Numerous conceptual frameworks of critical thinking have been developed and considered for this study. The Transactional Model of Critical Thinking (TMCT) reflects the effects of specific personal antecedent characteristics, attributes, and environmental conditions upon critical thinking outcomes (Gendrop, S.C., & Eisenhauer, L.A., 1996). It emphasizes influences such as age, cognitive style, culture, attitudes, and values as contributing factors. The Critical Thinking Model for Nursing Judgment (Kataoka-Yahiro, M. & Saylor, C.A., 1995) recognizes three levels of critical thinking in nursing: basic, complex, and commitment. The higher the level, the greater expertise needed for making sound clinical judgments. It is divided into specific knowledge, experience, and attitudes. Donabedian’s Quality of Care Model encompasses structure, process, and outcomes. It incorporates the course of action and the consequence of the care given (Fesler-Birch, D.M., 2005). All three of these conceptual frameworks emphasize the evaluation of structure and process of care. However, there is little agreement on the relationship between improving clinical practice and patient outcomes. Since these frameworks were limited
under hypothetical conditions (what is expressed or intended) compared to assessments of performance when faced with actual clinical situations (what is actually done), they were deemed inadequate for guiding this study.
Argyris and Schon (Argyris, C., & Schon, D., 1974) built on the work of Freud and Jung and suggested that there is a theory consistent with what people say they will do and a theory consistent with what they actually do (Argyris, C., 1980) i.e. an Espoused Theory (what is expressed) and a Theory-in-Use (what is done). The theoretical framework for this study is based on Argyris and Schon’s Theories of Action Espoused and Theory-in-Use. This theory has three elements; governing values, action strategies, and outcomes. Governing values are those dimensions or values that people try to keep within acceptable limits. Action strategies are the plans or assessments used by people to keep their governing values acceptable. Outcomes are the end result of the action and can be intended or unintended (Anderson, 1997; Argyris, C., & Schon, D. , 1974).
Espoused Theory represents the views and values people believe their behavior is based on. Theory-in-Use represents the views and values implied by their behavior ( Argyris, C., Putnam, R., & McLain-Smith, D. , 1985). Argyris suggests that although people design the action, they are often unaware of the design or that this action differs from their espoused theory. Effectiveness or intended outcomes result from attaining congruence between Espoused Theory and Theory-in-Use (Argyris, C., 1987). If there is a disconnection between what is expressed (Espoused Theory) and done (Theory-in-Use), the mismatch may result in an unintended outcome. The discovery of this mismatch then leads to a learning process which incorporates the invention of new meaning and production of new action. The theorists hypothesize that this subsequent learning process results in increased effectiveness in decision-making and better
acceptance of failures and mistakes (Argyris, C., & Schon, D. , 1974). There are inconsistencies and weaknesses in this theory. Decisions based on espoused theory can always have exceptions and be reconsidered. Action-decisions, on the other hand, are very concrete because they immediately trigger an action. It is unclear if the authors have considered the emotional aspect and potential fear of embarrassment that may influence the decision-making process. Although Argyris & Schon’s work has illuminated important inconsistencies between theorizing and pedagogical interventions through the use of reflective exercises, there is an absence of empirical data comparing theoretical to simulated or actual performance.
The proposed study applied the three elements of the theory as well as the concepts of Espoused Theory and Theory-in-Use in determining the relationship between critical thinking skills and simulation-based performance evaluated using VTV and HFHS, in student nurses prepared at the diploma, associate, and baccalaureate level. In this conceptualization (Figure 1), the governing value in the study is critical thinking. The action strategy is the assessment used to keep the governing value acceptable, operationalized using a traditional critical thinking
evaluation method (CCTST); VTV in which written text is used to assess the ability of the student nurse to determine the course of action to take; and HFHS in which direct observation is used to assess the course of action taken by the student nurse. Both the VTV and HFHS
assessment characterizes the nurses’ ability to recognize the clinical problem, report essential clinical data, initiate independent nursing interventions and assessments, anticipate medical orders, understand decision rationale, and prioritize care. The written answers (VTV) will represent the Espoused Theory and HFHS will represent the Theory-in-Use or the observable action that the student takes. For both assessments, the same patient scenario was used and the actions taken by the student nurse to manage the problem were evaluated in the same manner.
Outcomes are the end result of the action and can be intended or unintended. An intended outcome of the CCTST is a score reflecting strong critical thinking skills. An intended outcome of both the VTV and HFHS assessment is successful simulation-based performance as measured by the students’ ability to recognize the clinical problem, report essential clinical data, initiate nursing interventions, and prioritize the care of the patient. Additionally, an intended outcome will be represented by a relationship between strong critical thinking skills and successful simulation-based performance (VTV and HFHS) (Figure 1).
Critical Thinking Strong Critical Thinking Skills Successful Simulation Laboratory Performance Unsuccessful Simulation Laboratory Performance Age Race Gender Academic Preparation Internship/Residency Program
Experience as a Nurses Aide HFHS Exposure Critical Thinking Disposition
Average Critical Thinking Skills
Weak Critical Thinking Skills Critical Thinking Skills
(CCTST) •Analysis •Inference •Evaluation •Inductive Reasoning •Deductive Reasoning Simulation Laboratory Performance
Espoused Theory (narrative) = VTV Theory-in-Use (observed action) = HFHS
•Problem Recognition •Reporting Essential Clinical Data •Independent Nursing Interventions
•Anticipating Medical Orders •Decision Rationale •Prioritization Go ve rn in g V alu e Ac ti on S tr ategy O utco m es