Caring behaviours directly and indirectly affect nursing students' critical thinking

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Critical thinking is important in nursing education and practice 1 because it is essential in helping nurses to handle complicated health conditions and to manage patient issues effectively. Willingness to think critically is a requirement for safe and profound clinical practice 2. Critical thinking includes both critical thinking skills, that is analysis, interpretation, inference, explanation, self‐regulation and evaluation 1; and a disposition towards critical thinking, that is characteristics (e.g. inquisitive, open‐minded, aware, reflective) and habits of the mind of critical thinkers 4. Although critical thinking often has been used interchangeably with other terms, for example decision‐making, problem‐solving, clinical reasoning and nursing process 5, in practice, it refers to clinicians' awareness of complexity, their willingness to work at analysing situations and their skills in processing information 4.
Caring is considered to be the essence of nursing 6. Lininger 8 defined nursing as caring and referred to ‘actions and activities directed towards assisting, supporting, or enabling another individual or group with evident or anticipated needs to ameliorate or improve a human condition or life way, or to face death’ (p. 46). Although caring has been conceptualised as a human trait, an affect and a moral imperative 9, caring should be performed to be observable. A concept analysis 10 identified the action taken by the nurse as a defining attribute of nurse caring, and the four important actions are nursing services, touch, presence and competence.
Caring is an elusive concept not only to define but also to measure. In a study by Beck, eight of the 11 quantitative instruments 11 designed to measure caring behaviours achieved acceptable reliability levels. Larson 12 defined nurse caring behaviours as ‘the acts, conduct, and mannerisms enacted by professional nurses which convey to the patient concern, safety, and attention’ (p. 4) and developed the Caring Assessment Report Evaluation Q‐sort (CARE‐Q) to measure caring. Hinds 13 defined caring behaviours as ‘the composite of purposeful nursing acts and attitudes which seeks to (i) alleviate undue discomforts and meet anticipated needs of patients, (ii) convey concern for the well‐being of patients, and (iii) communicate professional competence to patients’ (p. 22).
Caring behaviours have been documented as a significant link to holistic nursing, critical thinking and the nursing process 14. Thayer‐Bacon 15 posited that, without caring, one cannot hope to be a good critical thinker. Additionally, caring behaviours have been shown to have a positive effect on critical thinking 16, which is what is proposed in this study.
Reflection has been widely explored in literature 17 and is generally agreed upon as involving a process rather than short‐lived thoughts or impressions 19. Mezirow 18 described reflection as the process by which individuals transform their meaning schemes and meaning perspectives, resulting in transformational learning. The process of reflection may lead to insights or awareness of one's personal achievements and to an ability to compare these achievements with those of other people 3.
By nature, reflection is the act of thinking and rethinking through one's self and may lead to insight. Grant et al. 21 developed a tool to measure self‐reflection and insight, defining self‐reflection as inspecting and evaluating one's thoughts, feelings and behaviours, and insight as a clear understanding of these thoughts, feelings and behaviours. Previous study 22 recommended that understanding nurses' self‐reflection and insight may be a stepping stone to cultivating their critical thinking. Koole et al. 23 found that medical students' reflection had a small but significant effect on the problem‐solving of a case. To understand the mental processes underlying behaviours, Aukes et al.
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