Taking Our Students on a Journey to Personal FreedomConcepts are to us like the air we breathe. They are everywhere. They are essential to our lives. But we rarely notice them. Yet only when we have conceptualized a thing in some way, only then, can we think about it. Nature does not give us, or anyone else, instructions in how things are to be conceptualized. We must create that conceptualization, alone or with others. Once conceptualized, a thing is integrated by us, into a network of ideas (since no concept or idea ever stands alone). We conceptualize things personally by means of our own ideas. We conceptualize things socially by means of the ideas of others (social groups). We explain one idea by means of other ideas. So if someone asked us to say what a “friend” is, we might say, as the Webster’s New World does, “a person whom one knows well and is fond of.” If that same person asked us to say what it means to “know someone well,” we would respond by introducing yet further ideas or concepts.
Humans approach virtually everything in experience as something that can be “given meaning” by the power of our minds to create a conceptualization and to make inferences on the basis of it (hence to create further conceptualizations). We do this so routinely and automatically that we don’t typically recognize ourselves as engaged in these processes. In our everyday life we don’t first experience the world in “concept-less” form and then deliberately place what we experience into categories in order to make sense of things. Every act in which we engage is automatically given a social meaning by those around us.
To the uncritical mind, it is as if things are given to us with their “name” inherent in them. All of us fall victim to this illusion to some degree. Thus we see, not shapes and colors, but “trees,” “clouds,” “grass,” “roads,” “people,” “children,” “sunsets,” and so on and on. Some of these concepts we obtain from our native language. Some are the result of our social conditioning into the mores, folkways, and taboos of particular social groups and a particular society. We then apply these concepts automatically, as if the names belonged to the things by nature, as if we had not created these concepts in our own minds.
If we want to help students develop as critical thinkers, we must help them come to terms with this human power of mind, the power to create concepts through which we, and they, see and experience the world. For it is precisely this capacity they must take charge of if they are to take command of their thinking. To become a proficient critical thinker, they must become the master of their own conceptualizations. They must develop the ability to mentally "remove” this or that concept from the things named by the concept and try out alternative ideas, alternative “names.” As general semanticists often say: “The word is not the thing! The word is not the thing!” If students are trapped in one set of concepts (ideas, words) — as they often are — then they think of things in one rigid way. Word and thing become one and the same in their minds. They are then unable to act as truly free persons.
Command of Concepts
Requires Command of Language Use
To gain command of concepts and ideas, it is important, first, to gain command of the established uses of words (as codified in a good dictionary). For example, if one is proficient in the use of the English language, one recognizes a significant difference in the language between needing and wanting, between having judgment and being judgmental, between having information and gaining knowledge, between being humble and being servile, between stubbornness and having the courage of your convictions. Command of distinctions such as these (and many others) in the language has a significant influence upon the way we interpret our experience. Without this command, we confuse these important discriminations and distort the important realities they help us distinguish. What follows is an activity which you can have students do to begin to test their understanding of basic concepts.
Testing Your Understanding of Basic Concepts
Each word pair below illustrates an important distinction marked by our language. For each set, working with a partner, discuss your understanding of each pair emphasizing the essential and distinguishing difference. Then write down your understanding of the essential difference. After you have done so (for each set of words), look up the words in the dictionary and discuss how close your “ideas” of the essential difference of the word pair was to the actual distinctions stated or implied by the dictionary entries. (By the way, we recommend the Webster’s New World Dictionary)
From practice in activities such as these, students can begin to become educated speakers of their native language. In learning to speak our native language, we can learn thousands of concepts which, when properly used, enable us to make legitimate inferences about the objects of our experience.
Command of Concepts Requires Insight into Social Conditioning
Unfortunately, overlaid on the logic of language is the logic of the social meanings into which we have been conditioned by the society by which we are raised and from which we take our identity (Italian-American Catholic father, for example). Taking command of these “social” meanings is as large a problem as that of taking command of the logic of educated usage (in our native language). We have a dual problem, then. Our lack of insight into the basic meanings in our native language is compounded by our lack of insight into the social indoctrination we have undergone. Social indoctrination, of course, is a process by which the ideology (or belief system) of a particular group of people is taught to fledgling members of the group in order that they might think as the dominant members of that group do. Education, properly conceived, empowers a person to see-through social indoctrination, freeing them from the shackles of social ideology. They learn to think beyond their culture by learning how to suspend some of the assumptions of thinking within it.
The Journey to Personal Freedom
To move toward personal freedom we must develop the ability to distinguish the concepts and ideas implicit in our social conditioning from the concepts and ideas implicit in the natural language we speak. We must understand the divergent basis for both. For example, people from many different countries and cultures may speak the same natural language. The peoples of Canada, Ireland, Scotland, England, Australia, Canada, and the United States all speak English. By and large they implicitly share (to the extent to which they are proficient in the language) a similar set of basic concepts (that are codified in the 23 volumes of the Oxford English Dictionary). Nevertheless, though sharing this linguistic heritage, these various peoples do not share the same social conditioning. What is more, a person from China or Tibet could learn to speak the English language fluently without in any sense taking in our social indoctrination.
Unfortunately, very few students have sufficient insight into the differences between a natural language and the various cultures that might all use it. They fail to see, therefore, that natural languages — French, German, English, Swahili, or Hindi — are repositories of concepts that, by and large, are not “ideological.” They are not to be equated with the concepts implicit in the social indoctrination fostered by particular social or cultural groups. Indeed, we can use concepts from our native language to critique social indoctrination, just as this article is doing. Command of language makes social critique possible.
In the United States, for example, most people are raised to believe that the U.S. form of economic system (capitalism) is superior to all others. When we are speaking in ideological ways, we call it “free enterprise.” We also often assume (ideologically) that no country can be truly democratic unless it uses an economic system similar to ours. Furthermore, we assume that the major alternative economic systems are either “wrong” or “enslaving” or “evil” (the “evil empire”). We are encouraged to think of the world in this simplistic way by movies, the news, schooling, political speeches, and a thousand other social rituals. Raised in the United States, we internalize different concepts, beliefs, and assumptions about ourselves and the world than we would had we been raised in China or Iran (for example). Nevertheless, no lexicographer would confuse these ideological meanings with the foundational meanings of the words in a bona fide dictionary of the English language. The word "communism" would never be given the gloss of an economic system that enslaves the people. The word "capitalism" would never be given the gloss of an economic system essential to a democratic society.
However, because we are socially conditioned into a self-serving conception of our country, many of our social contradictions or inconsistencies are hidden and go largely unquestioned. Leaving social self-deception undisturbed is incompatible with developing the critical thinking of students. Command of concepts cannot be separated, then, from recognition of when they are, and when they are not, ideologically biased.
The Challenge We Face
If we are committed to helping students think well with concepts, we must teach them how to strip off surface language and consider alternative ways to talk and think about things. This includes teaching them how to closely examine the concepts they have personally formed as well as those into which they have been socially indoctrinated. It means helping students understand that, being fundamentally egocentric, humans tend to be trapped in “private” meanings. Thinking sociocentrically we are trapped in the world-view of our peer group and that of the broader society.
Both set of binders make it hard to rationally decide upon alternative ways to conceptualize situations, persons, and events. Being so trapped, most students are unable to identify or evaluate either meanings in a dictionary or the social rituals, pomp, and glitter of social authority and prestige. Students live their lives, then, on the surface of meaning. They do not know how to plumb the depths.
When we are teaching well, students go beneath the surface. They learn how to identify and evaluate concepts based in natural languages, on the one hand, and those implicit in social rituals and taboos, on the other. They become articulate about what concepts are and how they shape our experience. They can, then, identify key concepts implicit in a communication. They begin to practice taking charge of their ideas and therefore of the life-decisions that those ideas shape and control. Crazy and superficial ideas exist in our society because crazy and superficial thinking has created them. They exist for mass consumption in movies, on television, in the highly marketed “news,” and in the double speak of the ideological world of “law and order.” They do damage everyday to the lives of people.
The challenge to teaching with this end in view is a significant one. It is one we must pursue with a keen sense of the long-term nature of the project and of its importance in the lives of students. We may begin in modest ways for example, with the proper use of the dictionary or how to identify the mores and taboos of one’s peer group — but begin we must, for the quality of the thinking of the students of today determines the quality of the world they shall create tomorrow.
Adapted from the book, Critical Thinking: Tools for Taking Charge of Your Learning and Your Life, by Richard Paul and Linda Elder.
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to analyze the concept of critical thinking (CT) in Rodger's evolutionary perspective.
documentary research undertaken in the Cinahl, Lilacs, Bdenf and Dedalus databases, using the keywords of 'critical thinking' and 'Nursing', without limitation based on year of publication. The data were analyzed in accordance with the stages of Rodger's conceptual model. The following were included: books and articles in full, published in Portuguese, English or Spanish, which addressed CT in the teaching and practice of Nursing; articles which did not address aspects related to the concept of CT were excluded.
the sample was made up of 42 works. As a substitute term, emphasis is placed on 'analytical thinking', and, as a related factor, decision-making. In order, the most frequent preceding and consequent attributes were: ability to analyze, training of the student nurse, and clinical decision-making. As the implications of CT, emphasis is placed on achieving effective results in care for the patient, family and community.
CT is a cognitive skill which involves analysis, logical reasoning and clinical judgment, geared towards the resolution of problems, and standing out in the training and practice of the nurse with a view to accurate clinical decision-making and the achieving of effective results.
Descriptors: Nursing, Thinking, Concept Formation, Nursing Process, Decision Making
The concept of critical thinking (CT) has, over the last two decades, been one of the most discussed in the area of the teaching and clinical practice of Nursing 1 - 2 .However, as a transversal domain, it extends to the various areas in which people work, from the most simple and routine, to the most complex and painstaking professional and academic tasks 3 - 4 .
The literature on CT has its roots in two academic disciplines: philosophy and psychology 4 - 6 . However, one can also observe a third axis in the field of education 4 , 6 . In philosophy, one seeks to define the hypothetical critical thinker based on her qualities and characteristics 4 , 6 , while psychology seeks to describe the critical thinker based on her skills or actions 4 . In the ambit of education, there is a focus on the teaching and assessment of CT skills. As a result, there is a lack of consensus regarding the concept of CT in the literature, especially in the area of Nursing, which is influenced by these three axes.
In the area of healthcare - including nursing - the aging of the population, the increase in the complexity of illnesses and consequently in the care required, as well as the demand for services, require a professional with skills in CT, problem resolution and decision-making, and who is capable of appropriately accessing information, leading to safe, efficacious clinical practice which is based in scientific evidence 3 , 7 - 8 .
CT is an essential tool for the teaching and care practice of the nurse, and must not be confused with intelligence, but, rather, understood as a skill which can be learned 9 - 10 . This being the case, because of the importance of the need to train professional nurses able to think critically, the Red Iberoamericana de Investigación en Educación en Enfermería (RIIEE) addressed this issue in its multicentric investigation project 11 carried out in 16 countries in Ibero-America, this study being part of this investigation.
Researching CT in conjunction with an international investigation network 11 ) encouraged the authors to undertake the present work, as, as has been observed in the literature in Nursing 4 , 7 , 11 - 12 , the term CT presents variations, causing frequent disagreements, which indicates the need for refining and clarifying the concept. As a result, this study's objective is to analyze the concept of critical thinking in the teaching and clinical practice of Nursing, in the perspective of Rodger's evolutionary model of concept analysis 13 . The rationale for this study of the conceptual analysis of CT, specific to Nursing, is that it promotes clarification for future studies in the ambit of these professionals' academic and clinical practice.
A documentary study 14 ) based on the evolutionary model of concept analysis proposed by Rodgers 13 . This model understands the concept as a reverberation of the phenomena, which are dynamic, as they change over time and have a direct relationship with the context of their use. They have an inductive, nonsequential and descriptive character, indicating systematic rigor, considering a definition which presents conceptual problems 13 .
The process of analysis of the concept took place based on its substitute terms and related concepts, attributes, antecedents, and implications, and involves five stages 13 . In the first stage, the concept of interest was identified 13 , in the present study, CT, including the expressions and substitute terms used for the concept in the literature.
In the second stage, undertaken in February 2015, the authors proceeded to consult with the Cinahl, Lilacs and Bdenf databases 13 , due to these being considered to be important in the context of the Brazilian and foreign scientific production, in the ambit of Nursing. Use was also made of the Dedalus database, for obtaining textbooks of Nursing from the Collective Catalog of the Libraries of the University of São Paulo. As a specific descriptor for CT was not found, the same was inserted in the search as a keyword, along with the descriptor 'Nursing'. The works were identified using the search strategy of critical thinking AND nursing and its variations for Portuguese and Spanish, without limiting the search by year of publication. A total of 529 works were located in the databases mentioned.
In the third stage, for collection of the relevant data, identification of the attributes, and the contextual basis of the concept 13 , the following were defined as inclusion criteria: textbooks and articles of Nursing published in full, published in English, Portuguese or Spanish, and which addressed CT in the teaching and clinical practice of Nursing. The following were defined as exclusion criteria: duplicated studies and those which did not address aspects related to the concept of CT.
In the fourth stage, for analysis of the data and identification of their characteristics 13 , firstly the reading of the titles of the works selected in the second stage was undertaken, based in the criteria of inclusion and exclusion. A total of 481 works was obtained. Next, the abstracts were read in order to select those which addressed the issue of CT in the context of Nursing. Based on this refinement, 47 works were selected, including both books and articles. Following individual and thorough reading of each text in full, a sample of 42 was defined for analysis, including books and articles. At this point, the authors proceeded to reading based on the guiding questions: what are the characteristics/attributes of CT? What are the conditions/means which viabilize CT? What are the consequences of CT? In this stage, through an inductive process, theattributes, antecedents and consequence of the concept, which appeared with the greatest frequency, were identified in the texts. The organization of the stages of the phenomenon analyzed took place through typing, with each characteristic being listed separately, according to the number of authors who addressed it. The data were organized in a Microsoft Office Excel(r) 2013 spreadsheet.
In the fifth stage, implications or hypotheses for continuity of the development of the concept were listed 13 .
Of the 42 works selected for analysis, eight were text books and 34 were articles, with 28 (66.6%) published in English, 12 (28.6%) in Portuguese, and two (4.8%) in Spanish. Of these, the oldest dated from 1997, and the most recent from September 2014: items were included by title, authors, and cataloguing data of the book or periodical (Figure 1). The results below were organized inductively, based on what Rodgers 13 proposes as substitute terms, the attributes, antecedents and consequences, and implications/hypotheses of the concept.
Works included for analysis, by title, authors and book or periodical. São Paulo, State of São Paulo (SP), Brazil, 2015.
The identification of the substitute terms represents the first approximation with the concept to be analyzed 13 , for understanding the origin, development, functions and interconnections of a concept with other similar words or expressions. The substitute terms for CT identified were: analytical thinking 15 (14.3%), critical-creative thinking 16 (12%), nonlinear thinking 17 (9.5%) and critical-holistic thinking 16 (9.5%).
Differently from the substitute terms, the concepts related to CT (Table 1) have a link and closeness to it, but are not synonymous with it.
Factors/concepts related to Critical Thinking, by number of works analyzed. São Paulo, SP, Brazil, 2015
CT is characterized by higher-level thinking, which involves knowledge, experiences, dispositions (attitudes or habits of mind) and intellectual abilities. These essential characteristics, or attributes, were identified in the empirical material for analysis as skills and dispositions for CT, and are presented in Table 2.
Attributes (skills and dispositions) of the concept of Critical Thinking, by number of works analyzed. São Paulo, SP, Brazil, 2015
The antecedents, like the consequences of a concept, are conditioned to a contextual basis, in this case, the concept of CT in Nursing. In addition to this, they are related to the situational, temporal, sociocultural and course-related contexts of the profession at the present time 13 . The antecedents are considered the events, situations or phenomena which precede the concept investigated, while the consequences are situations which result from the occurrence of the concept in question (Table 3).
Antecedents and Consequences of the concept of Critical Thinking by number of works analyzed. São Paulo, SP, Brazil, 2015
The implications and hypotheses represent, respectively, the results and possibilities to be achieved 13 by a critical thinker in the ambit of Nursing and are important aspects for the development of the concept over time 13 . In accordance with the frequency as certained in the works, the implications and hypotheses are listed in Table 4.
Implications and hypotheses of the concept of Critical Thinking by number of works analyzed. São Paulo, SP, Brazil, 2015
Substitute terms and related factors/concepts
The concept of CT remains little clarified in the Nursing literature 1 , 16 , it being possible to identify a number of close words/expressions which are capable of representing or even explaining attributes and skills of an ideal critical thinker. In this regard, it becomes important to make it clear that substitute terms figure as expressions with meanings which are similar to the concept of CT. This aspect was discussed in one review study 16 , which indicated that clinical reasoning and CT are, often, used as synonymous terms inappropriately, as CT involves skills and attitudes which are necessary for the development of clinical reasoning.
Based on the empirical material researched, the most frequent substitute term was analytical thinking, followed by critical-creative thinking. These substitute terms, to the contrary of clinical reasoning, are synonyms, as they present a semantic interconnection with CT. As a result, when a nurse assesses a patient's health problem, observing, examining, recognizing and raising hypotheses regarding health problems, she is using analytical thinking, which can also be termed CT 17 .
On the other hand, the related factors (Table 1) have a correlation of cause or effect with the concept. For CT, the main related factors identified are aptitudes which are necessary for undertaking the stages of the Nursing process, such as decision-making 16 , clinical judgment 18 - 19 ) and clinical reasoning 11 . This relationship is not one of mere causality, it having been demonstrated in one study 20 that CT skills establish a relationship between themselves and, in the same way, with the stages of the diagnostic process in Nursing. Furthermore, CT involves skills and attitudes which are fundamental for achieving excellent goals of diagnostic accuracy. It is emphasized that, as a structural element of CT, clinical reasoning leads to clinical judgment, resulting in clinical decision-making 12 , 15 , 20 .
Another term which has been described many times coupled with CT, nearly forming a single term, is the concept of reflexive thinking 11 , 15 - 16 . The reasoning for this may be related to the fact that some authors consider reflection to be a skill of the critical thinker. Based on the hypothesis that reflection leads to critical thinking, one experimental study 21 , using reflexive writing, was undertaken with 70 undergraduate students of nursing. As a result, a significant increase was observed in the CT skills among the students of the experimental group. It is, therefore, relevant to undertake studies of this issue, as they assist in the process of understanding and evolution of the concepts.
Generally speaking, the identification of the substitute terms and related factors, respectively, made it possible to broaden the list of synonymous concepts and those which are interrelated. As a result, the related concepts allow the correct application of words which contain within themselves similar philosophical presuppositions, in this case, CT. Besides this, they assist in the understanding of the application of the concept of CT in the context of the practice of the student or nurse, and its importance for diagnostic reasoning, clinical judgment and efficacious decision-making.
Attributes of the concept of CT
The attributes bring together a real definition of the concept, different from the nominal definition provided in dictionaries, which simply substitute one word or expression with another which is synonymous 13 . As a result, the attributes are an integral part of a concept, corresponding to its characteristics. The sum of these attributes typifies and characterizes the concept. As presented in Table 2, the attributes which qualify CT are made up of skills and dispositions.
It is inferred, based on these results, that in the literature there is a major influence of the Delphi Report 22 , a consensus undertaken at the beginning of the 1990s by an interdisciplinary group of specialists in CT from the area of the humanities, social sciences, and education, defining the essential characteristics of the ideal critical thinker. The report 22 ) describes a significant proportion of the attributes identified in this study, such that these constitute the characteristics examined in most of the psychometric scales for assessing the development of CT.
In the literature analyzed, the skill mentioned most frequently for a critical thinker was "analysis" 11 , 15 , 19 , 22 ) or the ability to break something down in order to achieve an understanding of a given situation. It is believed that this skill is essential in academic and professional activity in Nursing, in that the understanding of the whole is limited to analysis of the parts, whether in the learning of a technique or in taking the patient history.
The most frequent disposition was "open-mindedness" 19 , 22 ) or impartiality in assessment, overcoming preconceptions in a rational way for prudent judgment and later decision-making. However, as studies indicate 4 , 6 , 20 , these skills and dispositions must be constantly exercised, given that the human mind tends to base its decisions on patterns of the cause-and-effect type, often intuitively, without careful examination of the possible alternatives.
As a result, for the improvement in the attributes of CT, the student or professional of Nursing must adopt a stance of seeking, in a careful, rational and active way, the improvement of the cognitive and affective aspects which are inherent to her professional and personal activities 21 , 23 . Based on this definition, it may be perceived that CT is a practical activity based on the sensible search for reason, through skills and dispositions, it being essential for the individual to have an inclination or attitude for carrying these out 20 . In this process, the importance of thinking about thought (metacognition) 4 ) is underlined as a necessary path to developing CT skills.
Antecedents of the Concept
Based on the categories presented in Table 3, the emphasis on the development of CT in the teaching and training of the student of Nursing is clear 11 , 16 , as well as the importance of the Teaching Policies, in particular the Brazilian National Curricular Guidelines (DCNs)of the undergraduate courses in Nursing 11 , 24 - 25 ) as phenomena which have leveraged the discussions and highlighted the importance of training nurses in the skill of thinking critically.
In Brazil, the DCNs 25 ) bestow curricular flexibility, which viabilizes pedagogical projects geared towards specific goals or demands. As a result, there is the possibility of a teaching permeated by CT, as it progresses towards problematizing training, linking teaching, work and community.
Another aspect also evidenced as a predecessor of CT was the seeking of better results in clinical practice 14 , 18 , 22 ) and the scientific and technological advance 25 - 26 , which represent an important challenge at the time of writing, as a result of the competencies and skills which are necessary and required for the students and nurses in order to respond efficaciously to the complexity of the health systems. In this regard, studies 16 , 19 , 23 indicate that the rapid technological and scientific advances in the area of health, added to the rapid expansion of Nursing's body of knowledge, have required critical thinkers in the profession.
The challenge of training a nurse who is capable of acting in a way that responds to the demands of a society in constant transformation is closely related to the need for cognitive, attitudinal and instrumental development so as to seek better results in practice and in health management 15 , 23 , 27 . Besides this, the nurse's decision-making must take into account the evidence deriving from professional experience, the scientific literature and the patient's requirements, with a view to the safety and quality of the health services.
Consequences of the concept of CT
The consequences of a concept are closely related to the antecedents and must follow them 13 . As a result, the consequences presented in Table 4 are considered to be situations which result from the occurrence of CT. Hence, they trigger actions in practice and/or teaching.
The consequence identified with the highest frequency was "clinical decision-making" 7 , 23 , followed by "clinical judgment" 11 , 19 - 20 ) and "clinical reasoning" 12 , 15 . The latter two, although distinct, are fundamental in the nurse's practice and lead to clinical decision-making. Clinical reasoning involves mental processes applied in the activities of the nurse who, based on a judgment based on knowledge, will take an appropriate decision. In this process of intellectual action, which results in clinical intervention, CT acts as a regulator of the patterns of thinking 8 , 12 . It thus covers an attitude of being disposed to considering, in a conscious way, the problems which arise in the ambit of the clinical experience or of teaching.
For effective decision-making based in CT, therefore, persistent effort is required for examining any situation or supposed form of knowledge in the light of evidence which supports new conclusions in regard to it 10 , 15 . One study 23 ) which assessed the structural elements of CT in 20 nurses from emergency services corroborated these findings, as it emphasized the importance of CT for clinical decision-making, as well as its interconnection in the managerial, multi-professional and teaching ambits. It is relevant to emphasize that the first three consequent terms identified previously also appeared as related concepts in Table 1, reinforcing the tenuous interconnections with CT.
Implications and hypotheses of the concept of CT
The main implications and hypotheses listed in Table 4 are related to the nurse's care practice. As a result, the most frequent implications for a critical thinker in Nursing were: achieving effective results in care to the patient, family and community 19 , 23 (35.7%) and safety and quality of the care 12 , 16 , 23 (33.3%). Therefore, it is believed that the structural elements of CT (skills and dispositions), continuously exercised in the ambit of nursing, entail effective and safe care. It is inferred that CT can be a mediating instrument in the improvement of reasoning and the exercise of practice, conferring upon the nurse competences and skills for diagnosing accurately.
For this, it is important to consider CT as a process of dynamic and continuous improvement which can be learnt by the nurse. As a result, the improvement of reasoning skills, the constant search for new knowledge, the aim of solving problems and issuing judgments is required, enabling the nurse to predict, diagnose and validate the conclusions obtained, always reviewing these critically 19 , 26 - 27 .
One longitudinal Australian study 28 ) assessed CT skills in 134 students, at two points: upon entering the undergraduate course in Nursing, and three years later, after graduating, using the Health Sciences Reasoning Test. It was concluded that the students significantly increased their CT scores after progressing through the course, principally improving their abilities in analysis and deduction. The students who had the highest scores in the test had better academic performance. These results corroborate the importance of the undergraduate course in helping the students to progress in their CT skills.
As indicated by the works analyzed 15 , 23 , 26 , it is believed that, as she progresses in the dimensions of CT, the student or nurse can achieve greater professional satisfaction and autonomy in her work process. Among various factors analyzed in one study 29 , the nurses reported that they achieved greater professional satisfaction as they achieved greater autonomy. In this regard, CT and its structural elements are intermediary tools which lead the professional to assertiveness in her clinical actions, creating safety, autonomy and satisfaction.
The concept analysis, based in Rodger's evolutionary model, clarified the phenomenon and allowed a correct understanding of CT, with implications for education and care in Nursing.
As antecedents of the concept, emphasis was placed on the need for training in critical thinking while still on the undergraduate course, with a consequent search for better results in clinical practice. This being the case, the main concepts related to CT are those which make up the stages of the Nursing Process, such as decision-making, clinical judgment, and clinical reasoning.
As a result, the understanding of the related factors, attributes, antecedents and consequences of CT made it possible to infer CT as a cognitive skill which involves a process of analysis, logical reasoning and clinical judgment, geared towards problem resolution. From this perspective, it has been emphasized in the training and care practice of the nurse, with a view to accurate clinical decision-making and to achieving effective results in the Nursing interventions for the patient, family and community.
As limitations of the study, the fact is highlighted that studies were selected from Latin American databases, with the exception of Cinahl. However, the study met the needs of the multicentric RIIEE project. As a consequence, broader studies become important, considering that the concept changes over time. Furthermore, it is necessary to develop the clarification of the concept of CT in other areas of knowledge.
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