A description of pedagogical practices and student nurses’ critical thinking in a private nursing education institution in Pietermaritzburg, KwaZulu-Natal : a case study
Authors:   , Bridgelall Nisha 
Published: May 2022

Health care in South Africa has steadily evolved into a dynamic and complex environment coupled with the added burden of severely constrained resources. At the same time nurse practitioners are challenged daily, to provide safe, comprehensive and quality patient care. Clinical practice in nursing requires nurse graduates who are adequately trained in critical thinking skills (CTS). However, empirical evidence has highlighted that there is a lack of nurse graduates with this competency in the work environment. Consequently, the demand to produce self-directed, autonomous nurse professionals who are critical thinkers, has become a vital criterion in student nurse training. Therefore, it is incumbent that nurse educators integrate the development of CTS into their teaching strategies. Since critical thinking is an on-going process in using theory to guide clinical practice, it is imperative that nurses’ critical thinking abilities in clinical practice be measured. This will ensure the graduation of qualified nurse professionals who will deliver safe, qualitative, optimal and comprehensive nursing care with positive outcomes. Previous studies concur that it is the nurse educator who is responsible for inculcating this fundamental concept in student nurses however, finding methods for teaching the process of critical thinking has been a challenge for nurse educators that has spanned many decades. Now more than ever before there is a need for nurses who possess high-level CTS as a key competency, who can make effective clinical decisions, solve complex clinical problems, and provide quality patient care. This study focused on measuring student nurses’ critical thinking abilities in clinical practice and describes current instructional practices of nurse educators at the selected nursing educational institution (NEI). Alfaro-LeFevre’s (2016) theoretical model offers a definition of critical thinking (CT) as applied in the context of clinical practice. It describes the construct of CT as the integration of four components. For each of the components, Alfaro-LeFevre proposes a series of indicators of CT, called critical thinking indicators (CTIs). The CTIs are descriptions of behaviors that demonstrate the knowledge, attitudes, and skills that stimulate critical thinking in clinical practice (AlfaroLeFevre 2016). Aim The aim of this study was to measure the CTS of student nurses in the clinical setting and to describe the pedagogical practices of nurse educators at a selected NEI in Pietermaritzburg, KwaZulu-Natal. The findings of this study will contribute to CT development of nurses which is a fundamental skill for success within the rapidly changing healthcare arena of contemporary society. Methodology A descriptive, qualitative case study design using a multi-method approach to collecting data within a post positivist paradigm was adopted. The population comprised nurse educators and nursing students in a nursing college. The Nursing Critical Thinking in Clinical Practice Questionnaire (N-CT-4 Practice) developed by Zuriguel‐Pérez et al. (2017) was chosen as the most appropriate instrument to assess student nurses’ critical thinking in practice. A sample of 120 student nurses completed this selfadministered quantitative data tool. Concurrently, qualitative focus group discussions were held to explore the pedagogic practices of nurse educators at the selected NEI. Results Qualitative and quantitative evidence in this study revealed that CTS were not being developed, initiated or supported both in the classroom and in the clinical environment. The relationship between socio-demographic factors such as age, language barriers, selection criteria, low motivation and negative attitudinal dispositions in students appeared to be major obstacles and inhibiting factors in critical thinking development. There was a lack of the use of creative and innovative pedagogic methods by nurse educators and the predominant practice was the lecture-method. The clinical setting presented further obstacles such as staff shortages, lack of clinical support, poor role modelling, lack of learning opportunities and lack of equipment and supplies. Conclusions The healthcare environment is dynamic and complex in and of itself, but the complexity is magnified by numerous further obstacles that exist as enumerated above. Critical thinking skills development is being severely compromised due to these issues. This has further widened the theory-to-practice gap which is a major concern in providing safe and beneficial patient outcomes. Now more than ever before, there is an urgent need for nurses who possess high-level CTS for effective clinical decision-making, problem-solving and the provision of quality patient care. Concerted efforts must be made to transform the classroom environment with creative and innovative teaching methodologies. Nurse educators lack adequate resources and must be equipped on how to teach for critical thinking development. Pedagogic practices must accommodate the millennial cohort who make up the majority of the nursing students. English comprehension as a compulsory subject in the beginning of the nurse training must be added to nursing curriculums. The effectiveness of teaching strategies must be measured for critical thinking development to demonstrate change over time. A clarion call is made for all stakeholders, the nursing faculty, nurse leaders in the clinical environment, professional bodies and legislature to come together and redesign the nursing curriculum to address the diversity of issues that infiltrate and impact the nursing profession. Recommendations It is recommended that further research be conducted on CTS measurement in multiple private and public NEIs and that the clinical settings be varied so as to ascertain a more comprehensive outcome. Given that personal characteristics function as an activating element in thinking ability, it is recommended that further studies be conducted to explore the demographic determinants of students such as selection criteria, age, language, diverse learning needs and backgrounds. Further research is recommended to explore the correlation between the clinical experience of nurses and the acquisition of CTS in the South African context. The addition of English language modules for students challenged in this regard should be considered. Alternative approaches in educational design in order to maximize learning for millennial students is recommended. Further studies to ascertain whether nurse educators are adequately equipped to teach for CTS development will add to the body of knowledge. This is the first study of this nature with this specific instrument to measure CTS that has been conducted in South Africa and the findings may therefore serve as baseline data for further research in this area.