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Critical Thinking Disposition as a Measure of Competent Clinical Judgment: The

Development of the California Critical Thinking Disposition Inventory

Article  in  Journal of Nursing Education · November 1994

DOI: 10.3928/0148-4834-19941001-05 · Source: PubMed

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 The Disposition Toward Critical Thinking as a Measure of Competent
Clinical Judgment:
The Development of the
California Critical Thinking Disposition Inventory1

Noreen C. Facione
University of California, San Francisco

Peter A. Facione
Santa Clara University

Carol A. Giancarlo
University of California, Riverside

Abstract

Assessing critical thinking skills and the disposition to use them is crucial in nursing
education and research. The CCTDI uses the Delphi Report's consensus definition of
Critical thinking as the theoretical basis to measure the disposition toward critical thinking.
Item analysis and factor analysis techniques were used to create seven attribute scales that
grouped the Delphi descriptive phrases into larger, more unified constructs: Open-
mindedness, Analyticity, Cognitive Maturity, Truth-seeking, Systematicity, Inquisitiveness,
and Self-Confidence. The initial reliability coefficients (Cronbach's alpha .90 overall and .71 -
.80 for the seven internal scales) remained relatively stable when the 75-item instrument was
administered to 1,019 additional college students (.90 overall, .60 -.78 scales). The alpha
levels in the second sample. The instrument has subsequently been used to assess the
disposition toward critical thinking in junior high school through the doctoral level.
Psychometric research using the CCTDI and related instruments offers the potential of
testing a number of interesting hypotheses regarding the attributes of mind which might
contribute to improved clinical judgment and critical thinking in nursing.

1
This paper appeared as Facione NC, Facione, PA, & Sánchez, (Giancarlo) C A, (1994). Critical thinking
disposition as a measure of competent clinical judgment: The development of the California Critical
thinking Disposition Inventory. Journal of Nursing Education. Volume 33 Number (8). Pages 345-350.
 Critical Thinking Defined for Nursing
With the publication of the Delphi Research project on critical thinking (APA, 1990), there now
exists a cross-disciplinary conceptual definition of critical thinking that proves quite useful to nursing
research and education. This consensus definition of critical thinking (CT) allows nursing to move
beyond narrow, linear models of CT currently operative in many nursing education settings according to
the survey of nursing school administrators conducted by Jones & Brown (1991). The use of the
Delphi Report's broader, richer, definition of CT has the potential to advance our understanding and
assessment of the cognitively complex clinical judgment process inherent in nursing practice.

The following Delphi description of the attributes of mind of an ideal critical thinker:

"The ideal critical thinker is habitually inquisitive, well-informed, trustful

of reason, open-minded, flexible, fair-minded in evaluation, honest in
facing personal biases, prudent in making judgments, willing to
reconsider, clear about issues, orderly in complex matters, diligent in
seeking relevant information, reasonable in the selection of criteria,
focused in inquiry, and persistent in seeking results which are as precise
as the subject and the circumstances of inquiry permit." (APA, 1990, p.
3)

This expert consensus with regard to the dispositional dimension of critical thinking was
announced in 1990, after two years of work by a panel of 46 theoreticians drawn from throughout the
United States and Canada and representing several academic fields. The expert consensus cited above
captures what some have called "The Critical Spirit" -- a style, a set of attitudes which define a personal
disposition to prize and to use critical thinking in one's personal, professional, and civic affairs (Dewey,
1933; Kurfiss, 1988; Paul, 1990; Siegel, 1988; Oxman-Michelli, 1992). Upon close scrutiny, the
above description of the ideal critical thinker encompasses valuable attributes of mind a nurse might
reasonably be expected to display while exercising expert clinical judgment.

The Delphi participants identified the core CT cognitive skills to be: interpretation, analysis,
inference, evaluation, and explanation. The experts characterized critical thinking, per se, as the process
of purposeful, self-regulatory judgment; an interactive, reflective, reasoning process. This definition of
CT is similar to that used by nurse researcher Joan Thiele in her descriptions of teaching clinical
decision-making (1993). In critical thinking a person gives reasoned consideration to evidence, context,
theories, methods and criteria in order to form a purposeful judgment, and at the same time monitors,
corrects, and improves the process through meta-cognitive self-regulation.

This non-linear process permits a person to apply critical thinking cognitive skills to each other
as well as to the problem at hand. Hence, when adept at CT one finds oneself able to evaluate one's
own inferences, analyze one's own justifications, or interpret one's own analyses. The meta-cognitive
aspect of CT permits self-correction and reasoned adjustments not just in the process of inference itself,
but in the selection of criteria, the choice of methods, the interpretation of evidence, and the application
of models or theoretical categories. It would be hard to argue that these abilities, and the disposition to
engage in them, would not be assets for the practicing professional who aspires to genuine expertise in
Competent Clinical Judgment and the CCTDI, 1994 Journal of Nursing Education. Volume 33 , Page 2
nursing, education, management, law enforcement, or almost any other field.

The 1990 Delphi conceptualization of CT grounds the 1993 national survey of educators,
theoreticians, policy-makers and employers conducted under the auspices of the US Department of
Education through The National Center for Postsecondary Teaching, Learning and Assessment (Jones,
1993). The survey results extend our collective understanding of CT, advancing us beyond the
potentially idiosyncratic perspectives of individual theoreticians or the potentially narrower foci of
specific disciplines. The more cross-disciplinary consensus with regard to the theoretical construct, the
greater the hope that measurement tools, research findings, and pedagogical strategies developed in one
discipline or professional field might prove valuable to scholars and teachers in another.

Educating good critical thinkers is more than developing CT skills. A complete approach to
developing good critical thinkers includes nurturing the disposition toward CT, an effort many see as
integral to insuring the use of CT skills outside the narrow limits of a given instructional setting (Scheffler,
1965; Meyers, 1986; Mayfield, 1987; APA, 1990; Chaffee, 1992; Wade and Tavris, 1993).
Motivational theory (Lewin, 1935) provides the theoretical grounds for the assumption that the
disposition to value and utilize critical thinking would impel an individual to achieve mastery over CT
skills, being motivated to close the gap between what is valued and what is attained. In a sense, critical
thinking comes about as a result of the joining of a particular set of abilities, sensitivities, and inclinations,
(Perkins, Jay, & Tishman, 1993).

Conceptual Descriptions of the Seven CCTDI Scales

and their Application to Nursing and Nursing Education

Measurement of the relationship between the disposition to value and utilize CT and the
attainment of CT skills has been constrained by a lack of measurement instruments designed to measure
the disposition toward CT. The California Critical Thinking Disposition Inventory (CCTDI) (Facione &
Facione, 1992) is the first instrument designed to measure seven CT dispositional aspects whose initial
delineation stems from the Delphi Report. Building on the relatively rare occurrence in social behavioral
research, cross-disciplinary consensus on an attitudinal construct, development of the CCTDI began
with this theoretical clarity and proceeded to derive a measure of the construct through iterative
empirical methods. Seven CT attribute-of-mind scales were created: Inquisitiveness, Systematicity,
Analyticity, Truth-seeking, Open-mindedness, CT Self-confidence, and Maturity. The seven
CCTDI attribute-of-mind scales are discipline neutral, yet each can be readily interpreted within a
variety of professional disciplines. Just as earlier we saw the conceptual parallel between the Delphi
description of the ideal critical thinker and the nurse with ideal clinical judgment, so here we can readily
perceive the conceptual linkages between the descriptions of each of the seven scales and attributes of
mind we value in practicing clinicians and would seek to instill in nursing students. A note of caution is in
order, however. Like any other educational test or psychometric instrument, the CCTDI is not intended
as a device that produces absolute conclusions about individuals. Rather, the CCTDI is one measure of
mental attributes which, in the context of other measures, qualitative and quantitative, provide data of
potential use in sensitively and sensibly deepening of our understandings groups or individuals.

Competent Clinical Judgment and the CCTDI, 1994 Journal of Nursing Education. Volume 33 , Page 3
 The Inquisitiveness scale on the CCTDI measures one's intellectual curiosity and one's
desire for learning even when the application of the knowledge is not readily apparent. An
inquisitive person might be apt to agree with prompts like "No matter what the topic, I am eager to
know more about it," and "Learn everything you can, you never know when it could come in handy."
Considering that the knowledge base for competent nursing practice continues to expand, a deficit in
inquisitiveness might signal an attitudinal limitation of one's potential to develop one's knowledge for
advanced clinical practice. Broad curiosity about advances in nursing might become a motivation for
one's continuing nursing education.

The Systematicity scale measures being organized, orderly, focused, and diligent in
inquiry. No particular kind of organization, e.g. linear or non-linear, is given priority on the CCTDI.
The systematic person might be apt to agree with "I always focus the question before I attempt to
answer it," but disagree with "My trouble is that I'm easily distracted." Few would argue that being
organized is not an important element in competent clinical practice. Contrasting nursing characterized
by good organization, focus, and diligence with nursing that lacks these attributes illustrates how these
deficits appear to put a nurse at risk for negligence in practice.

The Analyticity scale targets prizing the application of reasoning and the use of evidence
to resolve problems, anticipating potential conceptual or practical difficulties, and consistently
being alert to the need to intervene. A person inclined toward being analytical would be apt to agree
with "It bothers me when people rely on weak arguments to defend good ideas," and with "You could
describe me as logical," but the person might disagree with "There is no way to know whether one
solution is better than another." Analyticity is a core mental attribute for the nurse as researcher, to be
sure. We can hypothesize that the nurse clinician who is disposed to think analytically could be
expected to anticipate difficulties, such as events likely to threaten the safety or limit health potential of a
given individual, and to seek to intervene. This clinician might be more likely to seek out the connections
between clinical observations with her/his theoretical knowledge base.

The Truth-seeking scale targets the attribute of being eager to seek the best knowledge in a
given context, courageous about asking questions, and honest and objective about pursuing
inquiry even if the findings do not support one's self-interests or one's preconceived opinions.
We might expect the truth-seeking nurse to be more likely to reevaluate new information and evidence.
In contrast, weakness in truth-seeking might have the debilitating affect of leading one to discount
important considerations or dismiss counter-evidence. A person weak in truth-seeking might be heard
agreeing with "I believe what I want to believe." For nursing as a profession, strength in truth-seeking
can be hypothesized to support the development of nursing practice based on tested theory, rather than
rote habit. On the personal level, a deficit in truth-seeking may put individual patients at risk due to the
nurse's discounting of the evidence of missed diagnosis or changing status.

The Open-mindedness scale addresses being tolerant of divergent views with sensitivity
to the possibility of one's own bias. Open-mindedness is central to the goal of culturally competent
care advanced by the American Academy of Nursing (American Academy of Nursing, 1992).
Conversely, dispositional intolerance of divergent views might preclude effective nursing interventions in
such varied patient populations as those with substance abuse problems, those in the criminal justice
Competent Clinical Judgment and the CCTDI, 1994 Journal of Nursing Education. Volume 33 , Page 4
system, and those enmeshed in urban violence, or those with moral or religious views divergent from
one's own.

The CT Self-Confidence scale seeks to measure the trust one places in one's own reasoning
processes. CT self-confidence allows one to trust the soundness of one's judgments and to lead
others in the resolution of problems. An appropriate level of CT self-confidence, increasing in
relation to mastered CT skills, would be the desired developmental trajectory in the nursing student and
the nurse clinician. Whether an individual's level of CT self-confidence is warranted is another matter,
however. Some under-estimate their ability to think critically, while others over-rate their CT ability. It
would not be unreasonable to speculate that nurses who over-rate their CT abilities might act with
inadequate caution, while those whose CT self-confidence is lower than their actual CT skills level might
be less inclined toward leadership in the intimate patient-nurse dyad and in larger group settings.

The Maturity scale targets the attribute of being judicious in one's decision-making. The CT-
mature person can be characterized as one who approaches problems, inquiry, and decision making
with a sense that some problems are necessarily ill-structured, some situations admit of more
than one plausible option, and many times judgments must be made based on standards,
contexts and evidence which preclude certainty. A person who is weak here might agree with "The
best way to solve problems is to ask someone else for the answers," or with the statement "Things are
as they appear to be." Strength in cognitive maturity would appear to facilitate authentic and sound
ethical decision-making, particularly in complex situations and time-pressured environments. Cognitive
maturity in CT would appear to be critical to the development of expertise as a clinician, or as a nursing
administrator, researcher, educator or policy-maker.

In describing each scale of the CCTDI, potential conceptual connections to professional nursing
practice were suggested. Whether these connections obtain in actual clinical settings is a matter for
further research and empirical testing. At this point in the development of critical thinking theory, we can
only conjecture that, everything else being equal, those who possess the overall disposition toward
critical thinking will become the more thoughtful and effective practitioners. To advance nursing science
and practice this conjecture, as well many other interesting hypotheses, assumptions, and truisms about
which attributes of mind most contribute to effective clinical judgment in nursing practice will be
subjected to closer scrutiny and psychometric testing.

Development and Description of the CCTDI

In developing the CCTDI, multiple pilot item prompts were written for each phrase of the
consensus description of the ideal critical thinker. The resulting 250 prompts were screened by college
level CT educators to identify possible ambiguities of interpretation. A selection of 150 pilot prompts
were retained in a preliminary version of the instrument. The pilot version was administered to a
representative sample of 164 students during the spring semester of 1992 at three different
comprehensive universities, one in Canada, one in California, and one in the Midwestern United States.

Competent Clinical Judgment and the CCTDI, 1994 Journal of Nursing Education. Volume 33 , Page 5
 Seventy-five items, (sixteen of which are cited above and below as examples), were chosen for
retention in the final form of the instrument based on both their internal consistency and their ability to
discriminate between respondents. The seven scales of the CCTDI are composed of nine to twelve
items, and are interspersed throughout the instrument. The 75 CCTDI statement prompts express
familiar opinions, beliefs, values, expectations and perceptions. Phrased in standard English, they use no
technical vocabulary or CT jargon. No college level content knowledge is presumed. Persons are
invited to express the extent to which they agree or disagree with each of total of 75 item statements.
Responses are recorded using a six-point Likert scale ranging from "strongly agree" to "strongly
disagree." Thus, respondents agree or disagree (there being no neutral option) with each item prompt.
For each item, to agree (or disagree) is consonant with (or in opposition to) a recognized CT mental
attribute.

Face validity may or may not be a desirable characteristic in a self-report attitudinal inventory.
On the one hand, an attitudinal instrument with low face validity appears not to be addressing the
intended target. On the other, an attitudinal instrument with high face validity may trigger in some
respondents the tendency to answer with the socially expected response rather than an accurate self-
report. In terms of face validity, those college instructors who have taken the CCTDI are quick to
volunteer that the item prompts strike them as appropriate to the targeted disposition. It is hard, for
example, to describe a person as a serious truth-seeker if the person agrees with statements like these:
"I look for facts that support my views, not facts that disagree," "Many questions are just too frightening
to ask," and "I know what I think, so why should I pretend to ponder my choices." Those who score
low on the open-mindedness scale typically agree with the statements: "Others are entitled to their
opinions, but I don't need to hear them" and "You are not entitled to your opinion if you are obviously
mistaken."

To mitigate against eliciting socially desirable responses, the scale items are interspersed and the
names of the seven scales are not revealed on the test instrument, nor is the name of the instrument itself
or its connection to critical thinking. The name of the instrument is given only by its initials, "CCTDI".
Items on the final version of the CCTDI discriminate well between respondents, attracting endorsements
from those individuals who oppose the value of various aspects of the disposition toward CT.

The CCTDI is not intended to be a measure of the person's CT ability or skill. A person may
value being objective, but not be able to achieve objectivity. A person may be disposed toward
approaching problems analytically and systematically, but not be adept at the CT skills required to do
so. The exact relationship or interaction between specific clusters of CT dispositional attributes and
specific CT cognitive skills has yet to be elucidated. Preliminary theoretical explorations suggest that the
relationship is complex and developmental in nature, and that gender or cultural ideology may be an
important influence, (Facione, Facione, & Sanchez, 1994).

Measuring the Disposition toward CT: Validity and Reliability Issues

Theory and research on the dispositional dimension of CT is relatively underdeveloped as

compared to investigations of CT skills (Facione, 1992; Perkins, Jay, & Tishman, 1993) For the most
Competent Clinical Judgment and the CCTDI, 1994 Journal of Nursing Education. Volume 33 , Page 6
part theoreticians regard CT as being a set of cognitive skills as distinct from the disposition to use those
skills, (APA, 1990). Although the consensus is that to educate one in CT requires the development of
both the skills and the dispositional dimension, we are only beginning to explore the extremely complex
theoretical and empirical relationships between specific skill and dispositional elements.

Literature reviews have yielded no instruments, with the exception of the CCTDI, which purport
to measure validly and reliably the dispositional dimension of CT. The remaining commercially available
CT instruments measure CT skills, such as one's ability to draw correct inferences, properly analyze
statements, and accurately evaluate reasons. In general these instruments pre-date the Delphi Research
Project (Watson & Glaser, 1980; Ennis, Millman, & Tomko, 1985; Ennis & Weir, 1985) and thus use
less robust theoretical definitions of the CT construct. One instrument, the California Critical Thinking
Skills Test (CCTST) (Facione, 1990;1992) is based on the Delphi construct. It is increasingly being
used to assess CT skills in student samples (Carter-Wells, 1992; Love, 1993) and research reports on
its utility in nursing samples are becoming available (Ouzts, 1992). Because the CCTDI appears to be
the first objective means to measure the dispositional dimension of CT, convergent validity studies
between various CT disposition measures is not yet possible. However, significant correlations
supporting the concurrent validity between individual CCTDI scales and established psychological
scales targeting close constructs have been observed (Sanchez, 1993).

One of the factors of the Big-Five model of human personality (Costa & McCrae, 1985,
1992), openness to experience, is defined as "a broad dimension of personality manifested in a rich
fantasy life, aesthetic sensitivity, awareness of inner feelings, need for variety in actions, intellectual
curiosity, and liberal value systems" (McCrae & Costa, 1987, p.145). Relationships was hypothesized
to exist between the disposition toward CT and openness to experience. In a sample of 200
undergraduate students, five of the seven scales of the CCTDI were significantly related to the
openness to experience construct: Truth-Seeking (r=.27, p<.001), Open-mindedness (r=.33, p<.001),
CT Self-Confidence (r=.25, p<.004), Inquisitiveness (r=.37, p<.001), and Cognitive Maturity (r=.30,
p<.001) (Sanchez, 1993).

The disposition toward critical thinking was also examined in relation to ego-resiliency, a
person's ability to alter their modal perceptual and behavioral functioning to adapt to situational
constraints (Block & Block, 1980). The ego-resilient person is believed to be not only flexible
interpersonally, but cognitively as well, with several problem-solving strategies available to them when
faced with difficult tasks. Sanchez (1993) found that all seven of the CCTDI scales were positively
correlated with Block's measure of ego-resiliency. The highest correlates were with systematicity
(r=.47, N=200, p<.001), truth-seeking (r=.41, N=200, p<.001) and inquisitiveness, (r=.39, N=200,
p<.001) indicating that ego-resiliency was most highly associated with the focused diligence, objectivity,
and intellectual curiosity of the CT cognitive style.

Competent Clinical Judgment and the CCTDI, 1994 Journal of Nursing Education. Volume 33 , Page 7
 Significant relationships have been noted between the overall disposition toward CT and
absorption, the personality disposition or inclination to be engaged in absorbing and self-altering
experiences (Tellegen & Atkinson, 1974; Tellegen, 1981, 1982). Sanchez observed the CCTDI scale
scores to be significantly correlated (N = 200 undergraduates, Pearson's r .31, p <.001) with an
external absorption factor, namely, cognitive engagement with one's surroundings but not significantly
related to an internal absorption factor, namely, self-generated experiences resembling altered states of
consciousness (Sanchez, 1993). Placing the CCTDI disposition scales in relation to known
psychological measures adds support for
their convergent and divergent validity.
Table 1 Additional research studies continue to
study the CCTDI and to locate the
Factor loadings for CCTDI scale items disposition toward CT within the existing
knowledge base regarding cognitive
Scale Mean Loading Range decision-making and meta-cognition.
Truth-seeking .421 .179-.587
Open-mindedness .407 .190-.693 In scale construction, factor
Analyticity .387 .029-.583 analytic methods are used to determine
Systematicity .458 .341-.611 (a) the internal statistical structure of the
set of variables said to measure a
CT Self-confidence .528 .369-.660 construct and (b) the statistical cross
Inquisitiveness .500 .330-.646 structures between the different
Maturity .470 .219-.667 measures of one construct and those of
other related constructs (Nunnally,
1978). For the CCTDI, factor analytic
approaches were used directly to do (a) as well as indirectly to do (b).

Factor analysis of responses to the pilot CCTDI supported the existence of several common
(but not necessarily discrete) factors in the disposition toward critical thinking. A review of the content
of the items which loaded under each factor permitted an examination of these groupings in relation to
the dispositional phrases that guided their construction. The Delphi description of the ideal critical
thinker was thus reduced from nineteen descriptive phrases to seven dispositional characteristics or
attributes of mind. This more parsimonious array was framed by both the empirical (statistical)
relationships pertaining between these factors and the conceptual relationships pertaining within the
descriptive phrases. In an important respect the CCTDI refines and extends the conceptualization of CT
expressed in The Delphi Report.

Competent Clinical Judgment and the CCTDI, 1994 Journal of Nursing Education. Volume 33 , Page 8
 Table 2

Internal Consistency Reliability

Scale Name Cronbach's Alpha Homogeneity Ratio Item to Total Correlation

Truth-seeking .71 .170 .167-.467
Open-mindedness .73 .191 .205-.573
Analyticity .72 .197 .272-.510
Systematicity .74 .211 .269-.568
CT-Confidence .78 .284 .393-.569
Inquisitiveness .80 .297 .317-.627
Maturity .75 .233 .175-.597

Since the CCTDI is an instrument based on a conceptual definition rather than one which
presents a cleanly faceted model achieved primarily through empirical methods, it is not surprising that
several of the CCTDI items load on more than one factor. The mean and range of each scale's factor
loadings are presented in Table 1 below. Two items with high face validity loaded poorly on their
respective scales. Because they were conceptually consistent and contributed to the overall internal
reliability of the scale they were retained. Table 2 lists validation sample Cronbach's alpha internal
consistency reliability coefficients, homogeneity ratios, and the range of the item to total correlations
within each scale.

To determine if the initial alpha reliability of .90 would hold, to check the stability of the scales,
and to field test the printed presentation of the statement prompts and the design of the answer sheet, a
pre-publication version of the CCTDI was pilot tested on an independent sample of 156
undergraduates, high school students, and post-baccalaureates during the summer of 1992. Alpha
reliabilities for the seven individual scales in the initial CCTDI pilot sample ranged from .71 to .80. The
alpha reliability for the overall instrument, measuring the overall disposition toward CT, was .91. Later
in 1992 and early in 1993 the publication version of the CCTDI was administered to two additional
samples totaling 1019 freshmen college students. The alpha levels in the later samples remained
relatively stable (ranging from .60 to .78 on the scales and .90 overall), thus empirically supporting the
internal reliability of the instrument and each scale (Facione, Facione, & Sanchez, 1994).

Potential Educational Uses of CCTDI Profiles

CCTDI scores can be displayed in a profile grid such as the ones in Figures 1-3. Figure 1
displays the scale scores of an individual student whom we shall name "Jeff." One must be cautious not
to over-interpret the CCTDI profile of an individual. Before drawing firm conclusions about an
individual one should seek data developed over time using multiple measures and modalities. Student
advising is effective when it is tailored to the individual's needs and abilities. The examples below, actual
Competent Clinical Judgment and the CCTDI, 1994 Journal of Nursing Education. Volume 33 , Page 9
nursing student profiles from the validation sample, are intended as illustrations of how advisors might
factor CCTDI data into a fuller and richer advising conversation.

Looking at his CCTDI profile, it would appear that Jeff is inclined toward open-mindedness
about divergent views and intellectual curiosity. Jeff would appear to endorse, in a minimal way,
approaching problems systematically. Jeff's profile suggests a considerable lack of self-confidence
when it comes to critical thinking. Why might this be? Has Jeff recently suffered some major academic
problem, or is his reasoning self-confidence linked in some way to his overall self-esteem? Jeff's low
CCTDI score on the Maturity scale may indicate difficulty in deciding between competing points of view
and an inability to determine when it is necessary to come to closure on an issue. Jeff's academic
advisor might use this CCTDI profile, along with other data about Jeff, as a starting place for a
discussion with Jeff about his approach to his studies. The advisor might build Jeff's self-esteem by
noting his inquisitiveness and open-mindedness. The advisor might suggest to Jeff that greater
systematicity might be an asset, particularly in finding successful ways of approaching ill-structured
problems.

Figure two is the profile of a student we shall name "Teresa." Her CCTDI profile suggests she
is very confident of her critical thinking ability and looks for opportunities to debate an issue. But
Teresa shows apparent deficiencies in five of the seven CCTDI attribute scales. She might have
endorsed the CCTDI items "College is generally a waste of time" and "I look for facts that support my
views, not facts that disagree." Scoring low on the Truth-seeking and Systematicity scales, we might
predict that she would be unlikely to reconsider decisions in light of new evidence or to approach
problems with some systematic plan for arriving at a clinical judgment. Teresa offers challenges to the
academic advisor who will need to bring hard data about her actual clinical and academic performance
into the discussion.

Using Jeff's CCTDI profile, Jeff's clinical professors might better select clinical opportunities to
build on his strengths, and guide and support him in achieving a more accurate appraisal of his CT
ability. Teresa's CCTDI profile provides an indication of what might turn out to be serious impediments
to her being a successful learner. It might be useful to separate these from the faculty's possible affective
response to her behavioral style. Teresa's advisor might consider having a straight forward discussion
with her about her weaknesses in relation to critical thinking and how these might unnecessarily limit her
full potential for development in the clinical setting.

Since its introduction in 1992, the most common use of the CCTDI has been to provide a
profile of the disposition toward CT of a group of students for purposes such as student assessment
and program evaluation. Figure 3 displays the means and ranges of CCTDI scale scores for a group of
students. This data is from one of the later validation samples, an entering freshmen cohort at a private
comprehensive university (N = 587). This student group had a mean SAT Verbal score of 511, SAT
Math of 584 and an average high school grade point average of 3.47. Faculty at this university used this
data to discuss implications for possible curriculum and pedagogy change in the critical thinking
component of the English composition course. Instructional methods which produce active learning
offer promise for nurturing CT in students (Ewell, 1993). Faculty at this university and at others
consistently confirm that the CCTDI offers a picture of the students' disposition toward CT which
Competent Clinical Judgment and the CCTDI, 1994 Journal of Nursing Education. Volume 33 , Page 10
resonates extremely well with the faculty's professional judgment of freshmen students based on actual
classroom experience.

Among the questions raised by the faculty at university where this freshman sample was taken
was the extent to which the grading criteria might be used to support different dispositional aspects of
CT. A subsequent institutional analysis of composition grades at that university revealed that the faculty
grading correlated best with the CCTDI scale score on Analyticity. While pleased to learn this about
themselves, faculty were concerned about the apparent weakness of their students on Truth-Seeking.
They determined to put greater emphasis on the search for best knowledge within a context in future
semesters, and by focusing more attention on how data and reasons are presented, used, and evaluated
in class and on student essays.

Conclusion

Nursing education is not merely a fact-loading process. It is the acquisition of the ability to
identify health and illness problems; it is the learning of skills and strategies needed to make rigorous and
honest inquiry into the unique circumstances of such problems; it is the mastering of sound methods to
select the optimal choice among potential interventions to solve such problems; and it is the ability to
evaluate the effectiveness of interventions to achieve intended outcomes. Knowing must be examined
within a process framework that demands theoretical connections between believed facts and practice
observations (Meleis, 1988; Tanner, 1987).

The 1990 Delphi Report provides a robust definition of the construct of critical thinking,
encompassing both cognitive skills and personality dispositions. Defined as purposeful, self-regulatory
judgement, critical thinking is a construct which greatly overlaps the conceptual boundaries of the
process nurses call clinical judgement. Optimally, the measurement of clinical judgement in nursing
students and practicing nurses should be approached through multiple measures. To the traditional
assessment of clinical judgement through 1) expert ratings of clinical performance by clinical professors
and 2) evaluations of written patient assessments and intervention plans, can now be added the
objective measures of 3) critical thinking skills and 4) the disposition to think critically. With a richer,
multi-modal assessment strategy program educators and advisors can be better equipped to nurture
critical thinking in decision-making in their students as well as the long range outcome of expert clinical
judgement in the professional nurses they educate.
References

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