient health outcomes. The National League
for Nursing (NLN) has stated that, to facilitate learning effectively, nurse
educators must “create opportunities for learners to develop their crit-
ical thinking…skills” (National League for Nursing, 2005, p. 1).
Critical thinking skills also can help students pass the National Coun-
cil of State Boards of Nursing (NCSBN) Registered Nurse certification test
(NCLEX-RN). For example, a recent study of 218 baccalaureate nursing
students showed that those who passed the NCLEX-RN scored signifi-
cantly higher on critical thinking tests than those who failed (Giddens
and Gloeckner, 2005). To promote high NCLEX-RN pass rates—and
help alleviate the current nursing shortage—it is imperative that nursing
faculty find ways to help build students' critical thinking skills.

0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.nedt.2013.04.002
68 J. Naber, T.H. Wyatt / Nurse Education Today 34 (2014) 67–72
While the importance of equipping nurses with critical thinking
skills is well-documented, it is unclear how best to accomplish this
goal. Simply providing content does not produce problem-solving and
analytical skills during patient interactions or teach post-interaction re-
flection or evaluation (McGuire et al., 2009). Yet published research
shows that junior and senior level nursing students score higher on crit-
ical thinking tests than their freshman and sophomore counterparts
(McCarthy et al., 1999). Further, students in baccalaureate nursing pro-
grams (BSN) had higher critical thinking scores than individuals in
other degree tracks, such as Associate Degree Nurses (ADN) (Shin et
al., 2006). While educators use reflective writing, writing assignments
based on student experience, to increase understanding and the ability
to reason and analyze (Kennison, 2006), there is little empirical evi-
dence regarding this strategy's effectiveness in increasing critical think-
ing skills.
Literature
Several studies have compared California Critical Thinking Skills
(CCTST) and California Critical Thinking Dispositions Inventory (CCTDI)
test scores between samples — the same instruments used in this
study. One study proposed that BSN students have higher scores than
ADN and RN-to-BSN students (Shin et al., 2006). Two studies supplied
evidence that test scores increase during a nursing program (McCarthy
et al., 1999; Thompson and Rebeschi, 2000), while another showed
that the increase was not significant (Giddens and Gloeckner, 2005).
One study provided evidence that experience does not increase critical
thinking skills and education only produces minimal increases (Ingram,
2008). Giddens and Gloeckner (2005) concluded that CCTST and CCTDI
test scores are higher in students who pass the NCLEX than those who
fail. A literature review by Adams (1999) found no conclusive evidence
that nursing education increases critical thinking skills. Overall, the stud-
ies mentioned above explained little about the similarities and dif-
ferences between the compared samples or what strategies affected
critical thinking skills and disposition, the affective component of critical
thinking.
There is evidence, however, that Paul's (1993, described below)
model of critical thinking can be used as a framework to teach critical
thinking (Broadbear and Keyser, 2000), and that it can be used in
combination with writing to increase critical thinking skills (Reed
and Kromrey, 2001). There is no mention in the literature, however,
of incorporating Paul's model (Paul, 1993) into a specific writing in-
tervention to increase critical thinking skills and/or disposition.
Beginning in the 1980s as a result of college students' literary defi-
ciency, the Writing Across the Curriculum (WAC) movement, which is
based on the Writing to Learn (WTL) paradigm, emphasizes the impor-
tance of writing in college courses, particularly in programs of nursing
(Allen et al., 1989). Graduates need writing ability to obtain jobs, as writ-
ing is considered a “threshold skill” for hiring and promotion (College
Entrance Examination Board, 2004). WTL model assumptions—that
writing is learning and that writing helps produce critical thinking—
encourage nursing faculty members and administrators to include writ-
ing assignments in their curricula. Requiring short, in-class writing as-
signments or the assembly of portfolios (collections of writing samples
from various courses) are two strategies for including writing in nursing
curricula (Allen et al., 1989). While increased student support and
improved faculty–student relationships have been reported after imple-
menting these strategies, no empirical evidence shows that they im-
prove critical thinking skills or disposition.
Reflective writing is specifically mentioned in the literature as a
pedagogical strategy that can increase critical thinking in college stu-
dents (Craft, 2005; Heinrich, 1992; McGuire et al., 2009; Rooda and
Nardi, 1999). One study provided the components of a reflective jour-
nal assignment (Heinrich, 1992), however, the literature about such
components is limited and vague. Faculty reported that developing
strategies to improve critical thinking is difficult (Kataoka-Yahiro
and Saylor, 1994), indicating a possible deficiency in current nursing
curriculum.
Analytical Framework
Paul's model for critical thinking was the guiding framework for this
study (Paul, 1993). According to Paul and Scriven (1987, p.1), critical
thinking is the intellectually disciplined process of actively and skillfully
conceptualizing, applying, analyzing, synthesizing, and/or evaluating
information—gathered from or generated by, observation, experience,
reflection, reasoning, or communication—as a guide to belief and action.
According to Paul (1996) critical thinking disposition includes valuable
intellectual traits, such as fair-mindedness and intellectual humility,
which people develop as they become ideal critical thinkers. Both criti-
cal thinking skills and disposition are important elements of developing
critical thinking abilities (Facione et al., 1994).
Paul's model centers around three aspects of thinking: elements of
good reasoning, intellectual standards used to assess quality of think-
ing, and intellectual traits or dispositions. Of particular interest are
the eight elements Paul states are necessary for any reasoning pro-
cess: the purpose of the thinking; the problem to be solved; informa-
tion such as data and observations; inferences, interpretations, or
solutions; concepts such as theories or definitions; assumptions; con-
sequences; and point of view (Paul, 1993; Reed and Kromrey, 2001).
Paul (1993) highlights the intellectual standards necessary for eval-
uating critical thinking and says they must be applied whenever stu-
dents want to verify the quality of their reasoning about any problem,
or situation. According to Paul (1993), thinking critically involves hav-
ing command of these standards: clarity, accuracy, precision, relevance,
depth, breadth, logic, and fairness. Paul also discusses the affective or
dispositional component of critical thinking that addresses traits of
the reasoning mind such as intellectual humility, intellectual autonomy,
intellectual integrity, intellectual courage, perseverance, confidence in
reason, intellectual empathy, and fair-mindedness (Paul, 1996; Reed
and Kromrey, 2001).
Aims
The aims of this study were:
• To test the effectiveness of a novel reflective writing intervention,
based on Paul's (1993) model of critical thinking, for improving crit-
ical thinking skills and dispositions in baccalaureate nursing stu-
dents during an eight-week clinical rotation
• To determine common characteristics among participants who earn
high scores on the instruments
• To determine if there are relationships between scores and institu-
tion, gender, age, ethnicity, and/or health care experience
Methods
Design
This study consisted of a reflective writing intervention that was
administered to a group of baccalaureate nursing students. The de-
sign for this study was experimental, and more specifically, a level
III pretest–posttest design. A level III study uses an experimental de-
sign to test variables. This study included an experimental group
(whose members completed an intervention between pretest and
posttest), a control group (whose members completed pre- and post-
test), and random assignment of groups; therefore, a level III pretest–
posttest design was most appropriate (Wood and Ross-Kerr, 2011;
Fisher and Foreit, 2002). For this study, reflective writing was defined
as a writing assignment about an activity that students have experi-
enced (such as class readings, clinical rotations, or group activities)
 J. Naber, T.H. Wyatt / Nurse Education Today 34 (2014) 67–72
which highlights what students learned from the activity (McGuire et
al., 2009).
Settings and Participants
Researchers used a convenience sample of 70 students in the junior
year of baccalaureate nursing programs from two universities located in
the southern United States. One university has a Carnegie designation of
L4/R (Large, four year, primarily residential), while the other is desig-
nated L4/NR (Large, four year, primarily non-residential).
All participants had completed general education courses and
were enrolled in nursing courses full-time. Each participant was en-
rolled in an adult health nursing course with a clinical component.
The clinical experiences took place at local acute care facilities in
areas where patients were acutely, but not critically, ill. Clinical objec-
tives included utilization of the nursing process, demonstration of
growth as a professional nurse, therapeutic communication with cli-
ents, and collaboration with team members. In addition to clinical
experiences, participants studied complex didactic information and
took tests requiring in-depth synthesis of the material; both types
of activities—didactic and clinical—required critical reflection.
Ethical Considerations
Institutional Review Board approval was obtained from all sites in
2010. All potential participants were informed of the study, both in
writing, in an informal document, and verbally, by the researcher.
Participation was voluntary, with no consequences to students who
declined participation or to participants who withdrew from the
study. Participants were randomized into either the control or exper-
imental group, and they were assigned a random number for the
CCTST and CCTDI. Scores were saved into a computer database
which was password-protected.
Data Collection
During the first week of classes, the Principal Investigator (PI) vis-
ited the nursing courses and explained the study, its risks and bene-
fits, and the writing component. All participants were informed of
the dates, times, and locations for the pre- and post-intervention
CCTST and CCTDI tests and that they would receive a $10 gift card
for participation. The pre-intervention CCTST and CCTDI tests were
administered to participants at the beginning of the semester, and
the unidentified pre- and posttests were scored by Insight Assess-
ment as required by the copyright owners of the measures.
During the semester, all participants took part in the usual didactic
and clinical activities at their institutions. They had clinical learning
experiences two days a week for their adult health nursing course
without any concurrent clinical experiences for other classes.
The intervention consisted of six reflective writing assignments
given to the experimental group participants during the first eight
weeks of the semester. The assignments were formulated using educa-
tional reflective writing strategies—reflection, journaling, triangulation,
and faculty feedback—found during the literature review. The interven-
tion included seven (of eight) elements of Paul's (1993) model of critical
thinking and was partially based on the NLN Scenarios for Simulation in
Nursing Education (2007), which are derived from the 2007 NCLEX-RN
test plan (National Council of State Boards of Nursing, 2007). The follow-
ing is a sample study intervention with the corresponding elements of
Paul's (1993) model of critical thinking included in parentheses: The
first assignment will be a reflection on a patient with nausea, particular-
ly post-surgical. Reflect on a time when you encountered a patient with
nausea or post-surgical nausea. For this assignment, determine the pur-
pose of your writing and what issue you are writing about (the purpose
of the thinking). Document what you observed and experienced (data
and observations) in the clinical setting. What conclusions (inferences,
69
interpretations, or solutions) did you come to by the end of the experi-
ence? Describe anything you could have done differently during the
experience. Did you apply any definitions, principles, or concepts (con-
cepts such as theories or definitions) that you have learned in the class-
room? If so, what were they? What interventions did you implement?
Did you notice any pre-existing assumptions (assumptions) that you
brought to the experience? If so, what were they? What consequences
(consequences) does this experience have for you or your patient?
From what point of view (point of view) did your thoughts about this
experience originate?
Assignments were emailed approximately once a week and in-
cluded a link to SurveyMonkey (a free online survey software and
questionnaire tool). The link provided the assignment's due date
(within 72 h of receipt), the required length (at least 300 words),
and a reminder not to share study information. Participants then re-
ceived specific assignment instructions, a reminder that they would
receive feedback before the next assignment was emailed, and notifi-
cation of the next assignment's due date. Students submitted their
completed work via SurveyMonkey.
Each assignment asked participants to reflect on a clinical experi-
ence by answering a series of questions about a specific patient health
problem. If they had not yet encountered that particular problem,
they could substitute another health problem they addressed during
a recent clinical experience.
The week after the final clinical rotation (when all writing assign-
ments were complete), the post-intervention CCTST and CCTDI tests
were administered to the participants in the same quiet, comfortable
classroom setting where they took the pretest.
Measurements
The CCTST is a standardized test, specifically designed for college-
aged students, that contains 34 multiple-choice items targeting interpre-
tation, analysis, evaluation, explanation, and inference skills. Scores
range from 0 to 34, and there is considerable overlap between the con-
cepts included in Paul's (1993) model of critical thinking and the
CCTST, despite differing terminology (Reed, 1998). Internal consistency
for the CCTST ranges from 0.68 to 0.70. The CCTST has been used in pre-
vious research with undergraduate nursing students (Giddens and
Gloeckner, 2005; Ingram, 2008; McCarthy et al., 1999; Shin et al., 2006;
Thompson and Rebeschi, 2000).
The CCTDI was developed by Facione and colleagues to measure seven
aspects of critical thinking disposition: truthseeking, open-mindedness,
analyticity, systematicity, critical thinking self-confidence, inquisitive-
ness, and maturity of judgment (Facione et al., 1994). The CCTDI was
the first instrument to measure each of these seven aspects using a
subscale (Facione et al., 1994). This test includes 75 statements to
which students either agree or disagree, and the possible range for total
CCTDI scores is from 70 to 420. Alpha reliabilities for the seven subscales
in the initial sample ranged from .71 to .80, and the alpha reliability for
the overall critical thinking dispositions was .91, indicating high internal
consistency among items (Bartlett and Cox, 2002).
Demographic information was gathered including age, race, gen-
der, and months of health care experience (excluding clinical learning
experiences).
Data Analysis
The statistical analysis, performed using SPSS 18.0 (SPSS Inc.,
2009), used means and independent sample t-tests to compare base-
line CCTST and CCTDI scores. A MANCOVA was performed to deter-
mine if there were group differences with regard to the average
change in CCTST and CCTDI subscales while controlling for experi-
ence. Significance level was set at 0.5 using a two-tailed test; there-
fore any p-values smaller than .05 were considered significant.
70 J. Naber, T.H. Wyatt / Nurse Education Today 34 (2014) 67–72
Results
The sample of 70 students (n = 34 from Institution One [I1], n =36
from Institution Two [I2]) had 36 participants in the control group and
34 in the experimental group. Of the control group, 19 (52.8%) were
from I1 and 17 (47.2%) were from I2. Of the experimental group, 15
(44.1%) were from I1 and 19 (55.9%) were from I2. The majority of re-
spondents (72.8%) were between the ages of 20 and 22, and 71.4%
had zero months of health care experience aside from clinical learning
experiences required for nursing school. Months of experience for the
entire sample ranged from 0 to 180 (M = 7.99 ± 28.49). Table 1 com-
pares the age and months of experience for the control and experimen-
tal groups and the two institutions.
According to the non-parametric test, Mann–Whitney U, there
was no significant difference between control and experimental
groups in age (p = 0.53; z = − 0.63) or months of experience
(p = 0.29; z = − 1.06). There was also no significant difference be-
tween I1 and I2 in age (p = 0.22; z = − 1.22) or months of experi-
ence (p = 0.18; z = − 1.34).
The groups were homogeneous based on ethnicity and gender
after testing using Chi square. There was, however, a significant dif-
ference between I1 and I2 on ethnicity (p = 0.01; χ² = 7.35).
There were no significant pre-intervention differences between
the control and experimental groups on total CCTST, total CCTDI, or
any of the subscales. The total CCTDI mean score for the control
group was 308.72 ± 29.72, and for the experimental group was
307.59 ± 26.16. The total CCTST mean score for the control group
was 18.22 ± 4.92, and for the experimental group was 18.26 ± 4.32.
Using multivariate analysis of covariance (MANCOVA), total
scores and each set of subscales were tested between the groups
with regard to the average change in total scores and subscales
while controlling for experience. According to the non-parametric
Wilks' lambda test results, a significant difference was found (p =
0.03; f = 2.51) between the control and experimental groups on
the truthseeking subscale. According to the individual analysis of co-
variance (ANCOVA), there was a significant difference (p = 0.03) in
the truthseeking subscale. This indicates that experimental group
members, who completed the reflective writing interventions, had a
significant increase in truthseeking abilities when compared to con-
trol group members, who did not complete the reflective writing
interventions.
No significant difference (F = 0.16, p = 0.69) was found between
the control and experimental groups on CCTDI total scores. According
to the Wilks' lambda results, no significant group difference was found
(F = 1.35, p = 0.26) between groups with respect to the CCTST
subscales. Although none of the CCTST subscale scores changed signifi-
cantly, the experimental group's scores increased on four of the five sub-
scales. In addition, the experimental group's scores were higher than the
control group's scores on three of the five subscales. According to the in-
dividual ANCOVAs, no significant difference (F = 0.16, p =0.69) was
found when comparing control and experimental group differences on
CCTST total scores.
Discussion
The experimental group's total CCTST and CCTDI scores did not in-
crease significantly following the intervention. The control group's total
Table 1
Participant age and months of experience shown by institution and group.
Institution One Institution Two
Age Months of experience Age Months of experience
N 34 34 36 35
Mean 21.85 2.35 24.03 13.46
SD 2.16 6.53 6.35 38.98
CCTST and CCTDI scores did not increase significantly from the pre- to
the post-intervention test. The most noteworthy result was the signifi-
cant increase in the experimental groups' CCTDI truthseeking subscale
score when compared to the control group. This increase may be
explained by accepting that the intervention helped make students
more “eager to seek the best knowledge…, [more] courageous about ask-
ing questions, and [more] honest…about pursuing inquiry” (Facione et
al., 1994, p. 346). As suggested in the literature, the writing intervention
may have helped nursing students to question if the information they
were receiving was true, valid, and accurate; and gain courage to ask
questions of other health care providers (Allen et al., 1989; Emig, 1977;
Luthy et al., 2009; McGuire et al., 2009). This idea is supported by
McGuire et al. (2009) who found that reflective writing as a pedagogical
strategy allows students to integrate their thoughts and experiences
with didactic material in order to more adequately understand both
the experiences and the didactic material, and with this understanding
comes courage to question circumstances in the clinical setting. Further,
Luthy et al. (2009) stated that writing promotes learning, and writing ef-
fectively makes nurses more likely to incorporate evidence into clinical
practice and to be successful communicators in practice. The study re-
sults indicated that the reflective writing assignments may have helped
encourage participant learning, which may help prepare future nurses
to communicate more professionally and courageously with other health
care professionals.
Some common characteristics were identified in the six partici-
pants who scored in the top 10% on the pretest and the posttest
truthseeking subscale. Most participants also scored in the top 10%
on the majority of the other subscales, particularly analyticity. This in-
dicates that these truthseeking participants also rank high among
peers in other critical thinking dispositions and that they excel at an-
alyticity (applying reason), using evidence to resolve problems, antic-
ipating potential difficulties, being aware of the need to intervene,
and connecting clinical observations with a theoretical knowledge
base. Also, four of these six participants had the most healthcare ex-
perience, indicating that such experience can increase the likelihood
of students seeking the best knowledge, being courageous in asking
questions, and being honest when pursuing the truth.
The experimental group scored lower than the control group on
pre-intervention CCTDI total scores, although not significantly lower.
The experimental group's mean age (M = 22.83 ± 5.27) was slightly
lower than the control group's (M = 23.12 ± 4.52). While no current
research shows a relationship between age and CCTDI scores, it is possi-
ble that the study participants who deviated from the normal age distri-
bution had other responsibilities, such as employment, that decreased
their critical reflection throughout the intervention and lowered their
test scores. The other non-significant differences between groups in
total pre-intervention CCTDI mean scores can be accounted for by differ-
ences in institution, age, ethnicity, and health care experience between
the two groups.
Neither group had significant improvements from pre- to post-
intervention CCTDI scores. One possible conclusion is that the
intervention's time frame (eight weeks) was too short and its fre-
quency (six assignments) was too low to produce significant changes.
In a study by Bartlett and Cox (2002), physical therapy students com-
pleted the CCTDI at the beginning and end of their junior year. That
study's significant CCTDI score increases were attributed to the stu-
dents completing a heavy clinical component. Three other studies
Control Experimental
Age Months of experience Age Months of experience
36 35 34 34
22.83 5.69 23.12 4.52
5.27 24.45 4.52 32.33
 J. Naber, T.H. Wyatt / Nurse Education Today 34 (2014) 67–72
(McCarthy et al., 1999; Thompson and Rebeschi, 2000; Giddens and
Gloeckner, 2005) provide evidence that critical thinking disposition
improves from nursing program entry to exit. Similar to these results,
two of these studies—Bartlett and Cox (2002) and Thompson and
Rebeschi (2000)—had the greatest pre to posttest subscale increase
in the truthseeking category. Perhaps this eight-week writing inter-
vention produced truthseeking changes similar to those that the
clinical component produced over one year in the Bartlett and Cox
(2002) study and those that the nursing program produced in three
years in the Thompson and Rebeschi (2000) study. However, it
simply may take more than eight weeks for total critical thinking
skills and disposition to improve significantly.
Methodological Considerations
This study shows the need to weigh period and frequency careful-
ly in future study design. On the one hand, students who chose not to
participate in or withdrew from this study may have done so because
a half semester was too long of a commitment. On the other hand, a
longer intervention with more writing assignments may have pro-
duced results that are more significant.
The interventions received some positive feedback. Participants and
nurse educators (who were not part of the study), reported that the as-
signment instructions were clear. Following the post-intervention tests,
several participants stated that the amount of writing and time involved
was reasonable, the questions were clear, and they were encouraged to
reflect on important aspects of their nursing care.
Although pre-intervention tests and post-intervention tests were
given under similar circumstances at both institutions, there were dif-
ferences that could have affected results. For example, although work-
load was similar according to course instructors, different assignments
at the two institutions could have affected perceived or actual student
workload. Students had different critical thinking opportunities even
if they were at the same institution and in the same clinical groups
due to the unique qualities of available patient populations.
The PI emailed feedback to all participants on each writing assign-
ment. Participants also received subsequent emails reminding them
to read and study their feedback. Some participants responded to
the feedback, while others did not. If participants responded, the PI
replied to their questions and comments; therefore, some partici-
pants received more interaction than others did. It is possible that
the intervention or this feedback contributed to the CCTST score
changes. Future studies should have more specific guidelines about
researcher feedback and interaction with participants. Future re-
search also should investigate the best way to structure faculty feed-
back to encourage critical thinking. Finally, research could investigate
if having more doctorally prepared faculty or more writing through-
out the curriculum affects critical thinking scores.
The control group consisted of more students from I1 than from I2.
Characteristics of I1 participants include a greater percentage of fe-
males, of White students, of students with less health care experience,
and of younger students. Future research needs to explore the relation-
ship between these characteristics and inquisitiveness subscale scores.
In addition, the study's small sample size could have contributed to
the lack of significant findings.
While this was a quantitative study, the reflective writing assign-
ments produced a large amount of reflective, qualitative data. Partic-
ipants offered a great deal of insight into the clinical experiences of
junior-level baccalaureate nursing students. They described accom-
plishments, fears, frustrations, inspiring situations, experiences that
made them question themselves, and patients that captivated them.
Participants reported that the assignments gave them an opportunity—
that they would not have had otherwise—to think critically about
their patient interactions. This data could serve as a basis for a future
qualitative study.
71
Conclusion
This study tested the effectiveness of a novel reflective writing inter-
vention, based on Paul's (1993) model of critical thinking, for improving
critical thinking skills and dispositions in baccalaureate degree nursing
students during an eight-week clinical rotation. Although there was
only one significant subscale increase between the control and experi-
mental groups from pre- to post-intervention tests, much valuable in-
formation was gleaned from this study. An innovative intervention
that used a convenient format of administration, completion, and sub-
mission was implemented. The researchers' extended understanding
of this intervention, based on the statistical data, is that this reflective
writing intervention did contribute to an increase in truthseeking in
participants. Therefore, this intervention may help nursing students
seek the best knowledge for practice and communicate with health
care professionals effectively.
In light of the study aims, the intervention was effective at increas-
ing truthseeking behaviors, and based on the experimental group's
scores, over a greater length of time, these increases may have been
significant as well.
Also, most participants who had high truthseeking scores also
scored in the top 10% on the majority of the other subscales and
had the most healthcare experience. Future studies could examine
the correlations between these factors.
The results of this study make it imperative for nursing schools to
consider including reflective writing—especially assignments based
on Paul's (1993) model—in nursing courses. If future studies, testing
over longer periods of time, show significant increases in critical
thinking, those interventions could be incorporated into nursing cur-
riculum and change the way nurse educators evaluate students.
Role of the Funding Source
The researchers would like to acknowledge the Delta Epsilon and
Gamma Chi Chapters of Sigma Theta Tau International for the research
grants that partially funded this dissertation study. The funding helped
researchers pay for gift card incentives, travel for data collection, and
the data collection instruments.
References
Adams, B.L., 1999. Nursing education for critical thinking: an integrative review. Journal
of Nursing Education 38 (3), 111–119.
Allen, D.G., Bowers, B., Diekelmann, N., 1989. Writing to learn: a reconceptualization of
thinking and writing in the nursing curriculum. Journal of Nursing Education 28
(1), 6–11.
American Association of Colleges of Nursing, 2008. The Essentials of Baccalaureate
Education for Professional Nursing Practice. U.S. Government Printing Office,
Washington, DC.
Bartlett, D.J., Cox, P.D., 2002. Measuring change in students' critical thinking ability:
implications for health care education. Journal of Allied Health 31 (2), 64–69.
Broadbear, J.T., Keyser, B.B., 2000. An approach to teaching for critical thinking in
health education. Journal of School Health 70 (8), 322–326. http://dx.doi.org/
10.1111/j.1746-1561.2000.tb07266.x.
College Entrance Examination Board, 2004. Writing: a ticket to work…or a ticket out. A sur-
vey of business leaders. Available at: http://www.collegeboard.com/prod_downloads/
writingcom/writing-ticket-to-work.pdf.
Craft, M., 2005. Reflective writing and nursing education. Journal of Nursing Education
44 (2), 53–57.
Emig, J., 1977. Writing as a mode of learning. College Composition and Communication
28 (2), 122–128.
Facione, N.C., Facione, P.A., Sanchez, C.A., 1994. Critical thinking disposition as a mea-
sure of competent clinical judgment: the development of the California Critical
Thinking Disposition Inventory. Journal of Nursing Education 33 (8), 345–350.
Fisher, A., Foreit, J., 2002. Designing HIV/AIDS Intervention Studies: An Operations
Research Handbook. Population Council, Washington, DC.
Giddens, J., Gloeckner, G.W., 2005. The relationship of critical thinking to performance
on the NCLEX-RN. Journal of Nursing Education 44 (2), 85–89.
Heinrich, K.T., 1992. The intimate dialogue: journal writing by students. Nurse Educator
17 (6), 17–21.
S.P.S.S. Inc., 2009. PASW Statistics for Windows, Version 18.0. SPSS Inc., Chicago.
Ingram, M., 2008. Critical thinking in nursing: experience vs. education (Doctoral
dissertation). UMI Number: 3304800. Available at: http://gradworks.umi.com/
3304800.pdf.
72 J. Naber, T.H. Wyatt / Nurse Education Today 34 (2014) 67–72
Kataoka-Yahiro, M., Saylor, C., 1994. A critical thinking model for nursing judgment.
Journal of Nursing Education 33 (8), 351–356.
Kennison, M.M., 2006. The evaluation of students' reflective writing for evidence of
critical thinking. Nursing Education Perspectives 27 (5), 269–273.
Luthy, K.E., Peterson, N.E., Lassetter, J.H., Callister, L.C., 2009. Successfully incorporating
writing across the curriculum with advanced writing in nursing. Journal of Nursing
Education 48 (1), 54–59.
McCarthy, P., Schuster, P., Zehr, P., McDougal, D., 1999. Evaluation of critical thinking in
a baccalaureate nursing program. Journal of Nursing Education 38 (3), 142–144.
McGuire, L., Lay, K., Peters, J., 2009. Pedagogy of reflective writing in professional edu-
cation. Journal of the Scholarship of Teaching and Learning 9 (1), 93–107 Available
at: http://www.eric.ed.gov/PDFS/EJ854881.pdf.
National Council of State Boards of Nursing, 2007. 2007 NCLEX-RN detailed test plan: can-
didate version. Available at: https://www.ncsbn.org/2007_NCLEX_RN_Detailed_Test_
Plan_Candidate.pdf.
National League for Nursing, 2005. Core competencies of nurse educators with task state-
ments. Available at: http://www.nln.org/facultydevelopment/pdf/corecompetencies.
pdf.
National League for Nursing, 2007. Simulation in Nursing Education Scenarios. The
National League for Nursing, New York, NY.
Paul, R., 1993. Critical Thinking: What Every Person Needs to Survive in a Rapidly
Changing World. Foundation for Critical Thinking, Santa Rosa, CA.
Paul, R., 1996. Valuable intellectual traits. Available at: http://www.criticalthinking.
org/articles/valuable-intellectual-traits.cfm.
Paul, R., Scriven, M., 1987. Defining critical thinking. Available at: http://www.
criticalthinking.org/pages/defining-critical-thinking/766.
Reed, J.H., 1998. Effect of a model for critical thinking on student achievement in primary
source document analysis and interpretation, argumentative reasoning, critical thinking
dispositions, and history content in a community college history course (Doctoral disser-
tation). Available at: http://www.criticalthinking.org/resources/JReed-Dissertation.pdf.
Reed, J.H., Kromrey, J.D., 2001. Teaching critical thinking in a community college histo-
ry course: empirical evidence from infusing Paul's model. College Student Journal
35 (2), 201–215.
Rooda, L.A., Nardi, D.A., 1999. A curriculum self-study of writing assignments and
reflective practice in nursing education. Journal of Nursing Education 38 (7),
333–335.
Shin, K., Jung, D.Y., Shin, S., Kim, M.S., 2006. Critical thinking dispositions and skills
of senior nursing students in associate, baccalaureate, and RN-to-BSN programs.
Journal of Nursing Education 45 (6), 233–237.
Thompson, C., Rebeschi, L.M., 2000. Critical thinking skills of baccalaureate nursing
students at program entry and exit. Nursing and Health Care Perspectives 20 (5),
248–252.
Wood, M., Ross-Kerr, J., 2011. Basic Steps in Planning Nursing Research: From Question
to Proposal, 7th ed. Jones and Bartlett, Sudbury, MA.