Critical thinking is emphasized from the first course in a nursing education program. Complex, higher-order thinking processes are necessary for a nurse to consider multiple factors while making decisions and planning interventions for patients (Alfaro-LeFevre, 2016). Acquisition of increasingly complex concepts during a nursing program is foundational to safe and effective patient care. This study explores the possibility that cognitive developmental factors may be related to the acquisition of critical thinking.

Piaget's cognitive developmental levels provide a theoretical model for this study. Image-based scientific studies of brain development indicate support for Piaget's theories (Crone & Ridderinkhof, 2011). Piaget's final stage of cognitive development, formal operations, involves abstract reasoning skills that relate to critical thinking traits (Inhelder & Piaget, 1958; Pascual-Leone & Johnson, 2011). Although few studies exist linking the presence of advanced cognitive development with critical thinking, the importance of cultivating and understanding the developmental nature of critical thinking has been studied extensively (Paul & Elder, 2012).

This study was guided by three research questions:

1. Is there a relationship between overall level of critical thinking and overall level of cognitive development in beginning nursing students after controlling for gender, age, prior schooling, and English-as-a-second-language (ESL) status?

2. Is there a relationship between individual critical thinking traits and specific cognitive operations after controlling for gender, age, prior schooling, and ESL status?

3. Is there a relationship between the level of cognitive development and the level of general knowledge after controlling for gender, age, prior schooling, and ESL status?

METHOD

This correlational study investigated the possibility that the developmental level of cognitive processing is related to the ability to perform critical thinking activities in beginning nursing students. In addition to the overall relationship between formal operational thinking and critical thinking, analyses of the theoretical subsets (scales) of formal thinking and the subsets (scales) of critical thinking were performed to discover possible relationships. A third analysis was conducted comparing the level of cognitive development to the level of achievement in general knowledge. This study was conducted through a series of multiple regression analyses, taking into consideration that the assumptions of linear regression were met (e.g., linearity, normality, homoscedasticity, independence, and model specification). Issues of influence and collinearity were also examined.

Sample

Two hundred ten first-semester students in a prelicensure associate degree nursing program were eligible for the study; the sample total was 190. Most students were women (83.3 percent); 16.4 percent had a prior bachelor's degree. English was the first language for 84.1 percent; 15.9 percent stated English was their second language. Students reported their race/ethnicity: white (n = 78), Filipino (n = 46), other Asian (n = 13), African American (n = 8), Hispanic (n = 18), Native American (n = 2), and nonresponder (n = 24). Based on G*Power estimates of multiple regression, with power set at .80 and probability set at .05, using three predictors, a medium effect size (.15) would be detectable using a sample size of 77.

Instruments

Three instruments were used to study participants in a classroom setting: 1) Assessment Technologies Institute (ATI) Critical Thinking Assessment: Entrance (CTA-Ent), 2) ATI Test of Essential Academic Skills 2.0 (TEAS), and 3) Lawson's Classroom Test of Scientific Reasoning (Lawson CTSR).

ATI has established reliability for the ATI CTA-Ent resulting in a global Cronbach's alpha, as well as the Guttman split-half coefficient of .69 for all 40 items for first-time examinees. Alpha and beta validations by a representative sample of schools of nursing were performed, and modifications of items were accomplished based on item analysis (ATI, 2006).

ATI established reliability for the ATI TEAS; the Cronbach's alpha coefficient for the entire TEAS for web is .913 (4.89). Test-retest estimates of score reliability for the individual subtest scores ranged from .667 in Science to .882 in Reading and Math. The TEAS technical manual provides a detailed account of the content domains and describes an extensive process by which items were developed (ATI, 2003).

Lawson CTSR face validity was established by a panel of six expert judges who were in 100 percent agreement that the items on this instrument required concrete or formal reasoning according to Piaget's constructs. For convergent validity, the Pearson product-moment correlation between the in-class total test score and the summed level of responses on two clinical interview tasks that purported to measure the same construct was .76 (statistically significant at <.001). Factorial validity was sought by using a principal components analysis that resulted in three principal factors (concrete, early formal, and formal reasoning), accounting for 66 percent of total variance. Reliability estimates resulted in good internal consistency with Cronbach's alpha coefficient at .86 (Lawson, 2000).

Procedures

The study was approved by the institutions as well as an institutional review board. Participants were given study information in both oral and written form. Permission to use scores for the ATI CTA-Ent and ATI TEAS was also obtained. Rights and privacy of the subjects were protected during sampling, data collection, and data analysis. Results of the Lawson CTSR administered to nursing students by the researcher were added to the study data.

The predictor variables were the Lawson CTSR and subscales (Conservation, Proportion, Identification and Control of Variables, Probability, Correlation, and Hypothetico-deductive); criterion variables were the ATI CTA-Ent and subscales (Interpretation, Analysis, Explanation, Inference, Evaluation, and Self-Regulation) and ATI TEAS and subscales (Total, Read, Math, Science, English). A sequential/hierarchical approach to multiple regression was used for all questions.

RESULTS

Overall Lawson CTSR results indicated that 31 percent of beginning nursing students were still fully in the concrete stage, 50 percent were in the transitional stage, and 19 percent were fully formal operational in their thinking. Question 1 results revealed that critical thinking is predicted by the level of cognitive development as measured by the Lawson CTSR total score. Covariates of gender, age, prior schooling, and ESL status did not add any explanation to this model.

Question 2 was tested to determine which of the cognitive development subscales in the Lawson CTSR total score uniquely predicts variance in critical thinking subscale scores as measured by the ATI CTA-Ent total score above and beyond what can be predicted by the set of control variables (gender, age, prior schooling, and ESL status) and the remaining cognitive development subscales in beginning nursing students. This is somewhat supported in that some subscales of cognitive development predicted some subscales of critical thinking.

Question 3 results showed that, as cognitive development increases, general knowledge is increased even after controlling for gender, age, prior schooling, and English language status. It was also demonstrated that (unlike research questions 1 and 2) an individual's age, gender, prior schooling, and ESL status were significant in predicting levels of general knowledge as measured by the ATI TEAS assessment, with prior schooling being the most significant in that it predicted the total score as well as three of the four subscales.

DISCUSSION AND IMPLICATIONS

The results of this study indicate a relationship between the presence of formal operational reasoning and critical thinking. Acknowledgment that possibly two thirds of the beginning nursing students who enter prelicensure degree nursing programs are thinking at a concrete level implies that they have not brought the necessary skills to consistently practice critical thinking. This indicates a need for nurse educators to construct early nursing courses to connect prior knowledge to new, forming a scaffold for the acquisition of critical thinking.

CONCLUSION AND RECOMMENDATIONS

Study results are applicable to the population studied: undergraduate, prelicensure nursing students. Additional studies, including longitudinal research, are recommended to confirm these results. If a certain level of cognitive development is necessary to the acquisition of critical thinking, then exploration of nursing education methodologies is warranted. The results of this study indicate a need for instructional activities that bridge the place where many students are (concrete) to where they need to be (abstract) to maximize critical thinking.

Giddens, Caputi, and Rodgers (2015) confirm that thinking skills are best developed when knowledge is constructed through exploration of concepts that help manage the plethora of information available to students. With curricula moving away from heavy content loads and toward a conceptual basis, the mental capacity to employ the inductive and deductive reasoning necessary to disassemble or assemble content is needed more than ever.

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