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Concept mapping: A strategy for teaching and evaluation in nursing education
Nurse Education in Practice (2006) 6, 199–206
Nurse Education in Practice www.elsevierhealth.com/journals/nepr
Concept mapping: A strategy for teaching and evaluation in nursing education Raisa B. Gul a b
a,*
, Jeanette A. Boman
b,1
Aga Khan University, School of Nursing, P.O. Box 3500, Stadium Road, Karachi 74800, Pakistan Athabasca University, Canada
Accepted 8 January 2006
KEYWORDS
Summary In the past decade an increasing emphasis has been placed on the importance of critical thinking in nursing. Nurse educators are faced with the challenge of finding ways to promote and evaluate critical thinking in nursing students, and various teaching strategies have been identified to achieve this goal. Concept maps are considered a powerful metacognitive tool that can facilitate the acquisition of knowledge through meaningful learning. Hence concept mapping can be used to promote and evaluate critical thinking. Based on the published nursing literature, the scope of concept mapping is discussed in this paper as a teaching and evaluation strategy for critical thinking in nursing education. c 2006 Elsevier Ltd. All rights reserved.
Critical thinking; Concept mapping; Teaching/learning; Evaluation
Introduction
The evolving health care practice arena requires nurses who are capable of providing safe, competent and efficient care within an increasingly complex array of patient care needs and interdisciplinary healthcare teams. More than ever before, nurses must be critical thinkers, problem-solvers and effective decision-makers capable of making constructive contributions to desired health care
* Corresponding author. Present address: 1-3867, 76 St. Edmonton, Alberta, Canada T6K-2P9. Tel.: +1 780 461 2402. E-mail addresses: [email protected], [email protected]. 1 Tel.: +1 780 434 3793.
outcomes. For these reasons, learning to think critically is now widely accepted as a basic goal in nursing education (Daly, 1998; Di Vito-Thomas, 2000; Facione and Facione, 1996; Maynard, 1996). Various strategies to promote critical thinking dispositions and skills have been tried in nursing education. The controversies around the definition and measurement of critical thinking have challenged how it can be taught and learned. One developing area in the literature regarding how this might be done involves the use of concept mapping (Daley et al., 1999; Hicks-Moore, 2005; Harpaz et al., 2004; Irvine, 1995; Novak and Gowin, 1984). In this paper we first review the meaning of critical thinking and various methods that been used to facilitate and measure it. As one promising
1471-5953/$ - see front matter c 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.nepr.2006.01.001
200 approach to facilitating critical thinking, we then review concept mapping in relation to what it is and how it works. Finally, we summarize the reports about concept mapping as a means to the critical thinking skills necessary for clinical learning in nursing practice. From this synthesis of the literature reviewed for this paper, we conclude that concept mapping is an important way to both teach and learn in clinical nursing education settings. At the end, we call for the need to now consider more deliberately the potential role of concept mapping as a strategy to evaluate critical thinking as a learning outcome in clinical nursing education.
Critical thinking What is critical thinking? Theories of critical thinking can be traced back to Socrates, Plato, and Aristotle (Adler, 1978). Almost 25 centuries ago when Socrates talked about rationality, he envisioned reasoning as a force for promoting moral good. His student, Plato, argued the goal of education should not be to provide information, but rather to enable students to question, examine, and reflect upon ideas and values presented to them. Then Aristotle, a student of Plato, posited that phenomena can be clarified through critical thinking, i.e., thinking both abstractly and logically (Adler, 1978; Daly, 1998). This connection between critical thinking and knowledge development was not recognized again until 1916 when John Dewey (cited in Daly, 1998) reintroduced the phenomenon of critical thinking as an educational outcome. To Dewey, critical thinking was a subset of the reflective process that involves ‘‘thorough assessment, scrutiny, and the drawing of conclusions in relation to the issue at hand’’ (Daly, 1998, p. 3).
What constitutes critical thinking? Much debate has occurred around how to adequately define critical thinking. To many, critical thinking is a broader, more complex process than the linear steps taken to solve a problem or make a decision. The American Philosophical Association (APA) conducted a Delphi research project in1990 involving 46 multidisciplinary experts who defined critical thinking as ‘‘a process of purposeful, selfregulatory judgment that uses interpretation, analysis, inference, evaluation, explanation and reflective reasoning to consider the evidence from all
R.B. Gul, J.A. Boman angles before deciding what to believe or do’’ (Wheeler and Collins, 2003, p. 340). While this definition has been widely accepted in the USA (Facione and Facione, 1996), the same conclusion has not been reached by those who see certain attitudes and dispositions like truth seeking, open-mindedness, inquisitiveness, analyticity, systematicity, confidence, flexibility, and perseverance as integral to critical thinking (Facione and Facione, 1996; Ignatavicius, 2001; Perciful and Nester, 1996; Staib, 2003). Within the nursing literature where intuition and creativity have been recognized as a dimension of critical thinking, several have suggested there are similarities between critical thinking and the nursing process (Daly, 1998; Perciful and Nester, 1996; Staib, 2003). Caring has also been recognized as an affective and necessary component of critical thinking (Tanner, 1997). With the ongoing examination of critical thinking processes within nursing practice, the definition of critical thinking will no doubt continue to evolve.
How is critical thinking facilitated? Facione and Facione (1996) argued that to be learned by others, critical thinking is an outcome that ultimately needs to be demonstrated, demanding constant metacognitive reflection on ‘‘what one is doing and why’’ (p. 133). As such, role modeling and mentoring have been identified as methods to teach critical thinking. Because critical thinking can challenge the status quo, it involves a risk however. A teaching and learning environment that fosters critical thinking must consequently be perceived as safe for the learner to genuinely engage in the process. One component of this safe environment is the teacher who not only talks about the importance of critical thinking in nursing practice but models it as well (Boman, 2004). Other strategies that engage students in an active learning process are also thought to foster critical thinking and related dispositions. For example, problem based learning, reflecting, concept mapping, debating, exploring case studies, and answering higher-level guiding questions all require the learner to participate in one way or another (Angel et al., 2000; Beeken et al., 1997; Chenoweth, 1998; Colucciello, 1999; Cravener, 1997; Di Vito-Thomas, 2000; Elliot, 1996; Ironside, 2003; Schell, 1998).
How can critical thinking be measured? Not surprisingly, the measurement of critical thinking in nursing education has been challenging
Concept mapping: A strategy for teaching and evaluation in nursing education (Adams, 1999; Angel et al., 2000; Daly, 1998; Maynard, 1996; Oermann, 1997; O’Sullivan et al., 1997; Perciful and Nester, 1996; Staib, 2003). Without a clearly accepted definition of critical thinking and agreement about the characteristics that constitute critical thinking, it is difficult to decide ‘what’ to measure. Other reasons include the continued educational emphasis on ‘covering content’ and the focus on psychomotor skill development as visible ‘proof’ of competence in nursing practice (Adams et al., 1999; Ferrario, 2004; King and Shell, 2002). As well, research-based practice in nursing education is still in a very early stage. An integrative review of nursing education research articles written between 1975 and 1995 revealed no consistent evidence that nursing education contributes to an increase in critical thinking among nursing students (Adams, 1999). Staib (2003) has also noted that most observations about critical thinking in nursing practice are anecdotal. Of the standardized tests that have been used to measure critical thinking of nursing students, the more well known are the Watson–Glaser critical thinking appraisal (WGCTA), the California critical thinking skills test (CCTST), and the California critical thinking disposition inventory (CCTDI). The limitations of each have been identified and debated in the literature. The WGCTA, one of the oldest and most widely used, has 80 items that focus on the logical and creative components of critical thinking. The CCTST, developed in the early 1990s, is general with no discipline-specific content. The 34 multiple-choice questions that compose it are designed to assess core critical thinking skills like the ability to evaluate, make inferences, and engage in deductive and inductive reasoning. The CCTDI, a fairly recent assessment tool is designed to measure critical thinking dispositions or habits of mind like open-mindedness, confidence, and inquisitiveness. The CCTDI and CCTST have been used in combination to measure critical thinking in general (Adams, 1999; Staib, 2003). None of these assessment tools have been accepted as adequate ways to measure critical thinking in nursing practice. Several nurse researchers have advocated for the development of tests that reflect the context and content of nursing (Angel et al., 2000; Daley et al., 1999; Maynard, 1996; Perciful and Nester, 1996; Stone et al., 2001). Perciful and Nester suggested that qualitative methods be more rigorously pursued to fully identify the components and process of critical thinking in nursing. With the constructs clearly established, a more logical development of standardized tests could then follow. Others have questioned the
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futility of such endeavors and gone on to suggest that the complex nature of critical thinking might be best analyzed with non-reductionistic methods. To Daley et al. (1999) concept mapping is one method that should be considered.
Concept mapping The development of concept maps originated from the work of Novak (1992) and his colleagues in the 1980s at Cornell University. Concept mapping has been widely used in science, mathematics, and educational psychology. Its utilization in nursing education is fairly recent (Irvine, 1995). In an introductory article outlining extensive evidence from other disciplines about the effectiveness of concept mapping in helping students learn, Irvine urged nurse educators to consider it as a teaching and learning strategy in nursing.
What are concept maps and concept mapping? Novak (1992) described a concept map as an organizational tool to represent knowledge as well as a metacognitive strategy to promote meaningful learning. These maps consisted of concepts and propositions with concept defined as a ‘‘perceived regularity in events or objects’’ and represented by words or symbols (Novak, 1992, p. 1) . Propositions, defined as ‘‘statements about an object or event, natural or constructed’’ (Novak, 1992, p. 1) became semantic units or units of meaning. Thus, where ‘disease’, ‘illness’, and ‘medication’ are construed as events and ‘person’, ‘hospital’, and ‘drugs’ as objects, a person suffering from a disease or admitted to a hospital is labeled as a ‘patient’ or ‘client’. When two or more concepts are connected with other words to form a meaningful statement, a proposition is created. For example, ‘A patient takes medications’ is a proposition where the concepts of ‘patient’ and ‘medication’ are connected. Concept mapping is a general method for describing ideas about a topic in a pictorial form. As a structured process, it is focused on a topic or construct of interest and involves input from one or more participants for an interpretable pictorial interrelated view of their ideas. As such, a concept map may be viewed as an alternative to natural language for communicating knowledge in a specific discipline. In many disciplines concept maps are commonly used to represent formal knowledge systems such as bond graphs in mechanical and
202 electrical engineering (Trochim, 2000). Depending on its intended use, concept mapping has also been referred to as cognitive mapping, mental mapping, concept webbing, concept trees, knowledge maps, clinical correlation maps, patterned note taking, and flow charting. All of these terms refer to the notion of presenting related ideas in a graphical manner (All and Havens, 1997; Fuszard, 1995; Horton et al., 1993; Irvine, 1995; Luckowski, 2003).
How are concept maps developed? Although concept maps may be designed in different ways, the hierarchal method is preferred by many for clarity and comprehension. The hierarchical organization presents more general and more inclusive concepts at the top of the map and more concrete and specific ones at the bottom. Such maps can be constructed by: (1) identifying a central word or theme (written in the center or at the top of a page and enclosed in a box or circle) about a subject of learning or area of concern around which the map is to be built; (2) identifying all of the concepts, items, descriptive words, or questions that may be associated with the main concept or subject at hand; (3) linking the sub-concepts to the main concept via the hierarchical or lateral nature of their relatedness with arrows, lines, symbols, simple phrases and signal words like lead, cause, have, need, are showing the linear flow or direction of the information in the map; and, (4) identifying the cross-links between the information in the map (For further illustrations, see All et al., 2003; Daley et al., 1999).
What is the theoretical underpinning of concept maps? The idea of concept mapping is based on Ausubel’s learning theory, which emphasizes the assimilation of new information into the students’ prior knowledge for subsequent meaningful learning. Ausubel et al. (1986) believed that the mind is organized in a top-down fashion and that students relate new information to previous knowledge contained in their cognitive structures. New concepts are sorted, related, and then added to the existing hierarchies to create meaning. Hence, learning takes place when a learner is able to organize, relate, and subsume concepts into his or her cognitive structures. In the process, the learner’s prior knowledge plays a crucial role. Ausubel et al. differentiated rote leaning, the memorization of material through repetition, from meaningful
R.B. Gul, J.A. Boman learning that occurs when new knowledge is connected to relevant concepts already known. Meaningful learning was purported to produce a series of changes within the entire cognitive structure with the modification of existing concepts and formation of new linkages between concepts. For these reasons, it was proposed that meaningful learning was lasting, powerful and hence superior to rote learning that was easily forgotten. Likening them to building blocks, Novak (1992) explained that ‘‘(c)oncepts are like the atoms of matter and propositions are like the molecules of matter so there is always opportunity to create new knowledge from the existing concepts through observation, analysis, synthesis and creativity’’ (p. 4). Novak argued that knowledge construction is nothing other than a relatively high level of meaningful learning. In other words, knowledge is a human creation; it is made (Beitz, 1998). The processes involved in developing concept maps in turn have been linked to creative thinking (Novak, 1992) as hierarchical structures and relevant crosslinkages are worked out and concepts are related to the ‘big picture’ rather than remaining as isolated, compartmentalized incidents (Kathol et al., 1998).
What are the advantages of concept mapping? The construction of a concept map is believed to enhance understanding about a given subject. Drawing from Ausubel et al.’s (1986) work, Daley et al. (1999) explained that concept learning occurs in three ways: subsumption, differentiation, and integrative reconciliation. Subsumption requires rearranging and reordering conceptual understanding and meaning by deductive or inductive thinking to develop a conceptual hierarchy and in turn, to learn and remember it. For instance, communication skills may be learned in one course as discrete interpersonal skills and then later be subsumed under managerial skills in a subsequent course. Where progressive differentiation involves learning how to analyze parts of a greater whole (e.g., learning that tenderness, redness in skin color and swelling are signs of inflammation), integrative reconciliation involves synthesizing (e.g., knowing that inflammation as a whole includes tenderness, redness in skin color, and swelling). In order to create a meaningful concept map, thinking is required to select key concepts, identify sub-concepts and related information or examples, identify links and cross-links, and choose link words or symbols. While concept mapping involves a logi-
Concept mapping: A strategy for teaching and evaluation in nursing education cal process, it does not necessarily lead to rigid structures as the same list of concepts can be viewed and interpreted in different ways. Their flexible nature allows for new points and cross-linkages from one idea to another without elaborative explanations otherwise required in a written narration. Indeed, Irvine (1995) asserted that concept mapping is an ‘‘integrated educational experience’’ and a means by which to enhance ‘‘meaningful learning’’ (p. 1179). Others have recognized it as a creative process that actively engages learners in cognitive, affective and psychomotor learning (Reilly and Oermann, 1992) and an outcome that reflects personal thinking and experience (Novak, 1992). While the advantages of concept maps to facilitate the development of critical thinking abilities, concept mapping has also been recognized for its value in assessing whether and how those abilities have been acquired (Beissner, 1992; Castellino and Schuster, 2002; Thayer-Bacon, 2000; Daley et al., 1999; West et al., 2000; Wheeler and Collins, 2003). As a way to ‘‘externalize’’ thinking processes (Facione and Facione, 1996, p. 132), concept maps make visible the otherwise unseen changes in how a learner thinks over time. This visibility of thinking process makes its easier for the faculty and student to recognize any development of knowledge that has occurred (Harpaz et al., 2004). Through the creation of a concept map, the ideas and words selected by a learner can be analyzed and rated according to given criteria related to a range of possible differences in simple to more complex thinking processes (Daley, 1996; Daley et al., 1999; Kathol et al., 1998; West et al., 2000; Wheeler and Collins, 2003). With concept maps, information can be presented in a condensed manner without the loss of complexity and meaning. The image of concepts, in a tangible form, can facilitate comprehension through a visual presentation that fosters an understanding of complex information ‘at-a-glance’ compared to the dense presentation of words and verbal compositions. Because of the ease in conceiving and storing a visual configuration of information for later retrieval (All et al., 2003; Irvine, 1995; Novak, 1992), the utility of concept maps has been recognized in continuing education and staff development, curriculum development, and analyzing qualitative data (Daley, 1996; Luckowski, 2003).
Concept mapping for clinical learning: Does it work? The value of concept mapping to facilitate clinical learning in nursing practice has been increasingly
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reported in the nursing education literature over the last decade (All and Havens, 1997; Baugh and Mellott, 1998; Beitz, 1998; Caelli, 1998; Cannon, 1998; Castellino and Schuster, 2002; Ferrario, 2004; Harpaz et al., 2004; Hicks-Moore, 2005; Kathol et al., 1998; Reynolds, 1994; Schuster, 2000, 2002; Wade, 1998). Many of these extol the same virtues of concept mapping that have been addressed in the non-nursing literature. For instance, Kathol et al. (1998) saw the value of concept maps as a way to quickly assess student knowledge in a given moment as well as its development over time. King and Shell (2002) observed how the creative, flexible nature of concept mapping accommodated all learners, what ever their stage of learning. Where beginning learners could be asked to develop simple maps with one major concept, such as vital signs, nurse–patient communication, or patient assessment, more advanced learners could be asked to develop increasingly complex maps with changes in the numbers, hierarchies, and interrelatedness of various concepts. All et al. (2003) discovered that giving learners the opportunity to refine their concept maps again after a first round of feedback resulted in significant improvements in student creativity. Most nursing educators who used concept mapping reported that students viewed it as a stimulating, interactive, and fun way to learn (Castellino and Schuster, 2002; Daley, 1996; Daley et al., 1999; Kathol et al., 1998; Wheeler and Collins, 2003). As well, they have been observed to reduce anxiety, increase motivation, and promote greater achievement, especially within the context of a group (Beitz, 1998). Where the nursing process has traditionally been used as a way to facilitate problem solving and critical thinking in nursing practice, it’s linear and prescriptive format is viewed by many as convenient, yet inadequate representation of the in-the-moment- and decision-making nature of nursing practice. Based on their increasing experience with the efficacy of concept maps, concept mapping has been promoted by several nursing educators as an alternative to the nursing process (Castellino and Schuster, 2002; Daley et al., 1999; Ferrario, 2004; Fuszard, 1995; Hicks-Moore, 2005; Kathol et al., 1998; King and Shell, 2002; Mueller et al., 2001). According to Beissner (1992), students who used concept mapping to develop linkages between patient problems and interventions consistently achieved higher problem-solving scores than those who did not. Rooda (1994) revealed that mind mapping improved students’ performance in a nursing research course where the grades of students taught to use mind mapping
204 were compared to those of a control group who did not use mind mapping. Those with mind mapping skills had a significantly (a = .001) higher average over the course of three examinations during one semester. In her examination of how nursing students learn to link theory with practice, Daley (1996) interviewed faculty and students involved in a clinical course, creating concept maps with the data collected. These were compared with concepts maps identified in the course syllabus and in turn used to determine areas of student confidence and confusion about nursing theory and its application to practice. In another study, Daley et al. (1999) explored how concept mapping could be used to teach the relationships among client pathophysiology, pharmacology and nursing interventions. An objective scoring scheme with a reliability score of .82 was used to evaluate the first and final maps of randomly selected students. A significant improvement was observed between the two measurement scores. Because these skills were directly related to the APA’s (1990) definition of critical thinking, Daley et al. concluded that concept mapping helped develop critical thinking abilities. Wheeler and Collins (2003) also examined concept mapping as a means for developing critical thinking skills among BScN students in their introductory clinical courses. The experimental group (n = 44) was taught to use concept mapping as a way to plan patient care and the control group (n = 32) was taught to use a traditional nursing care plan. CCTST was used to measure critical thinking in both groups at the beginning and completion of a 7.5-week clinical experience. Although, Wheeler and Collins noted significant differences within groups, they found no significant differences between the groups. Nevertheless, the experimental-group scores improved significantly on the overall score as well as the analysis and evaluation subscales. The control-group scores improved significantly only on the evaluation subscale and declined significantly on the inference subscale. As a result, Wheeler and Collins suggested that concept mapping was the superior of the two. Considering these results, Wheeler and Collins raised several questions including the capability of the CCTST instrument to measure critical thinking. Would the CCTDI instrument have been more sensitive to measuring the impact concept on critical thinking? Was the length of exposure to concept mapping sufficient to produce the desired results? In order to address such questions, these authors recommended replication of the study and proposed a longitudinal design with a larger sample.
R.B. Gul, J.A. Boman
Limitations of concept mapping One important factor to consider is student comfort with the process of concept mapping (Luckowski, 2003). Daley et al. (1999) reported that some students felt ‘‘lost’’ (p. 450) while trying to demonstrate the relationship of content in a map. Reynolds (1994) observed a similar response in that choosing the right words or phrases was difficult for students at the beginning. Mueller et al. (2001) suggested that linear thinkers might have difficulty seeing the map as anything but chaotic. Because of the importance of critical thinking however, any approach that calls for linear thinkers to develop more complex ways of seeing and making decisions in nursing practice must not be dismissed because they challenge the learner. Other limitations include the amount of time required for learning how to develop concept mapping as a process skill (All et al., 2003; Beitz, 1998; Hicks-Moore, 2005). While computer graphics have been suggested as a more efficient way to depict concept maps (Beitz), for those who lack computer skills, this could take more time to learn as well (Luckowski). Hicks-Moore observed that the initial time commitment by faculty learning to use concept maps as a teaching tool and students as a way to show their learning in clinical care situations, diminished with practice and hence, becoming familiar with concept mapping as a process.
Conclusions and future implications In spite of the variations in how critical thinking is defined and characterized or questions about whether it can be intentionally taught and learned, there is much support for critical thinking as an important metacognitive skill for developing the knowledge necessary for effective nursing practice. Continued exploration of strategies to promote critical thinking is imperative. From the literature reviewed for this paper, concept mapping has been identified as a technique for developing and evaluating critical thinking abilities. As a means by which to transform and externalize critical thinking, the value of concept maps is readily apparent. As a way to demonstrate complex relationships among various concepts and their sub-concepts, concept maps are a practical way to take notes, review for exams, solve problems, make decisions, and develop and document plans of action. The utility of concept maps for learning and evaluating
Concept mapping: A strategy for teaching and evaluation in nursing education critical thinking processes in music, mathematics, and engineering is well established. In nursing education and nursing practice, most of the commentary about the value of concept mapping has been anecdotal in nature; research-based evidence is limited. Furthermore, most of the attention given to concept mapping is how it can be used as a means for teaching and learning how to think in more complex and critical ways rather than in a simplistic linear manner. Many questions arise form the literature reviewed for this paper. Does the success of concept mapping rest within the process of construction alone? How might various teacher and learner abilities, propensities and characteristics influence the processes and outcomes of concept mapping? While most commonly considered as a strategy for teaching and learning, how can concept mapping be more fully developed as a way to evaluate critical thinking as a learning outcome. The time is ripe to experiment with and examine concept mapping as a strategy to teach, learn and evaluate the development of critical thinking skills so essential to competent, safe and efficient nursing practice (All et al., 2003; Daley et al., 1999; Wheeler and Collins, 2003).
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Nurse Education in Practice www.elsevierhealth.com/journals/nepr
Concept mapping: A strategy for teaching and evaluation in nursing education Raisa B. Gul a b
a,*
, Jeanette A. Boman
b,1
Aga Khan University, School of Nursing, P.O. Box 3500, Stadium Road, Karachi 74800, Pakistan Athabasca University, Canada
Accepted 8 January 2006
KEYWORDS
Summary In the past decade an increasing emphasis has been placed on the importance of critical thinking in nursing. Nurse educators are faced with the challenge of finding ways to promote and evaluate critical thinking in nursing students, and various teaching strategies have been identified to achieve this goal. Concept maps are considered a powerful metacognitive tool that can facilitate the acquisition of knowledge through meaningful learning. Hence concept mapping can be used to promote and evaluate critical thinking. Based on the published nursing literature, the scope of concept mapping is discussed in this paper as a teaching and evaluation strategy for critical thinking in nursing education. c 2006 Elsevier Ltd. All rights reserved.
Critical thinking; Concept mapping; Teaching/learning; Evaluation
Introduction
The evolving health care practice arena requires nurses who are capable of providing safe, competent and efficient care within an increasingly complex array of patient care needs and interdisciplinary healthcare teams. More than ever before, nurses must be critical thinkers, problem-solvers and effective decision-makers capable of making constructive contributions to desired health care
* Corresponding author. Present address: 1-3867, 76 St. Edmonton, Alberta, Canada T6K-2P9. Tel.: +1 780 461 2402. E-mail addresses: [email protected], [email protected]. 1 Tel.: +1 780 434 3793.
outcomes. For these reasons, learning to think critically is now widely accepted as a basic goal in nursing education (Daly, 1998; Di Vito-Thomas, 2000; Facione and Facione, 1996; Maynard, 1996). Various strategies to promote critical thinking dispositions and skills have been tried in nursing education. The controversies around the definition and measurement of critical thinking have challenged how it can be taught and learned. One developing area in the literature regarding how this might be done involves the use of concept mapping (Daley et al., 1999; Hicks-Moore, 2005; Harpaz et al., 2004; Irvine, 1995; Novak and Gowin, 1984). In this paper we first review the meaning of critical thinking and various methods that been used to facilitate and measure it. As one promising
1471-5953/$ - see front matter c 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.nepr.2006.01.001
200 approach to facilitating critical thinking, we then review concept mapping in relation to what it is and how it works. Finally, we summarize the reports about concept mapping as a means to the critical thinking skills necessary for clinical learning in nursing practice. From this synthesis of the literature reviewed for this paper, we conclude that concept mapping is an important way to both teach and learn in clinical nursing education settings. At the end, we call for the need to now consider more deliberately the potential role of concept mapping as a strategy to evaluate critical thinking as a learning outcome in clinical nursing education.
Critical thinking What is critical thinking? Theories of critical thinking can be traced back to Socrates, Plato, and Aristotle (Adler, 1978). Almost 25 centuries ago when Socrates talked about rationality, he envisioned reasoning as a force for promoting moral good. His student, Plato, argued the goal of education should not be to provide information, but rather to enable students to question, examine, and reflect upon ideas and values presented to them. Then Aristotle, a student of Plato, posited that phenomena can be clarified through critical thinking, i.e., thinking both abstractly and logically (Adler, 1978; Daly, 1998). This connection between critical thinking and knowledge development was not recognized again until 1916 when John Dewey (cited in Daly, 1998) reintroduced the phenomenon of critical thinking as an educational outcome. To Dewey, critical thinking was a subset of the reflective process that involves ‘‘thorough assessment, scrutiny, and the drawing of conclusions in relation to the issue at hand’’ (Daly, 1998, p. 3).
What constitutes critical thinking? Much debate has occurred around how to adequately define critical thinking. To many, critical thinking is a broader, more complex process than the linear steps taken to solve a problem or make a decision. The American Philosophical Association (APA) conducted a Delphi research project in1990 involving 46 multidisciplinary experts who defined critical thinking as ‘‘a process of purposeful, selfregulatory judgment that uses interpretation, analysis, inference, evaluation, explanation and reflective reasoning to consider the evidence from all
R.B. Gul, J.A. Boman angles before deciding what to believe or do’’ (Wheeler and Collins, 2003, p. 340). While this definition has been widely accepted in the USA (Facione and Facione, 1996), the same conclusion has not been reached by those who see certain attitudes and dispositions like truth seeking, open-mindedness, inquisitiveness, analyticity, systematicity, confidence, flexibility, and perseverance as integral to critical thinking (Facione and Facione, 1996; Ignatavicius, 2001; Perciful and Nester, 1996; Staib, 2003). Within the nursing literature where intuition and creativity have been recognized as a dimension of critical thinking, several have suggested there are similarities between critical thinking and the nursing process (Daly, 1998; Perciful and Nester, 1996; Staib, 2003). Caring has also been recognized as an affective and necessary component of critical thinking (Tanner, 1997). With the ongoing examination of critical thinking processes within nursing practice, the definition of critical thinking will no doubt continue to evolve.
How is critical thinking facilitated? Facione and Facione (1996) argued that to be learned by others, critical thinking is an outcome that ultimately needs to be demonstrated, demanding constant metacognitive reflection on ‘‘what one is doing and why’’ (p. 133). As such, role modeling and mentoring have been identified as methods to teach critical thinking. Because critical thinking can challenge the status quo, it involves a risk however. A teaching and learning environment that fosters critical thinking must consequently be perceived as safe for the learner to genuinely engage in the process. One component of this safe environment is the teacher who not only talks about the importance of critical thinking in nursing practice but models it as well (Boman, 2004). Other strategies that engage students in an active learning process are also thought to foster critical thinking and related dispositions. For example, problem based learning, reflecting, concept mapping, debating, exploring case studies, and answering higher-level guiding questions all require the learner to participate in one way or another (Angel et al., 2000; Beeken et al., 1997; Chenoweth, 1998; Colucciello, 1999; Cravener, 1997; Di Vito-Thomas, 2000; Elliot, 1996; Ironside, 2003; Schell, 1998).
How can critical thinking be measured? Not surprisingly, the measurement of critical thinking in nursing education has been challenging
Concept mapping: A strategy for teaching and evaluation in nursing education (Adams, 1999; Angel et al., 2000; Daly, 1998; Maynard, 1996; Oermann, 1997; O’Sullivan et al., 1997; Perciful and Nester, 1996; Staib, 2003). Without a clearly accepted definition of critical thinking and agreement about the characteristics that constitute critical thinking, it is difficult to decide ‘what’ to measure. Other reasons include the continued educational emphasis on ‘covering content’ and the focus on psychomotor skill development as visible ‘proof’ of competence in nursing practice (Adams et al., 1999; Ferrario, 2004; King and Shell, 2002). As well, research-based practice in nursing education is still in a very early stage. An integrative review of nursing education research articles written between 1975 and 1995 revealed no consistent evidence that nursing education contributes to an increase in critical thinking among nursing students (Adams, 1999). Staib (2003) has also noted that most observations about critical thinking in nursing practice are anecdotal. Of the standardized tests that have been used to measure critical thinking of nursing students, the more well known are the Watson–Glaser critical thinking appraisal (WGCTA), the California critical thinking skills test (CCTST), and the California critical thinking disposition inventory (CCTDI). The limitations of each have been identified and debated in the literature. The WGCTA, one of the oldest and most widely used, has 80 items that focus on the logical and creative components of critical thinking. The CCTST, developed in the early 1990s, is general with no discipline-specific content. The 34 multiple-choice questions that compose it are designed to assess core critical thinking skills like the ability to evaluate, make inferences, and engage in deductive and inductive reasoning. The CCTDI, a fairly recent assessment tool is designed to measure critical thinking dispositions or habits of mind like open-mindedness, confidence, and inquisitiveness. The CCTDI and CCTST have been used in combination to measure critical thinking in general (Adams, 1999; Staib, 2003). None of these assessment tools have been accepted as adequate ways to measure critical thinking in nursing practice. Several nurse researchers have advocated for the development of tests that reflect the context and content of nursing (Angel et al., 2000; Daley et al., 1999; Maynard, 1996; Perciful and Nester, 1996; Stone et al., 2001). Perciful and Nester suggested that qualitative methods be more rigorously pursued to fully identify the components and process of critical thinking in nursing. With the constructs clearly established, a more logical development of standardized tests could then follow. Others have questioned the
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futility of such endeavors and gone on to suggest that the complex nature of critical thinking might be best analyzed with non-reductionistic methods. To Daley et al. (1999) concept mapping is one method that should be considered.
Concept mapping The development of concept maps originated from the work of Novak (1992) and his colleagues in the 1980s at Cornell University. Concept mapping has been widely used in science, mathematics, and educational psychology. Its utilization in nursing education is fairly recent (Irvine, 1995). In an introductory article outlining extensive evidence from other disciplines about the effectiveness of concept mapping in helping students learn, Irvine urged nurse educators to consider it as a teaching and learning strategy in nursing.
What are concept maps and concept mapping? Novak (1992) described a concept map as an organizational tool to represent knowledge as well as a metacognitive strategy to promote meaningful learning. These maps consisted of concepts and propositions with concept defined as a ‘‘perceived regularity in events or objects’’ and represented by words or symbols (Novak, 1992, p. 1) . Propositions, defined as ‘‘statements about an object or event, natural or constructed’’ (Novak, 1992, p. 1) became semantic units or units of meaning. Thus, where ‘disease’, ‘illness’, and ‘medication’ are construed as events and ‘person’, ‘hospital’, and ‘drugs’ as objects, a person suffering from a disease or admitted to a hospital is labeled as a ‘patient’ or ‘client’. When two or more concepts are connected with other words to form a meaningful statement, a proposition is created. For example, ‘A patient takes medications’ is a proposition where the concepts of ‘patient’ and ‘medication’ are connected. Concept mapping is a general method for describing ideas about a topic in a pictorial form. As a structured process, it is focused on a topic or construct of interest and involves input from one or more participants for an interpretable pictorial interrelated view of their ideas. As such, a concept map may be viewed as an alternative to natural language for communicating knowledge in a specific discipline. In many disciplines concept maps are commonly used to represent formal knowledge systems such as bond graphs in mechanical and
202 electrical engineering (Trochim, 2000). Depending on its intended use, concept mapping has also been referred to as cognitive mapping, mental mapping, concept webbing, concept trees, knowledge maps, clinical correlation maps, patterned note taking, and flow charting. All of these terms refer to the notion of presenting related ideas in a graphical manner (All and Havens, 1997; Fuszard, 1995; Horton et al., 1993; Irvine, 1995; Luckowski, 2003).
How are concept maps developed? Although concept maps may be designed in different ways, the hierarchal method is preferred by many for clarity and comprehension. The hierarchical organization presents more general and more inclusive concepts at the top of the map and more concrete and specific ones at the bottom. Such maps can be constructed by: (1) identifying a central word or theme (written in the center or at the top of a page and enclosed in a box or circle) about a subject of learning or area of concern around which the map is to be built; (2) identifying all of the concepts, items, descriptive words, or questions that may be associated with the main concept or subject at hand; (3) linking the sub-concepts to the main concept via the hierarchical or lateral nature of their relatedness with arrows, lines, symbols, simple phrases and signal words like lead, cause, have, need, are showing the linear flow or direction of the information in the map; and, (4) identifying the cross-links between the information in the map (For further illustrations, see All et al., 2003; Daley et al., 1999).
What is the theoretical underpinning of concept maps? The idea of concept mapping is based on Ausubel’s learning theory, which emphasizes the assimilation of new information into the students’ prior knowledge for subsequent meaningful learning. Ausubel et al. (1986) believed that the mind is organized in a top-down fashion and that students relate new information to previous knowledge contained in their cognitive structures. New concepts are sorted, related, and then added to the existing hierarchies to create meaning. Hence, learning takes place when a learner is able to organize, relate, and subsume concepts into his or her cognitive structures. In the process, the learner’s prior knowledge plays a crucial role. Ausubel et al. differentiated rote leaning, the memorization of material through repetition, from meaningful
R.B. Gul, J.A. Boman learning that occurs when new knowledge is connected to relevant concepts already known. Meaningful learning was purported to produce a series of changes within the entire cognitive structure with the modification of existing concepts and formation of new linkages between concepts. For these reasons, it was proposed that meaningful learning was lasting, powerful and hence superior to rote learning that was easily forgotten. Likening them to building blocks, Novak (1992) explained that ‘‘(c)oncepts are like the atoms of matter and propositions are like the molecules of matter so there is always opportunity to create new knowledge from the existing concepts through observation, analysis, synthesis and creativity’’ (p. 4). Novak argued that knowledge construction is nothing other than a relatively high level of meaningful learning. In other words, knowledge is a human creation; it is made (Beitz, 1998). The processes involved in developing concept maps in turn have been linked to creative thinking (Novak, 1992) as hierarchical structures and relevant crosslinkages are worked out and concepts are related to the ‘big picture’ rather than remaining as isolated, compartmentalized incidents (Kathol et al., 1998).
What are the advantages of concept mapping? The construction of a concept map is believed to enhance understanding about a given subject. Drawing from Ausubel et al.’s (1986) work, Daley et al. (1999) explained that concept learning occurs in three ways: subsumption, differentiation, and integrative reconciliation. Subsumption requires rearranging and reordering conceptual understanding and meaning by deductive or inductive thinking to develop a conceptual hierarchy and in turn, to learn and remember it. For instance, communication skills may be learned in one course as discrete interpersonal skills and then later be subsumed under managerial skills in a subsequent course. Where progressive differentiation involves learning how to analyze parts of a greater whole (e.g., learning that tenderness, redness in skin color and swelling are signs of inflammation), integrative reconciliation involves synthesizing (e.g., knowing that inflammation as a whole includes tenderness, redness in skin color, and swelling). In order to create a meaningful concept map, thinking is required to select key concepts, identify sub-concepts and related information or examples, identify links and cross-links, and choose link words or symbols. While concept mapping involves a logi-
Concept mapping: A strategy for teaching and evaluation in nursing education cal process, it does not necessarily lead to rigid structures as the same list of concepts can be viewed and interpreted in different ways. Their flexible nature allows for new points and cross-linkages from one idea to another without elaborative explanations otherwise required in a written narration. Indeed, Irvine (1995) asserted that concept mapping is an ‘‘integrated educational experience’’ and a means by which to enhance ‘‘meaningful learning’’ (p. 1179). Others have recognized it as a creative process that actively engages learners in cognitive, affective and psychomotor learning (Reilly and Oermann, 1992) and an outcome that reflects personal thinking and experience (Novak, 1992). While the advantages of concept maps to facilitate the development of critical thinking abilities, concept mapping has also been recognized for its value in assessing whether and how those abilities have been acquired (Beissner, 1992; Castellino and Schuster, 2002; Thayer-Bacon, 2000; Daley et al., 1999; West et al., 2000; Wheeler and Collins, 2003). As a way to ‘‘externalize’’ thinking processes (Facione and Facione, 1996, p. 132), concept maps make visible the otherwise unseen changes in how a learner thinks over time. This visibility of thinking process makes its easier for the faculty and student to recognize any development of knowledge that has occurred (Harpaz et al., 2004). Through the creation of a concept map, the ideas and words selected by a learner can be analyzed and rated according to given criteria related to a range of possible differences in simple to more complex thinking processes (Daley, 1996; Daley et al., 1999; Kathol et al., 1998; West et al., 2000; Wheeler and Collins, 2003). With concept maps, information can be presented in a condensed manner without the loss of complexity and meaning. The image of concepts, in a tangible form, can facilitate comprehension through a visual presentation that fosters an understanding of complex information ‘at-a-glance’ compared to the dense presentation of words and verbal compositions. Because of the ease in conceiving and storing a visual configuration of information for later retrieval (All et al., 2003; Irvine, 1995; Novak, 1992), the utility of concept maps has been recognized in continuing education and staff development, curriculum development, and analyzing qualitative data (Daley, 1996; Luckowski, 2003).
Concept mapping for clinical learning: Does it work? The value of concept mapping to facilitate clinical learning in nursing practice has been increasingly
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reported in the nursing education literature over the last decade (All and Havens, 1997; Baugh and Mellott, 1998; Beitz, 1998; Caelli, 1998; Cannon, 1998; Castellino and Schuster, 2002; Ferrario, 2004; Harpaz et al., 2004; Hicks-Moore, 2005; Kathol et al., 1998; Reynolds, 1994; Schuster, 2000, 2002; Wade, 1998). Many of these extol the same virtues of concept mapping that have been addressed in the non-nursing literature. For instance, Kathol et al. (1998) saw the value of concept maps as a way to quickly assess student knowledge in a given moment as well as its development over time. King and Shell (2002) observed how the creative, flexible nature of concept mapping accommodated all learners, what ever their stage of learning. Where beginning learners could be asked to develop simple maps with one major concept, such as vital signs, nurse–patient communication, or patient assessment, more advanced learners could be asked to develop increasingly complex maps with changes in the numbers, hierarchies, and interrelatedness of various concepts. All et al. (2003) discovered that giving learners the opportunity to refine their concept maps again after a first round of feedback resulted in significant improvements in student creativity. Most nursing educators who used concept mapping reported that students viewed it as a stimulating, interactive, and fun way to learn (Castellino and Schuster, 2002; Daley, 1996; Daley et al., 1999; Kathol et al., 1998; Wheeler and Collins, 2003). As well, they have been observed to reduce anxiety, increase motivation, and promote greater achievement, especially within the context of a group (Beitz, 1998). Where the nursing process has traditionally been used as a way to facilitate problem solving and critical thinking in nursing practice, it’s linear and prescriptive format is viewed by many as convenient, yet inadequate representation of the in-the-moment- and decision-making nature of nursing practice. Based on their increasing experience with the efficacy of concept maps, concept mapping has been promoted by several nursing educators as an alternative to the nursing process (Castellino and Schuster, 2002; Daley et al., 1999; Ferrario, 2004; Fuszard, 1995; Hicks-Moore, 2005; Kathol et al., 1998; King and Shell, 2002; Mueller et al., 2001). According to Beissner (1992), students who used concept mapping to develop linkages between patient problems and interventions consistently achieved higher problem-solving scores than those who did not. Rooda (1994) revealed that mind mapping improved students’ performance in a nursing research course where the grades of students taught to use mind mapping
204 were compared to those of a control group who did not use mind mapping. Those with mind mapping skills had a significantly (a = .001) higher average over the course of three examinations during one semester. In her examination of how nursing students learn to link theory with practice, Daley (1996) interviewed faculty and students involved in a clinical course, creating concept maps with the data collected. These were compared with concepts maps identified in the course syllabus and in turn used to determine areas of student confidence and confusion about nursing theory and its application to practice. In another study, Daley et al. (1999) explored how concept mapping could be used to teach the relationships among client pathophysiology, pharmacology and nursing interventions. An objective scoring scheme with a reliability score of .82 was used to evaluate the first and final maps of randomly selected students. A significant improvement was observed between the two measurement scores. Because these skills were directly related to the APA’s (1990) definition of critical thinking, Daley et al. concluded that concept mapping helped develop critical thinking abilities. Wheeler and Collins (2003) also examined concept mapping as a means for developing critical thinking skills among BScN students in their introductory clinical courses. The experimental group (n = 44) was taught to use concept mapping as a way to plan patient care and the control group (n = 32) was taught to use a traditional nursing care plan. CCTST was used to measure critical thinking in both groups at the beginning and completion of a 7.5-week clinical experience. Although, Wheeler and Collins noted significant differences within groups, they found no significant differences between the groups. Nevertheless, the experimental-group scores improved significantly on the overall score as well as the analysis and evaluation subscales. The control-group scores improved significantly only on the evaluation subscale and declined significantly on the inference subscale. As a result, Wheeler and Collins suggested that concept mapping was the superior of the two. Considering these results, Wheeler and Collins raised several questions including the capability of the CCTST instrument to measure critical thinking. Would the CCTDI instrument have been more sensitive to measuring the impact concept on critical thinking? Was the length of exposure to concept mapping sufficient to produce the desired results? In order to address such questions, these authors recommended replication of the study and proposed a longitudinal design with a larger sample.
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Limitations of concept mapping One important factor to consider is student comfort with the process of concept mapping (Luckowski, 2003). Daley et al. (1999) reported that some students felt ‘‘lost’’ (p. 450) while trying to demonstrate the relationship of content in a map. Reynolds (1994) observed a similar response in that choosing the right words or phrases was difficult for students at the beginning. Mueller et al. (2001) suggested that linear thinkers might have difficulty seeing the map as anything but chaotic. Because of the importance of critical thinking however, any approach that calls for linear thinkers to develop more complex ways of seeing and making decisions in nursing practice must not be dismissed because they challenge the learner. Other limitations include the amount of time required for learning how to develop concept mapping as a process skill (All et al., 2003; Beitz, 1998; Hicks-Moore, 2005). While computer graphics have been suggested as a more efficient way to depict concept maps (Beitz), for those who lack computer skills, this could take more time to learn as well (Luckowski). Hicks-Moore observed that the initial time commitment by faculty learning to use concept maps as a teaching tool and students as a way to show their learning in clinical care situations, diminished with practice and hence, becoming familiar with concept mapping as a process.
Conclusions and future implications In spite of the variations in how critical thinking is defined and characterized or questions about whether it can be intentionally taught and learned, there is much support for critical thinking as an important metacognitive skill for developing the knowledge necessary for effective nursing practice. Continued exploration of strategies to promote critical thinking is imperative. From the literature reviewed for this paper, concept mapping has been identified as a technique for developing and evaluating critical thinking abilities. As a means by which to transform and externalize critical thinking, the value of concept maps is readily apparent. As a way to demonstrate complex relationships among various concepts and their sub-concepts, concept maps are a practical way to take notes, review for exams, solve problems, make decisions, and develop and document plans of action. The utility of concept maps for learning and evaluating
Concept mapping: A strategy for teaching and evaluation in nursing education critical thinking processes in music, mathematics, and engineering is well established. In nursing education and nursing practice, most of the commentary about the value of concept mapping has been anecdotal in nature; research-based evidence is limited. Furthermore, most of the attention given to concept mapping is how it can be used as a means for teaching and learning how to think in more complex and critical ways rather than in a simplistic linear manner. Many questions arise form the literature reviewed for this paper. Does the success of concept mapping rest within the process of construction alone? How might various teacher and learner abilities, propensities and characteristics influence the processes and outcomes of concept mapping? While most commonly considered as a strategy for teaching and learning, how can concept mapping be more fully developed as a way to evaluate critical thinking as a learning outcome. The time is ripe to experiment with and examine concept mapping as a strategy to teach, learn and evaluate the development of critical thinking skills so essential to competent, safe and efficient nursing practice (All et al., 2003; Daley et al., 1999; Wheeler and Collins, 2003).
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