Effectiveness of Mind Mapped Care Plans (MMCP) in Evaluating Critical Thinking Skill on Patient Care in Nursing Practice and the Attitude Among Nursing Students in Selected Nursing Institutions.

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Effectiveness of Mind Mapped Care Plans (MMCP) in evaluating

Critical Thinking Skill on patient care in Nursing practice

and the Attitude among nursing students

in selected Nursing Institutions

Signature of the Guide: _____________________________________

PROF.DR.A. CHARLES STEPHEN RAJASINGH, M.S.,M.Ch., RESEARCH GUIDE

C.S.I . JEYARAJ ANNAPACKIAM COLLEGE OF NURSING

MADURAI

A Thesis

Submitted to The Tamil Nadu Dr. M.G.R Medical University, Chennai,

for the award of the Degree of

Doctor of Philosophy in Nursing

Effectiveness of Mind Mapped Care Plans (MMCP) in evaluating

Critical Thinking Skill on patient care in Nursing practice

and the Attitude among nursing students

in selected Nursing Institutions

Signature of the Guide: _____________________________________

PROF.DR.A. CHARLES STEPHEN RAJASINGH, M.S.,M.Ch., RESEARCH GUIDE

C.S.I . JEYARAJ ANNAPACKIAM COLLEGE OF NURSING

MADURAI

Signature of the Co- Guide: ____________________________________ PROF.DR.C. JOTHI SOPHIA, M.Sc.(N).,Ph.D., RESEARCH CO-GUIDE

C.S.I. JEYARAJ ANNAPACKIAM COLLEGE OF NURSING

MADURAI

A Thesis

Submitted to The Tamil Nadu Dr. M.G.R Medical University, Chennai,

for the award of the Degree of

Doctor of Philosophy in Nursing

CERTIFICATE BY GUIDE

This is to certify that the thesis entitled “Effectiveness of Mind

Mapped Care Plans (MMCP) in evaluating Critical Thinking Skill on

patient care in Nursing practice and the Attitude among nursing students

in selected Nursing Institutions”, submitted by G. JAYA THANGA SELVI,

who registered for Ph.D in 2009 is a bonafide record of the research done by

her during the period of study under my supervision and guidance and that it is

not formed on any basis for the award of any other Degree, or Diploma,

Associateship, Fellowship or any other similar title or any other Universities.

I also certify that this thesis is her original independent work. I

recommend this thesis should be placed before the examiners for the award of

Ph. D degree.

---

C.S.I. JEYARAJ ANNAPACKIAM COLLEGE OF NURSING MADURAI 

CERTIFICATE BY CO- GUIDE

This is to certify that the work embodied in the thesis entitled

“

Effectiveness of Mind Mapped Care Plans (MMCP) in evaluating

Critical Thinking Skill on patient care in Nursing practice and the

Attitude among nursing students in selected Nursing Institutions

”

submitted by

Doctor of Philosophy in Nursing is a bonafide record of research done by her during

the period of study under my supervision and guidance that it has not formed the basis

for the award of any Degree, Diploma, Associateship, Fellowship or other similar title

in this university or any other university or institution of higher learning.

I also certify that this thesis is her original independent work. I recommend

this thesis should be placed before the examiners for the award of Ph. D degree.

--- PROF.DR.C. JOTHI SOPHIA, M.Sc (N).,Ph.D.,

RESEARCH CO- GUIDE

C.S.I JEYARAJ ANNAPACKIAM COLLEGE OF NURSING

DECLARATION

BY THE CANDIDATE

I hereby declare that this thesis entitled

Mapped Care Plans (MMCP) in evaluating Critical Thinking Skill on

patient care in Nursing practice and the Attitude among nursing students

in selected Nursing Institutions,”

is an original work done by me under the

guidance of

Prof.Dr.A.Charles Stephen Rajasingh, M.S., M.Ch.,

and

has not been submitted elsewhere, either partially or fully for the award

of any other Degree, or Diploma, Associateship, Fellowship or any other

similar title.

---

G. JAYA THANGA SELVI, M.Sc (N).,

Professor

C.S.I. Jeyaraj Annapackiam College of Nursing,

Madurai.

ACKNOWLEDGEMENT

“The lord will fulfil what he has planned for me”

First and foremost, my utmost gratitude to the omnipresent God for his

abundant grace enabling me to complete this thesis successfully.

“Gratitude is not only the memory but also the

respect of heart rendered to the person for his / her guidance”

Throughout my research in the doctoral programme, there have been many

wonderful relevant people who have provided support and helpful assistance in the

preparation and completion of this thesis.

I began my journey with Prof. Dr. C. Jothi Sophia, M.Sc (N)., Ph.D.,

Principal, C.S.I. Jeyaraj Annapackiam College of Nursing, who nurtured my

professional growth, for having given me an opportunity to upgrade my profession in

this esteemed institution. I am also profusely thankful to her, for constructive

suggestions and constant encouragement during the period of study, as my Research

Co-guide, which enabled me to accomplish this study into a good shape.

My thesis would not have been possible without my great Research Guide

Prof. Dr. A. Charles Stephen Rajasingh, MS., M.Ch., who has been instrument in my research journey. I also wish to express my immense thanks to my Guide for his

continuous support, critical eye, provocative questions, endless patience to listen and

proper guidance, which gave me great enthusiasm throughout my study period .

Dr. Gabriel Jeyachandran, M.Sc.,M.Ed.,M.Phil.,Ph.D., deserves my heartfelt thanks for his scholarly guidance, research insights he has shared, helpful

advice during tough times and guiding me in the right direction throughout the period

of my research.

I am bound to express a special word of appreciation to panel of experts for their enlightening suggestions, necessary corrections, valuable judgements and

recommendations while validating the content of the tool.

I owe my thanks to Mrs.Merline Jeyapal,M.Sc.(N)., Vice Principal and all the faculty members of C.S.I. Jeyaraj Annapackiam College of Nursing, for their suggestions and guidance that contributed the growth of this thesis.

I wish to express my special heartfelt thanks to all ethical committee members, C.S.I. Jeyaraj Annapackiam College of Nursing, for providing me an opportunity to undertake this study.

I convey my special thanks to all the Heads of Institutions and Principals, for permitting me to conduct this study in their esteemed institutions. I also offer them

my sincere thanks for their services and co-operation during my data collection

period.

I am extremely grateful to my sister Prof. Mrs.Jasmine Andrew, M.A., M.Phil., Ph.D., for helping me with her brilliant editorial skills in shaping this thesis.

I extend my sincere thanks to Mr. Manivel Samy,M.Sc.,MPhil., Bio-Statistician, Aravind Eye Hospital, Madurai, who offered valuable assistance in

statistical analysis of this study.

And lastly I would like to thank the study subjects of my study for the time they have sacrificed, their co-operative participation and the suggestions they offered

to improve my tool, without whose co-operation the study would not have been

completed.

This thesis is dedicated to my lovable husband Mr.Basil Paul Kirubakaran Grubb, in the progress of my highly demanding academic ventures. I express my deepest sense of love to my ever loving daughter baby Suvitha Olivia Grubb and son master Davidson Grubb, who have always stood by me and dealt with all of my absence from many family occasions with a smile.

I am indebted to my lovable parents Mr.M.Gnanakkan and Mrs. G.Soundravalli, who have played a major role in writing my thesis, in my

career and in my life by their prayer and steadfast encouragement.

I express my affectionate and deepest love to my mother-in-laws,

Mrs. Felcia Grubb and Mrs. Hilda Rajan, who have been the source of inspiration bytheir love and prayer.I am thankful to my sisters and my in-laws family for their prayers and noble encouragements.

Finally, I owe my deepest gratitude to Mrs. R. Shyla Kamalakumari and

Mrs.R.Jancy Rachel Daisy, Co-PhD scholars and my friends for their prayer, love, support, selfish guidance, motivation and for their input in various aspects of the

study.

Once again, I humbly acknowledge my sincere gratitude and appreciation to

all who have directly and indirectly contributed to this study.

With a thankful heart

ABSTRACT

A study was done to evaluate the Effectiveness of Mind Mapped Care Plans

(MMCP) in evaluating Critical thinking skill on patient care and the Attitude towards

care plan among nursing students in the selected institution of Tamil Nadu for the

award of the degree of Doctor of Philosophy in Nursing to The Tamil Nadu

Dr. M.G.R. Medical University, Chennai during the year 2012.

INTRODUCTION

“Intuitive mind is a sacred gift and the rational mind is a faithful servant”

- Albert Einstein

As nurses’ roles change in response to the dynamics of managed care and an

increase in use of biotechnology in health care, more is expected of them both in

terms of psychomotor and cognitive skills. Critical thinking skill is currently a highly

valued educational outcome throughout the educational spectrum, especially in

relation to higher and professional education. Nursing education worldwide is also

embracing the construct critical thinking skill as a desirable educational outcome and

realizes the importance of eliciting the evidence of critical thinking in nurse's

reasoning process. Creating an environment that engages students in the learning

journey to promote critical thinking skill is not always easy. Mind mapping in nursing is a brilliant way for all nursing students to understand their lessons better and absorb difficult medical concepts easily. Therefore, mind maps are developed to provide a

visual description of the thinking process.

objectives of this study were to: (1) determine the effectiveness of MMCP on critical

thinking skill of nursing students (2) find out the relationship between critical thinking

skill of nursing students and their attitude towards care plan. The adapted conceptual

framework in this study was on Daniel L. Stufflebeam (1971) CIPP (Context, Input,

Process and Product) model.

METHODS: The study used a quasi- experimental study of before and after control group design. A total of 257-III year B.Sc. nursing degree students from six nursing

institutions were included as interventional group (n=132) and control group (n=125)

through purposive sampling technique. The orientation of this new approach was 4

weeks. On the first week, following the pre- assessment, the interventional group was

given an introductory lecture on how to prepare Mind Mapped Care Plan (MMCP) as

an innovative instructional approach. Followed by, this new approach was reviewed

for remaining 3 consecutive weeks where the participants were given a same case

study scenario every week to prepare nursing care plans using mind map. Finally,

both the groups were again assessed for the critical thinking skills at three points of

time. Data collection tools included a (1) demographic variables,(2) check list on

critical thinking skill based on nursing process, (3) 5- Point Likert scale on attitude of

nursing students towards nursing care plan and (4) Teaching module on “Mind

Mapped Care Plan”.

RESULTS: The scores of critical thinking skill were compared between the two groups by unpaired‘t’ test. The findings revealed a significant difference between

control 3rd - post and interventional 1st, 2nd, 3rd post-test critical thinking skill scores

with the obtained overall ‘t’ value 39.73 was greater than statistical table value and

had higher score as compared to the control group. These findings proved that there is

a significant increase in the level of critical thinking skill among students in the

MMCP group than those who did not participate. With regard to post- test correlation

score, this study had an unexpected finding. The result shows that the obtained

coefficient correlation value in the control (r = 0.074) and the interventional(r = 0.03)

group indicate that there was possibly no correlation between critical thinking skill

and attitude, since the value was not statistically significant at P < 0.001 level.

This study concluded that MMCP might be an effective approach compared to

a traditional care plan approach for educating nursing students in terms of improving

critical thinking skill in the clinical settings.

RECOMMENDATIONS

The study recommended the following: (1) As for the result of this study, it is

recommended that the MMCP can be encouraged to utilize in clinical settings as a

TABLE OF CONTENTS

CHAPTER CONTENTS PAGE NO

CHAPTER I INTRODUCTION

1.1. Background of the study 1

1.2. Significance and need for the study 24

1.3. Statement of the problem 31

1.4.Aim 31

1.5. Objectives of the study 32

1.6. Hypotheses 32

1.7. Operational definitions 33

1.8. Assumptions 35

1.9.Delimitations of the study 36

1.10. Projected outcome 37

CHAPTER II REVIEW OF LITERATURE

2.1. Review of Literature 38

2.1.a)Review related to Mind Map 39

2.1.b)Review related to critical thinking skill 47 2.1.c)Review related to critical thinking skill and

traditional nursing care plans

57

2.1.d)Review related to Mind Map and critical thinking skill

62

2.1.e)Review related to attitude of nurses towards care plan / nursing process

67

2.2. Conceptual Frame Work 70

CHAPTER III MATERIALS AND METHODS

3.1. Research approach 76

3.2. Research design 76

3.3.Variables 77

3.4. Setting of the study 77

3.5. Population 78

3.6. Sample 78

3.8. Sampling technique 79

3.9. Sampling criteria 80

3.10. Description of the tool 81

3.10.a) Scoring and interpretation 85

3.10.b)Validity and Reliability 85

3.11. Pilot study 87

3.12. Method of Data collection 88

3.13. Plan for data analysis 94

3.14. Ethical considerations 95

CHAPTER IV RESULTS AND INTERPRETATION 97

CHAPTER V DISCUSSION

5.1. Development of Instrument 158

5.2. Distribution of sample according to their demographic variables

160

5.3. Effectiveness of Mind Mapped Care Plans on critical thinking skill and attitude of nursing students

164

5.3.a).Distribution of the subjects based on their critical thinking skill level before and after Mind Mapped Care plans

164

5.3.b) Distribution of the subjects based on their attitude level before and after Mind Mapped Care plans

165

5.3 .c) Area wise distribution of pre and post-test critical thinking skill mean scores among nursing students in the control and interventional groups

166

5.3.d) Area wise distribution of pre and post-test attitude mean scores among nursing students in the control and interventional groups

169

5.3.e)Item wise comparison for the subscale scores in critical thinking skill of nursing students in the control and interventional groups

170

5.3.f)Item wise comparison for the subscale scores in attitude towards care plan among nursing students in the control and interventional groups

172

5.3 .g) Comparison of differences in pre and post-test scores on critical thinking skill as well as attitude within the control and interventional group

174

5.3.h) Comparison of differences in pre and post-test scores on critical thinking skill as well as attitude of nursing students between the control and interventional groups

177

5.3 .i) Comparison of differences in pre and post-test scores on critical thinking skill of nursing students between the control and interventional groups at three different points of time

180

5.4. Relationship between critical thinking skill and attitude of nursing students

181

5.4.a) Correlation between critical thinking skill and their attitude of nursing students towards care plan

181

5.4.b) Relationship of critical thinking skill and attitude of nursing students with their demographic variables during the pre-test and post-test

184

5.5 Association of critical thinking skill and attitude of nursing students in the control and interventional groups with their demographic variables during the pre-test and post-test

185

5.5.a) Associate the critical thinking skill of nursing students in the control and interventional groups with their demographic variables

185

5.5.b) Associate the attitude of nursing students in the control and interventional groups with their demographic variables

186

CHAPTER VI SUMMARY, CONCLUSION AND RECOMMENDATIONS

6.1. Summary 187

6.1.a) Summary of the study 187

6.1.b) Summary of the findings 189

6.2.Limitations 195

6.3.Impact of the study 196

6.4. Implications of the study 197

6.4.a) Nursing Practice 197

6.4.b) Nursing Education 198

6.4.c) Nursing Administration 199

6.4.d) Nursing Research 200

6.5. Conclusion 201

6.6. Recommendations 202

LIST OF TABLES

TABLE NO TABLES PAGE NO

1.1.1 Concept Map VSs Mind Map 21

1.1.2 Mind Mapped Care Plan VSs Traditional care plan 23

2.2.1 Four aspects in CIPP 72

3.8.1 Name of the Institution 80

3.12.1 Data collection process 89

4.1.1 Distribution of nursing students according to their personal profile

102

4.1.2 Distribution of nursing students according to their institutional profile

108

4.2.1 Distribution of the subjects based on their critical thinking skill level

115

4.2.2 Distribution of the subjects based on their pre-test and post-test attitude level towards care plan

116

4.2.3 Area wise distribution of pre and 3rd post-test critical thinking skill mean scores among nursing students in the control group

117

4.2.4 Area wise distribution of pre and 3rdpost-test critical thinking skill mean scores among nursing students in the interventional group

118

4.2.5 Area wise distribution of control3rdpost-test and interventional 3rdpost-test critical thinking skill mean scores among nursing students

119

4.2.6 Area wise distribution of pre and post-test attitude mean scores among nursing students in the control group

120

4.2.7 Area wise distribution of pre and post-test attitude mean scores among nursing students in the interventional group

121

4.2.8 Area wise distribution of pre and post-test attitude mean scores among nursing students in the control group

122

4.2.9 Item wise comparison between pre and 3rd post-test critical thinking skill scores in the subscale of “Analysis” among nursing students in both the groups

123

4.2.10 Item wise comparison between pre and 3rd post-test critical thinking skill scores in the subscale of “Interpretation” among nursing students of both the groups

124

4.2.11 Item wise comparison between pre and 3rd post-test critical thinking skill scores in the subscale of “Inference making (diagnosis)” among nursing students in both the groups

125

4.2.12 Item wise comparison between pre and 3rdpost-test critical thinking skill scores in the subscale of “Inference making (Goal and outcome)”among nursing students in both the groups

126

4.2.13 Item wise comparison between pre and 3rd_post-test

critical thinking skill scores in the subscale of “Inference making (planning)” among nursing students in both the groups

127

4.2.14 Item wise comparison between pre and 3rdpost-test critical thinking skill scores in the subscale of “Explanation” among nursing students of both the groups

128

4.2.15 Item wise comparison between pre and 3rdpost-test critical thinking skill scores in the subscale of “Evaluation and Self regulation” among nursing students of both the groups

129

4.2.16 Item wise comparison between control post-test and interventional post-test attitude scores in the subscale of “Cognitive competencies” among nursing students in both the groups

130

4.2.17 Item wise comparison between control post-test and interventional post-test attitude scores in the subscale of “Affective competencies” among nursing students of both the groups

131

4.2.18 Item wise comparison between control post-test and interventional post-test attitude scores in the subscale of “technical competencies” among nursing students in both the groups

132

4.2.19 Item wise comparison between control post-test and interventional post-test attitude scores in the subscale of “interpersonal competencies” among nursing students in both the groups

133

4.2.20 Paired ‘t’-test for the comparison between control pre-test and 3rdpost-test critical thinking skill scores of nursing students

134

4.2.21 Paired ‘t’-test for the comparison between interventional pre-test and interventional 1st ,2nd,3rd post -test critical thinking skill scores of nursing students

135

4.2.22 Paired ‘t’-test for the comparison between control pre-test and post-test attitude scores of nursing

students towards care plan

136

4.2.23 Paired ‘t’-test for comparison between

interventional pre and post-test attitude scores of nursing students towards care plan

137

4.2.24 Unpaired ‘t’-test for the comparison between the control- pre and interventional1st ,2nd,3rd post-test for critical thinking skill scores of nursing students

138

4.2.25 Unpaired ‘t’-test for comparison between control 3rd post and interventional 1st _,2nd_{, 3}rd _{post-test critical}

thinking skill scores of nursing students

139

4.2.26 Unpaired ‘t’-test for comparison between control-pre and interventional post-test attitude scores of nursing students

140

4.2.27 Unpaired ‘t’-test for comparison between control- post and interventional- post-test attitude score of nursing students

141

4.2.28 One way Repeated measures Analysis of variance ( RM-ANOVA) in evaluating effectiveness of Mind Mapped Care Plans (MMCP) on critical thinking skill of nursing students between the control and interventional groups

142

4.3.1 Correlation between critical thinking skill and attitude of nursing students in the control and interventional groups

143

4.3.2 Multiple regression of control 3rd post-test between critical thinking skill and demographic variables of nursing students

144

4.3.3 Multiple regression of interventional-3rd _post-test

between critical thinking skill and demographic variables of nursing students

145

4.3.4 Multiple regression of control -3rd post-test between attitude and demographic variables of nursing

students

146

4.3.5 Multiple regression of interventional -3rd post-test between attitude and demographic variables of nursing students

147

4.4.1 Association between pre-test critical thinking skill scores and selected demographic variables of nursing students in the control group

148

4.4.2 Association between 3rd _{post-test critical thinking}

skill scores and selected demographic variables of nursing students in the control group

149

4.4.3 Association between pre-test critical thinking skill scores and selected demographic variables of nursing students in the interventional group.

150

4.4.4 Association between 3rd post-test critical thinking skill scores and selected demographic variables of nursing students in the interventional group

151

4.4.5 Association between pre-test attitude scores and selected demographic variables of nursing students in the control group

152

4.4.6 Association between pre-test attitude scores and selected demographic variables of nursing students in the interventional group

153

4.4.7 Association between post-test attitude scores and selected demographic variables of nursing students in the interventional group

LIST OF FIGURES

FIGURE NO FIGURES PAGE NO

1.1.1 Components of critical thinking skill 8

1.1.2 Mind Map- diagram 18

1.1.3 Mind-Mapping Guidelines 19

2.2.1 Core concepts of CIPP model 17

2.2.2 Conceptual Framework -

3.2.1 Schematic representation of research methodology 75

3.2.2 Research design 76

4.1.1 Distribution of nursing students based on their age 103

4.1.2 Distribution of nursing students based on their gender 104

4.1.3 Distribution of nursing students based on their selection of profession

105

4.1.4 Distribution of nursing students based on their aim of selecting profession

106

4.1.5 Distribution of nursing students based on their area of preference after course completion

107

4.1.6 Distribution of nursing students based on the courses offered in their institutions

109

4.1.7 Distribution of nursing students based onobtained clinical exposure their institutions

110

4.1.8 Distribution of nursing students based ontheir locality of the institution

111

4.1.9 Distribution of nursing students based on the duration of institution was started

112

4.1.10 Distribution of nursing students based on the type of institution

LIST OF APPENDICES

APPENDIX TITLE

A Copy of Letter seeking experts opinion with content validity

certificate

B Copy of Letter seeking permission for data collection

C Institutional Ethical clearance certificate

D List of experts

E Instrument ( Part I, II, III and IV)

F Criteria check list for validation of the tool

CHAPTER - I

INTRODUCTION

1.1. BACKGROUND OF THE STUDY

“Intuitive mind is a sacred gift and the rational mind is a faithful servant”

- Albert Einstein

The preceding quote denotes that nurse educators and students are to be

triggered by critical thinking skills to improve the quality of rational thoughts.

Thinking without doing is an academic exercise on fatality. Doing without thinking is

downright dangerous. Thus, critical thinking is an essential learning tool in

professional education.1

In the world of healthcare, nursing has long struggled to establish itself as a

profession. Throughout the history of nursing, unfavourable stereotypes (as

subservient and dependent on the medical profession) have negatively affected the

view of nursing as an independent entity. In its early developmental years, nursing did

not seek or have the means to control its own practice. Florence Nightingale, in

discussing the nature of nursing in 1859, observed that “Nursing has been limited to

signify little more than the administration of medicines and the application of

poultices.” As nursing research continues to work in establishing the profession as

independent in its own right, the value of nursing goals is understood and the

difference between nursing and other professions is being delineated. Nursing is now

recognized as both a science and an art concerned with the physical, psychological,

sociological, cultural, and spiritual concerns of the individual. The science of nursing

American Nurses Association (ANA) developed their first Social Policy Statement in

1980, defining Nursing as “the diagnosis and treatment of human responses to actual

or potential health problems.” Hence,the role of the nurse has shifted from one of the

“hand maiden” to one of an autonomous partner in health care delivery. Health care

organizations have made dramatic advances and transformations during the last few

decades, resulting in rapid growth of technology and theory. The need for critical

thinking in nursing has been accentuated in response to the rapidly changing health

care environment.2- 3

Nurses work in many different roles and settingseither directly or indirectly

related to patient care. Health care delivery has however changed with advances in

technology, disease treatment and prevention. So nurses need to become skilled in

higher-level thinking in order to effectively manage the complexchanges resulting

from the increasing demands andgreater accountability required of the profession.4

As nurses’ roles change in response to the dynamics of managed care and an increase

in use of biotechnology in health care, more is expected of them both in terms of

psychomotor and cognitive skills. The American Association for colleges of nursing

requires that critical thinking be reflected within academic nursing programs as a core

competency for programme accreditation.5

According to Russel6 nursing education has changed dramatically since

Florence Nightingale asserted the importance of education and moral standards to

fulfil the nurse’s role. In the years of Nightingale’s system, nursing education was

taken as hospital- based. However, it was transferred into the higher education sector

in the late of 20th century.6-7 According to Hart8 this transfer was influenced by the

society followed by economic efficiency, political reasons and the need for trained

staff.

Findings from a survey of 2000 nursing school faculties and administrators

sponsored by the National League of Nursing (NLN) reasoned that nursing education

is straggling behind in the world of technology.9 Brandon and All 10 emphasized that

the role of nursing is constantly changing. Professional nursing requires a

commitment to lifelong learning. A nurse needs to be self-directed, have an ability to

synthesize information, link concepts, and think critically. Simpson11 argues that

nursing’s future rests on nursing education’s response to a rapidly changing

technological environment.

Furthermore, Adams12 states that nursing education has to develop a student’s

ability to make decisions and solve problems which are necessary in providing high

quality nursing care which is safe and promotes wellness. These skills are rooted in

critical thinking which builds skills in making decisions and solving problems.

While nursing students are capable of critical thinking, the focus in

preparation programs has traditionally been on mastering content rather than applying

critical thinking to situations Nursing educators need to continue to develop and refine

educational strategies that promote the development of critical thinking and clinical

judgment skills that meet the learning needs of nursing students as well as the health

Critical thinking skill

"Not everything that can be counted counts,

and not everything that counts can be counted."

- Albert Einstein

Albert Einstein14 has beautifully explained that critical thinking is analyzing

and evaluating a situation logically in order to find out the correct result or

conclusion. This demands the brain to come out of its usual framework and think

about a situation or a problem from all possible aspects, before giving judgment. This

skill is essential for every individual, be it an adult or a child.

The South Carolina Higher Education Assessment Network developed the most

inclusive definition of critical thinking. This definition is:

“Critical thinking is a reflective, systematic, rational, and sceptical

use of cognitive representations, processes, and strategies to make

decisions about beliefs, problems, and or courses of action.”15

Etymology

The concept 'critical thinking' is derived from its roots in ancient Greek.

According to Paul, Elder and Bartell 23 the word 'critical' derives etymologically from

two Greek roots: 'kriticos', meaning discerning judgment, and 'kriterion', meaning

standards. Etymologically, the word implies the development of discerning judgment

based on standards.

Reilly and Oermann16 stated that critical thinking is a thought process

regarding patient care based upon clinical judgments. Historically, Thorndike17

alluded to critical thinking as a predominantly mental discipline, as “an increase of a

Alfaro-LeFevre18 describes that critical thinking in the nursing field including

outcome-directed, purposeful thinking; promote nurses to not focus on assumption but

make a decision based on evidence.

Critical thinking is the cognitive engine that drives the processes of knowledge

development and critical judgment in nursing.19

Van der Wal20 outlines two types of critical thinking one of which applies to

practical situations such as nursing practice emphasising the importance of skills that

support the identification of appropriate strategies and the decision making necessary

for effective problem solving. Critical thinking in nursing care is thus the ability to

analyse problems through inferential reasoning and reflection on past situations that

share similar clinical indicators. Such reasoning is necessary for effective decision

making in the delivery of complex patient management.

Oermann24 a renowned nurse author in critical thinking, stated that clinical

nursing education occurs in a dynamic, complex and challenging situation where

nurses are expected to use critical thinking as a fundamental principle to guide their

rational decision-making process and clinical judgment logically in a systematic

manner.

According to Bandman and Bandman25 critical thinking is the rational

examination of ideas, inferences, assumptions, principles, arguments, conclusions,

issues, statements, beliefs and actions.

According to Yıldırım32 _{critical thinking is “the process of searching,}

obtaining, evaluating, analyzing, synthesizing and conceptualizing information as a

guide for developing one’s thinking with self-awareness, and the ability to use this

Alfaro-LeFevre18 asserts that critical thinking belongs in nursing because

nursing is concerned with purposeful goal-directed thinking, with the primary aim of

making judgements grounded on factual evidence rather than conjecture.

Colucciello21 proclaims the use of critical thinking is vital in examining simple

and complex situations in nurses’ day-to-day responsibilities. It is an essential means

of establishing whether the information or assessment obtained has been accurately

captured in order to articulate specifically and distinctly what the information

conveys.

While the definition of critical thinking is broad and diverse in the literature

there is general agreement that it is purposeful, reasonable and goal-directed

thinking.20

Morrison and Walsh-Free29 asserted that critical thinking incorporates

assessment and multi-logical thinking as a key requirement for nurses to be able to

relate and apply concepts to clinical situations.

Critical thinking is not a single way of thinking, but is a complex,

multidimensional cognitive process dependent on reflective thought and tolerance for

ambiguity essential for decision making in nursing practice.45

`Prior to the Delphi Report22 there was no clear definition of critical thinking.

The final definition of critical thinking within this Delphi report is as follows:

“Critical thinking to be purposeful, self-regulatory judgement which results in

interpretation, analysis, evaluation and inference as well as explanation of the

evidential conceptual, methodological, criteriological or contextual considerations

upon which that judgement was based. Critical thinking is essential as a tool of

inquiry. Critical thinking is a pervasive and self-rectifying human phenomenon. The

personal biases, prudent in making judgements, willing to consider, clear about issues,

orderly in complex matters, diligent in seeking relevant information, reasonable in

selection of criteria, focused in inquiry and persistent in seeking results which are as

precise as the subject and the circumstances of inquiry permit”.

Critical thinking is gaining much popularity in nursing. Critical thinking has

come to the forefront in nursing following the mandate by the National League of

Nursing (USA),28 which stated that nursing programs must measure critical thinking

as an outcome criterion for accreditation. According to Raines.30 Nurses are

challenged to "think on their feet" in the multiple, complex, fast-moving

environments of today's nursing practice. The literature repeatedly stresses that nurse

must be able to think critically in order to process complex data and make sound

clinical judgments in the planning, managing and evaluating of the health care of their

patients. Even though the definition of critical thinking is diverse, there is no doubt

that this skill is essential in nursing education.

Critical Thinking in the Profession of Nursing is consistent with the Delphi

definitions and supportive of Kataoka, Yahiro and Saylor's31 _{definition of critical}

thinking in nursing as "the critical thinking process is reflective and reasonable

thinking about nursing problems without a single solution and is focused on deciding

what to believe and do". This definition broadens the concept of critical thinking in

nursing to include reflection of thoughts and recognition that there can be various

solutions to problems.

Kataoka, Yahiro and Saylor31 felt that to make good nursing judgments,

critical thinking must be used. They have identified five components of critical

thinking competencies, (4) Attitude or Paul's "traits of the mind" and (5) standards

(intellectual and professional).

“Education knits together critical thinking…with the fabric of students’.

Learning and thinking are interrelated lifelong processes. The above assertion

incorporates the concepts of critical thinking, life-long adult learning and the

professional mandates that nurses will practice.90

In nursing, critical thinking is the ability to think in a systematic and logical

manner with openness to question and reflect on the reasoning process which is used

to ensure safe nursing practice and quality care. Critical thinking when developed in

the practitioner includes adherence to intellectual standards, proficiency in using

reasoning, a commitment to develop and maintain intellectual traits of the mind and

habits of thought and the competent use of thinking skills which will develop the

abilities for sound clinical judgments and safe decision-making.133

Critical thinking skill

Facione, Facione and Sanchez26 state that having the requisite cognitive

critical thinking skills is essential to being a good critical thinker.

1 INTERPRETATION: interpreting problems as well as objective and

subjective data from common information sources, related to the care of the

patient.

2 ANALYSIS: examining ideas in problems, objective and subjective data and

possible courses of action related to the care of the patient;

3 INFERENCE: reaching conclusions which are appropriate to the care of the

patient.

4 EXPLANATION: clearly explaining and defending the reasoning in which an

individual arrives at specific decisions in the context of the health care of the

patient

5 EVALUATION: evaluating information relevance to particular patient care

situations; and

6 SELF-REGULATION: constantly monitoring one’s own thinking using

universal criteria.

These skills are employed interactively in the reflective reasoning process of

making a judgement of what to believe or do.

Daly27 states that the concept of critical thinking has only been recently

addressed in nursing literature related to the following issues:

-- The increasing interest in critical thinking in education;

-- Instructional methods to develop critical thinking in nursing education; and

Edwards131 proposes two phases in critical thinking skills. Those phases are

divided into some steps.

First phase: There are 5 steps in the first phases follows:

1st _{step: Interpret and organize the information is the first step, which will be done}

along with assessment in nursing process, nurses are expected to gather

data and make the mind map about the situation.

2nd step: The second step is hidden assumption. In this step, nurses are trying to

define other aspects like value and belief. They are expected to become

open-minded, especially with the opposite value and belief.

3rd step: The third step is engaging nursing knowledge. It is related to nursing theory

and perspectives.

4th step: The next step is to breakdown the information to make it easier for

analyzing.

5th step: Considering the other’s perspectives will be the next step. After considering

all aspects including analyzing the possible conflicts, finally the decision has

to be made.

Second phase: Furthermore, there are 4 steps in the second phase.

1st step: The first one is defending the decision. Nurses reconsider and rethink about

the decision that has been made.

2ndstep: After that, they need to be responsible and making the judgments on the

decision.

3rdstep: The next step is evaluating the process. It will include critical reflection,

correcting one self, learning from the process as well as planning for the

She believes that by applying these phases, nurses can be more independent

for doing long life learning

Critical thinking is currently a highly valued educational outcome throughout

the educational spectrum, especially in relation to higher and professional education.

Nursing education worldwide also embraces the construct critical thinking as a

desirable educational outcome and realizes the importance of eliciting the evidence of

critical thinking in nurses’ reasoning process.39

The term critical thinking has been used to describe fundamental skills used by

nurses for over a decade and yet a common understanding of the term and what it

exactly means has yet to be achieved.85-86 Even so, critical thinking is thought to be

the hallmark of the effective practitioner and the graduate nurse.87

Critical thinking skill and Nursing Process

Throughout any given day, a nurse uses thinking in a variety of situations.

Thinking is a process and is not necessarily linear in form. Costa51 identified traits

that are to be found in thinking as: - remembering, repeating, reasoning, reorganizing,

relating, and reflecting. Critical thinking differs from general thinking in that the

nurse now applies reason or logic to the situation to question the circumstances, seek

additional evidence, and to evaluate the outcomes or process.

Wilkinson33 proclaims that critical thinking cannot be facilitated or assessed in

a vacuum for it is used to apply basic core knowledge and skills to situation. Critical

thinking is inherent to the nursing process. Thus, the nursing process is a powerful

scientific vehicle which facilitates critical thinking. Varcoe 34 notes that the nursing

process is an analytical thinking process used to guide systematic and rational

Traditionally, nursing care was primarily based on the patient's medical

condition and prescriptive medical orders .35-36 In the 1960's, the combined effect of a

rapidly changing health care system and increasing demands on health care services

led to the introduction of defined roles for health care professionals.37

To establish the professional role of the nurse and develop nursing as a

separate discipline within the health care system, there was a deliberate move in

nursing. As part of this process, in 1967 a group of academics at Catholic University

in Washington, explicated an organisational framework called the nursing process.38

The nursing process comprised four stages as it was originally developed.

These stages were: assessment, planning, implementation and evaluation. During the

first decade of its use, several nurse scholars claimed there was a missing link in this

four stage nursing process.41-43 In 1980, the American Nurses Association endorsed

the diagnosis stage of the nursing process by defining nursing as “the diagnosis and

treatment of human responses to actual or potential health problems”.44

Logan 40 believed that the scientific process was akin to the critical thinking

process because both processes involve analysis, synthesis, deduction, and inference.

Jones and Brown 45defined critical thinking as reflective of the nursing

process, which consists of five steps, namely, assessment, diagnosis, planning,

implementation, and evaluation provides the basis for critical thinking skills in

nursing.

Sedlak and Ludwick 46_{stated that the nursing process and critical thinking}

should not be seen as separate from each other. Students' cognitive development can

be facilitated using critical thinking in the nursing process. Tucker and Flannery 47also

described a nursing care plan that provides students with a learning experience that

responsibility of nurse educators to integrate high level critical thinking skills into the

nursing process in the clinical setting.

Alfaro-LeFevre18 states “the nursing process is a systematic method of giving

humanistic care that focuses on achieving desired outcomes in a cost-effective

fashion”. It's systematic in that is consists of five steps.

According to Reilly and Oermann16 “nursing process is the methodology of

nursing practice”.

The characteristics of the nursing process as defined by Wilkinson33are:

dynamic and cyclic; client centred; planned and goal-directed; universally applicable;

problem-oriented; and a cognitive process. It is recognized as the foundation for

professional nursing practice, and provides the professional nurse with a framework

for decision making and problem solving in everyday practice and situations. This

process consists of five phases namely: assessment, diagnosis, planning,

implementation and evaluation.

Pesut and Herman48 assert that the nursing process should connect to nursing

practice. Due to increased technology and information, changes in the health care

system and a shift to a learning-centred focus, nurse educators need to enhance the

thinking strategies of students. Using critical and reflective thinking skills in the

nursing process is thought to improve contemporary nursing practice.

The nursing process serves as a useful conceptual framework for critical

thinking. Each component of the nursing process parallels the scientific method. We

can measure patient outcomes and the testing of hypotheses. Critical thinking is

inherent in making sound clinical reasoning.50

Alfaro-LeFevre18 insisted that nurse educators need to implement teaching and

high level of critical thinking and be prepared to provide nursing care in the 21 st

century. Active learning strategies have been identified as facilitating the

development of critical thinking, clinical reasoning, problem solving, and decision

making in nursing students who, in turn, can more readily apply that knowledge in the

clinical setting. He also states that in the context of clinical nursing education, critical

thinking skills of nurse learners are to be infused within the broad nursing process

framework. Clinical nursing education is a dynamic, constantly changing, real-life

environment in which theoretical knowledge is integrated with practice. The

facilitator is responsible for creating an environment that is conducive to the

development of critical thinking, while learners take the responsibility for

constructing their own knowledge and skills through active interaction to promote

critical thinking skills.

Oermann24 explains that "textbook characteristics" which were taught in the

classroom situation leave the nurse unsure about what nursing intervention to use in a

real-life, authentic situation where unstructured problems should be addressed. He

suggests that one way to curb this problem is to apply cognitive critical thinking skills

within the broad framework of the nursing process. The educator can ask

thought-provoking questions that are unique to the patient's problems and train the learners to

apply cognitive thinking skills within the framework of nursing process related to the

patient's problems.

Varcoe's34 _{stated that in spite of the benefits of the nursing process in}

facilitating critical thinking, nurse educators seem unable to implement and manage

the approach. The nursing process and its administrative implementation are heavily

criticised as time-consuming for nurses. It is argued that the role of nurses is to

involved with the nursing process. His argument is that there is confusion between the

theoretical critique of the nursing process and the critique of the administrative

implementation such as documentation.

Higginbotham, Masso and Prideaux52-54 state that although these theoretical

ideals have a prior support about the nursing process, some nurse clinicians continue

to display negative attitudes towards its use in practice. These clinicians believe that

due to work based issues and the complex nature of nursing; it is an inappropriate

framework for clinical use.

Karola55 mentioned that the critical thinking cannot be facilitated when the

nursing process is used in a robotic and dogmatic way, where nurses are mechanically

efficient as evidenced by focusing on routine, mass production, assembly-line,

task-orientated methods to provide efficient patient care.

Marshall49 who did a study on the use of problem solving methods for teaching

critical thinking in connection with the nursing process. In addition, this study

supported the usefulness of the nursing process for increasing knowledge and

understanding, application, and integration of nursing concepts. Moreover, it was

suggested that faculty need to examine their own perceptions about the nursing

process, define educational objectives in relation to critical thinking, and identify the

best strategies for promoting critical thinking in view of changing methods in clinical

practice. Nurse educators must focus on how to use critical thinking in the nursing

process in clinical settings to promote students' critical-thinking.

As per the views of Bell56 nurse educators have to create an appropriate

curriculum and develop innovative teaching strategies to facilitate the student’s

critical thinking skills in the learning process.

Toth57 examined various instructional strategies for developing critical

thinking abilities in 75 freshman nursing students using the California critical thinking

skills Test as the pre -test instrument in the first week and the post -test instrument in

the tenth week. Teaching strategies included case studies, large group discussion,

small group interaction, role playing, and questioning.

According to Koehler58 the educator's role in the nursing process is to have

the student develop critical thinking skills, that is, assess the patient, gather

information from the literature, select relevant points, relate all of this information to

the care of the patient, and illustrate the information graphically. This helps the

student establish priorities, seek relationships among information, and build on

previous knowledge. The nursing process provides a systematic guide or method to

assist students and novices in developing a style of thinking that leads to appropriate

clinical judgments.

A traditional teaching-learning environment tends to produce shallow, surface

thinkers who primarily rely on rote memory rather than careful understanding of the

content.59

It has been argued that outcomes of didactic learning fail to exhibit a

patient-oriented; critically thinking nurse capable of adequate decision making in practice, as

lecturing principally provides basic knowledge and theory.60

The other difficulties in promoting critical thinking skill are found by

Girot.61_{His study reveals two problems. First, the student’s abilities to encourage}

cognitive skills are more emphasized in the academic field rather than clinical

practice. Secondly, in actual practice, the student’s critical thinking ability is assessed

Moreover, Billings and Halstead62 acknowledge that mostly faculty use

traditional model in teaching which is mainly dominated by the teacher. They claim

that this model does not encourage critical thinking. The use of teacher-centred

learning has produced students who are passive in learning process, whereas, the

ability to think critically will be growth when students engage actively in the

learning process. It is one of challenges for nurse educators to create strategies that

bring students into active learning style.

Mind Map

“Mind maps as the external mirror of one’s own

radiant thinking which allows us to implement the thinking potential”.

Being a nurse is not an easy job and he or she will have hundreds of tasks to

accomplish in one single day. Also, this is one profession in which even a silly

mistake can take a person’s life away.

To err and forget is human nature and even nurses are humans. So how does

one make sure that they are always right and they never forget anything? Typically it

is a difficult thing for nurses to imagine a patient who has myriad problems and try to

interconnect those problems. Nurses, who use the mind mapping concept, show that

they perform their job much better and more efficiently. Nursing students can use

mind mapping tools to remember their lessons and also do well in examinations. Mind

mapping is a useful technique that can be used to achieve several things that need

memory and brain power in your day to day life. Mind mapping helps the brain to use

the cortical part of the brain and also you start being more creative using the

techniques.64

used to represent words, ideas, tasks, or other items linked to and arranged around a

central key word or idea. Tony Buzan66 first proposed mind-map as a fast critical

thinking technique. He was knighted for his contributions to our understanding of

how the brain functions. Buzan traces the development of mind mapping to research

performed in the 1950s. That research found that one side of the brain, the left side,

was the home of rational and linear thinking, of language and numbers. The right side

was home to holistic, associative, artistic thinking of pictures and music and colour.

Buzan reasoned that mind maps would optimize the brain’s ability to create, to learn,

to remember by combining elements that appeal to each side of the brain.

Mind mapping is a learning technique which uses a non-linear approach to

learning that forces the learner to think and explore concepts using visual-spatial

relationships flowing from a central theme to peripheral branches which can be inter-

related.68

A mind-map is a sketchily structured visual representation of one’s thoughts

which may lead to a train of related ideas. It is based on radiant thinking, a concept

which describes how the human brain processes ideas and information, whereby

different ideas are associated to each other through relationship hooks. A mind map

consists of a central idea or theme and related ideas branch out, connected together

via “relationship hooks”. Subsequent ideas are linked together, forming a hierarchical

Mind-Mapping Guidelines:

Tony Buzan65 suggests using the following guidelines for creating mind maps

and explained as follows:

1. Start in the centre with an image of the topic, using at least 3 colours or

multiple colours.

(Fig. 1.1.3)

2. Then you can just start entering ideas (Main Topics) that come to you when

you think of the Main Idea. You can just enter them or jot them down in the

order they come to you.

(Fig. 1.1.3)

3. Now you can go one step further, and break down each idea into its

component parts (Subtopics). Once you have a lot of ideas written down,

4. Use images, symbols, codes, and dimensions throughout your mind map.

5. Select key words and print using upper or lower case letters.

6. Each word/image is best alone and sitting on its own line.

7. The lines should be connected, starting from the central image. The central

lines are thicker and thinner as they radiate out from the centre.

8. Make the lines the same length as the word/image they support.

9. Develop your own personal style of mind mapping.

10. Use emphasis and show associations in your mind map.

11. Keep the mind map clear by using radial hierarchy, numerical order or

outlines to embrace your branches.

Wycoff 67stated that each brain hemisphere has specific traits and the

mind-mapping strategy encourages both right-brained and left-brained thinking. He further

explained that left-brained thinking includes language, logic, numbers, sequence,

focus on details, linear, symbolic representation, and judgment, while right-brained

thinking is nonjudgmental and includes images, rhythm, music, imagination, colour,

consideration of the whole, patterns, and emotions.

The predominant technique used by students to learn is a linear approach,

whereby the student outlines information into categories in a superior-to-inferior and

left-to-right spatial pattern. The mind map learning technique is an example of a

non-linear approach to learning that forces the learner to think radially using visuospatial

relationships.70- 71

Mind maps are multi-sensory tools that use visuospatial orientation to integrate

information and therefore help students organize and retain information.72

conceptual understanding of the fundamental principles of a huge amount of

information and enable one to assemble and integrate many concepts together and

promote active learning.73

Comparison of Concept Maps and Mind Maps

Mind maps are different than concept maps. The latter are flow charts that use

branch-like architecture, usually in a superior-to-inferior orientation, to organize

information. In addition, concept maps are devoid of pictures and colour.79 This is

explained in the following table:

Parameter Concept Map Mind Map

Hierarchical structure

Top to bottom Central to peripheral

Colour Unicolour Multicolour

Pictures None Multiple

Purpose Promotes critical

thinking by establishing

nonlinear relationships between concepts

Promotes critical thinking by establishing non-linear

relationships between concepts and enhances recall of

information through the use of dynamic colours and pictures.

Model It is a Medical model, in which

the disease as the central focus.

It is a Nursing model in which the client as the central focus.

Nursing

Process

Steps of Nursing Process to explore a disease and its ramifications, and require major ideas to be subsumed under one another

Steps of Nursing process are not “subsumed” under one another, but rather “coexist on an equal playing field”.

Mind Mapped Care Plan

The components of the nursing process are fundamental to thinking through

and meeting patient needs and preventing patient problems. But whole-brain thinking

is inhibited by the columnar care plans pervasively used to teach students to use and

record the components of the nursing process as they begin to plan and direct patient

care. The traditional format requires the completion of lines of thought in a very

limited, linear manner. This structure, while practical in theory, becomes problematic

when one looks at how nurses in practice truly think. As nurses care for patients, they

create in their mind's eye a whole patient picture that is comprised of a myriad of

interconnections between data sets associated with identified patient problems. Each

nurse has her or his own unique way of making these interconnections. A linear care

plan does not permit students to visually illustrate this higher level, interconnected,

whole-brain thinking. Joining mind mapping with care planning is the strategy we

used to achieve this goal.76

Traditional nursing care plans are linear-that is, they are designed in columns.

They speak almost exclusively to the left brain. The traditional nursing care plan is

organized according to the nursing process, which guides us in problem-solving the

nursing care we give. However, the linear nature of the traditional plan does not

facilitate interconnecting data from one “row” to another or between parts in a

column. Mind mapping allows us to show the interconnections between various client

symptoms, interventions or problems as they impact each other. Joining mind

mapping and care planning enables you to create a whole picture of a client with all

the interconnections identified. To begin mapping a client plan of care, you must

begin with the central topic-the client. Now, you are thinking like a nurse. Create a

hand just can’t start at the centre, then put the shape at the top. This will help you

keep in mind that the client is the focus of your plan, not the medical diagnosis or

condition. All other pieces of the map will be connected in some manner to the client.

Many different pieces of information about the client can be connected directly to the

client.69 This is explained in the following table:

Table 1.1.2. Mind Mapped Care Plan VSs Traditional care plan

MMCP TNCP

 It consists of a columnar or

tabular format of steps of nursing process.

 It is a graphical

representation of applying steps of nursing process.  Students coping from care

planning books when writing case studies.

 Changing mindless copy of textbook care plans.

 Inhibit the holistic view of the client.

 Promoting holistic view of the client.

 It inhibits critical thinking.  Encourages critical thinking.

Billings and Halstead62 define mind mapping as learning complex phenomenon

by diagramming the concepts and sub concepts.

King and Shell63 illustrate the process of mind mapping. For example, in

clinical practice the reason for seeking help´ is arranged as the centre of map. Then

other important data such as nursing diagnoses, sign and symptoms, nursing

intervention and other patient’s needs are clustered and linked to the centre. With the

identification of concept and diagram, students start to analyze the case and try to find

other information and relationships between components in the diagram and concept.

Mueller, Johnston and Bligh76 discuss the use of mind-mapped care plan by

nursing students to enhance their critical thinking. Integrating mind-maps into their

care plan encourages the student nurse’s critical thinking and links information such

as patient data and diagnoses together.

Clinical nursing education is an integral part of nursing education. So where

the learner is able to link the theoretical component of nursing process approach with

Mind Map to frame Mind Mapped Care Plan will facilitate critical thinking skill and

give us an opportunity to change the concept of the nursing process.

1.2. SIGNIFICACE AND NEED FOR THE STUDY

The goal of nursing education is to prepare students for safe clinical nursing

practice. Nurses use the nursing process to systematically collect and scientifically

analyze the client’s unique data to identify nursing problems or diagnoses, plan and

implement nursing interventions, and evaluate the client’s responses to those nursing

interventions. Nurse educators have traditionally taught students the nursing process

through the use of a nursing care plan that uses a linear columnar format. This style of

care planning may not foster critical thinking as many students draw information

directly from a care plan book without relating it to the client’s specific needs. Also,

these care plans are often completed retrospectively. Some argue that care plans are

obsolete in nursing practice and that thorough, accurate documentation reflects the

nursing process better than a document that requires continuous manual updating that

lends little to effective nursing practice. Yet there is still an important role in nursing

education for nursing care plans, as these are the basis for students learning how to

think like a nurse. More exploration of this issue is needed to determine if there are

meaningful manner, and apply important theoretical principles in the clinical setting.

Traditionally, nursing education has been based on a behaviourism model that has not

been conducive to advancing education practices It has been teacher-and

teaching-centred, using primarily lecture, rote memorization, and multiple- choice questions as

teaching strategies. This type of model is not exclusive to nursing education

curriculums. The National League for Nursing instituted accreditation criteria in 1990

requiring nursing programs to demonstrate the development of student critical

thinking skills consisting of “analysis, reasoning, decision making, and independent

judgment”. An active learning strategy is one in which the student learns by actively

participating in the learning process and thinking about what he/she is doing. An

innovative tool that can provide a meaningful learning experience for students by

acknowledging and building on prior knowledge, and making connections of

important client care concerns is a mind map.135

Mueller, Johnston and Bligh76 combined the Mind Map with the nursing care

plan as a way to teach the nursing students to view each plan as a whole picture and to

understand the relationships between the factors that affect the client. He also

identified three central issues that inhibit critical thinking when using a linear format

nursing care plan; 1. Linear nature, 2.Copying from care plan books, 3.Inhibits

holistic view of the client.

Mind maps are multi-sensory tools that use visuospatial orientation to

integrate information and therefore help students organize and retain information and

they provide an opportunity to effectively use b