a group reflection study on thinking styles of nurses of ...clinical situations and possibility of...
TRANSCRIPT
Jurnal Fikrah Jilid 8, Special Issue 1, 157-168, 2017
Available at : www.jurnalfikrah.org ISSN 1511-1113 © 2017 Pusat Pemikiran dan Kefahaman Islam (CITU)
157
A Group Reflection Study on Thinking Styles of
Nurses of Al-Zahra Cardiovascular Charity Hospital,
Shiraz
Marzieh Moattari
B.S.N, M.S.N, PhD in Nursing
Maryam Ghasemiardekani
B.S.N, M.S.N in nursing
Razieh PourAhmad
Ph.D . Associate professor of Department of Biostatistics.
Seyed Ziaaddin Tabei
Professor, Department of Medical Ethics and Philosophy of Health, School of
Medicine. Shiraz University of Medical Science
ABSTRACT
Background: Reflection is the internal exploration of subject. It is started by
experimenting. It produces and reveals concepts and results by changing the
perspective. Reflection is performed for effective and logical decision making
procedures by people who seek experiences to make new inferences and
evaluations. This study is aimed to determine effects of the following strategy on
thinking styles .
Method: This is a random trial study with control group. We have analyzed effects
of group reflection on thinking styles (dependent variable) of 66 nurses, using test
and control groups. Scores for the two groups were studied in two steps before
and after intervention. Nurses in test group participated in 8 sessions of
Jurnal Fikrah
851
reflection, each lasting for 2 hours. Group leader guided them to perform
reflection based on Gibbs cycle (1). Gibbs cycle includes description, feelings,
evaluation, analysis, conclusion, and action plan. We asked questions posed by
Rubenfeld and Scheffer (2) as challenging questions for critical thinking skills.
Conclusion: This study shows effects of intervention on changing the nurses’
thinking styles for function to legislator, forms to democratic, levels to general,
scope to external and for thinking style to liberal.
Keywords: Group reflection, Thinking style, Thinking, Nursing, Clinical
environment.
Introduction
Understanding reflection results in grasping the reality of nursing in clinical
environment and leads to paradoxes and challenges in daily performance of
nurses. The experience of applying reflection process in educational performance
of nurses creates a new knowledge, removing the gap between performance and
theory (3). Dewey (2000) defines reflective thinking models and states these
models change situations from paradoxical, ambiguous and conflicting to clear,
coherent and stable. He believes that reflection motivates the individual to seek
principles that resolve doubts. (4). Reflection is observing all scenarios from the
point of view of all people, relations, positions, chronological order, events and
etc. Reflection enables people to understand and generalize situations, therefore
they can study and visualize the experience in their field of attention (5).
Reflection can create critical thinkers and answers the questions regarding nature
of nursing and its theory (6). Also reflection can cause holistic approach to care,
promote theory and performance, motivate and self-regulating mechanisms (7).
Thinking is a common term among people and everyone uses; it though he/she
may not have a correct understanding of it. By thinking we can discover relations
between events and produce knowledge and science. Therefor duty of education
system is to create a proper situation for thinking, rather than saving and
transferring information (19). Thinking style which is the preferred method of our
thinking, explains that what happens in life depends not only on amount of
thinking, but also on our way of thinking (19). Having a proper understanding of
nurses thinking styles can help understand and predict their behaviors. Proper
education and planning of human resources in an organization requires
understanding the abilities of members of that organization. By this, we can
understand why some nurses are successful in their career and others are not (9).
Reflection Study on Thinking Styles
851
Sternberg uses the mental self-government theory to categorize thinking styles.
After studying thinking style types, researcher uses Sternberg model. In terms of
function, it includes legislative, executive and judicial thinking styles. Its forms
include monarchic (determined and willful), hierarchic (disciplined), oligarchic
(multidimensional) and anarchic (undisciplined). Thinking styles are global,
local, internal, external, liberal and conservative (8). According to mental self-
regulation theory, by having a specific thinking style in each category, people
gain some benefits and also might lose some (19). Thinking styles can’t be
considered independent from the environment where they are observed, since
people have an active interaction with their environment and widely change the
affecting environment (9). Thinking styles are dynamic. They can be taught and
applying a proper educational approach, people may be directed toward different
algorithms. So we can hope that different education methods can affect thinking
styles and enable nurses to use different dimensions of thinking styles –specially
their non-preferred styles- to deal with complicated and unique clinical situations.
We should accept that source of behaviors and functions in nurses is related to
their thinking styles. Nurses should act differently in varying situations, by using
their preferred thinking styles (12). Unfortunately, our education system mostly
uses traditional methods. These methods concentrate on increasing the knowledge
and does not focus on training thinking skills. After education, usual atmosphere
in hospitals doesn’t help grow or develop these skills either (1).
Method
Subjects of this study are nurses that have worked for at least 2 years in Al-Zahra
hospital. They were categorized into test and control groups. The population was
selected from nurses due to necessity of educating the thinking among nurses,
their availability and presence in reflection sessions, interaction with complicated
clinical situations and possibility of studying them. Nurses in test group
participated in 8 sessions, each lasting for 2 hours. In the first session
fundamentals of thinking styles and critical thinking were briefly introduced to
them. Other sessions were held in groups. Devised scenarios for different aspects
of critical thinking skills in two dimensions of mental habits and thinking skills
were studied. Group leader guided them to perform the reflection process
according to Gibbs cycle (15, 1). We also asked questions posed by Rubenfeld
and Scheffer in regard to critical thinking skills as challenging questions on the
subject (2). All principles of learning were considered which include: adaptation,
cooperation, commitment, ability to make relations, creating motivation and
Jurnal Fikrah
861
encouragement, devising active and dynamic processes, assigning goals and
standards, preparing suitable context for discussions among all group members,
answering the fundamental questions and leading the process (10). Devised
scenarios are based on critical thinking skills in two dimensions of mental habits
that include confidence, contextual perspective, creativity, flexibility,
inquisitiveness, intuition, open mindedness, perseverance and also cognitive
skills that included analyzing, applying standards, discrimination, information
seeking, logical reasoning, predicting and transferring knowledge. These are used
because there is significant similarity between thinking styles and critical thinking
skills. Thinking style is related to the abilities which are used preferably. Critical
thinking results in tendency towards targeted thinking. Therefore according to
Zhang (2003), we decided to perform group reflection by scenarios of critical
thinking.
Data collection methods
The tools in this study used to evaluate dependent variables of thinking styles are
as follows:
Sternberg thinking style Questionnaire
To assess thinking styles in this research, we used Sternberg’s thinking style
questionnaire. It has 104 questions, designed to discover thinking styles including
function, forms, levels, scopes and tendency. Each group of 8 questions evaluates
a specific thinking style. There are 7 choices ranging from “don’t agree at all” to
“completely agree”, and they were scored by values 1 to 7. Subjects choose the
answers that best describe their situation. Scores for each participant was
calculated based on the table for each aspect. If the score was high, subject has all
or some features of that aspect (19). There are numerous studies about validity of
this questionnaire. To assess validity of this questionnaire, we used confirmatory
factor analysis models in studies by Black (2008) and Valiallah Farzad in Iran
(2007) (11, 13). This questionnaire is translated to different languages and its
reliability has been proven in recent studies. In a study, reliability of the scale by
alpha cronbach method was 0.78 and in another it ranged between 0.72 and 0.86
(11).
Tests used in the study
We used frequency test to determine the number of nurses in each thinking style
based on their score. We used Chi-square test to study the changes for each
thinking style. In other words, we used this test to compare the two groups and
Reflection Study on Thinking Styles
868
see the amount of change or lack of them in their related thinking styles. We used
independent T-test to compare the thinking styles in both groups and paired t-test
as well, separately. Significance level of 0.05 was considered in all statistical
tests. These tests were performed by SPSS software (version 15).The results of
this study are shown in the tables.
Table 1: Demographic variables Control group Test group
Variables Percent Number Percent Number
- 31.39.7 - 30.610.6 Average age of population with standard
deviation
- - 3.03 1 Male sex
30.3 10 54.4 18 Marital situation
- 8.3 - 6.5 Work experience
39.3
18.1
42.4
13
6
14
45.4
12.1
39.3
15
4
13
Job status
Formal official
contractual
87.8
6.06
6.06
29
2
2
84.8
6.06
12.1
28
2
4
Organization level
Nurse supervisor
Head nurse
Table 2: study of thinking style frequency in test and control groups before and
after intervention, P value, average and standard deviation for each thinking
style
Average and standard deviation
P value
Frequency Thinking style
dimensions Control Test
Before After Before After Before After
number number number number
4.141.18 3.620.94 0.00 10 9 21 7 Function: legislative
Executive Judicial
5.311.16 0.914.29 0.27 20 21 9 20
5.050.92 51.50.96 0.27 3 3 3 6
5.141.07 1.162.63 0.03 10 12 20 10 Forms: monarchic Hierarchical
Oligarchic
Anarchic
4.091.93 76.31.15 0.39 4 3 5 5
3.381.27 93.31.23 0.28 6 5 5 2
4.101.11 4.290.88 0.40 13 13 3 16
4.321.08 2.851.19 0.026 11 12 25 10 Levels: global Local 3.461.28 5.061.11 0.1 22 21 8 23
4.571.68 4.460.92 0.00 12 16 27 14 Scope: external
Internal 4.781.10 4.80.89 0.59 21 17 6 19
5.140.93 4.321.18 0.031 9 10 25 13 Tendency: liberal
Conservative 4.011.18 5.190.98 0.4 24 23 8 20
Studying the thinking styles in test group before the intervention, nurses had a
tendency towards executive thinking style for function, anarchic in form,
conservative in level and internal in scope. After the intervention, their function
was legislative and form was monarchic. Regarding the level they were global
and in regard to the scope they were external and their tendency was liberal. The
styles of legislative, executive, monarchic, global, external, and liberal displayed
Jurnal Fikrah
861
a significant statistical difference (P value<0.05) after intervention. Thinking
styles of judicial, hierarchic, anarchic, oligarchic, local, internal and conservative
showed no significant difference (P value>0.05).
Table 3: Thinking style changes in function before and after the intervention in
both groups After
Before
Legislative Executive Judicial
Test Control Test Control Test Control
Legislative 10 9 0 0 0 0
Executive 11 1 9 20 0 0
Judicial 3 0 0 0 3 3
Based on the tables above, from 20 nurses with executive thinking, 9 remained in
the same style and 11 nurses changed their tendency towards legislator thinking.
3 judicial thinking nurses changed to legislative thinking. But in control group 20
nurses with executive thinking style remained the same. One nurse with executive
thinking style changed to legislator, without any meaningful statistical difference.
Table 4: Changes of thinking style in form before and after the intervention in
both groups After
Before
Monarchic Hierarchic Oligarchic Anarchic
test control test control test control test control
Monarchic 7 10 0 1 3 1 0 0
Hierarchic 0 1 5 3 0 0 0 0
Oligarchic 0 1 0 0 2 5 0 0
Anarchic 13 0 0 0 0 0 3 13
Based on the results of above tables, there were 16 anarchic nurses in test group
before the intervention. 3 of them remained the same after the intervention and
13 tended towards monarchic. 7 nurses kept their monarchic thinking style and 3
nurses changed from monarchic to oligarchic. 13 nurses with anarchic thinking
style in control group remained in the same style. From 12 nurses with monarchic
thinking style, 1 changed to hierarchic and 1 changed to oligarchic.
Table 5: Changes of thinking style for level before and after the intervention in
both groups
After
before
Global Local
Test Control Test Control
Global 10 11 15 1
Local 15 0 8 21
Based on tables above, of 23 nurses with local thinking style before the
intervention, 8 remained in this category and 15 moved to global thinking style
Reflection Study on Thinking Styles
861
after the intervention. Whereas in the control group only one nurse changed to
local thinking style, showing no significant difference.
Table 6: Changes of thinking style from the scope point of view before and
after the intervention in both groups.
After
before
External Internal
Test Control Test Control
External 14 12 0 4
Internal 13 0 6 17
Based on above tables, from 19 nurses with internal thinking style in test group,
only 6 remained the same and 13 nurses changed to external thinking style.
Whereas in control group only 4 nurses changed from external to internal thinking
style, without any significant differences.
Table 8: Changes of thinking style from the learning thinking style before and
after the intervention in both groups
After
before
Conservative Liberal
Test Control Test Control
Conservative 8 24 8 24
Liberal 0 1 0 1
Based on tables above, of 20 nurses with conservative thinking style in test group,
only 8 remained the same and 12 nurses went toward liberal. In control group
only one nurse changed to liberal thinking style, showing no statistically
significant difference.
Discussion
Results of the group reflection effect on thinking styles showed that after
intervention, executive thinking style changed to legislator from the function
point of view. Local thinking style changed to global as for level and moved from
internal towards external thinking style, changing the scope. Conservative
thinking style changed to liberal from tendency point of view. Also, anarchic
thinking style changed to monarchic in form. Legislative, executive, monarchic,
global, external and liberal thinking styles show statistically significant difference
(P value<0.05) after intervention. We didn’t observe statistically significant
difference (P value >0.05) in judicial, hierarchic, oligarchic, anarchic, local,
internal and conservative thinking styles after intervention. Studying control
group, we couldn’t find any changes in thinking styles. Results showed that after
Jurnal Fikrah
861
the intervention this group still had a tendency towards executive thinking style
from the function point of view. As for form, they changed towards anarchic and
from the tendency point of view they followed conservative thinking style. While
as for scope they changed toward external and as for level, they changed to local.
Comparing changes in two groups shows effects of group reflection on changes
in thinking styles. Studies on the effects of reflection on different styles such as
learning, thinking and cognitive styles are very few. There has been no evidence
for assessing effects of group reflection on changing the thinking style and their
effects on nurses’ performances. We used Gibbs cycle for intervention in group
reflection strategy. It seems that using this method and concentrating on all steps
of the scenario in order to review the scenarios that dealt with real nursing
situations in a clinical setting, has been effective on enhancing positive
characteristics of thinking styles. A short review will show us that first step of the
cycle is describing the events. All events of the scenario are described in detail
(15). This results in using and strengthening the local and global aspect of the
problem. In addition to studying details of the scenario, it has an overall view on
the effect of nursing intervention on the scenario. Nurse’s performance is studied
not only as result of his/her work and colleagues are considered in this evaluation.
While expressing feelings and thoughts, nurse is released from his/her own
framework to talk about feelings, thoughts, effect of events on feelings and his/her
feelings in regard to the resulting outcome of the scenario (14). It seems this had
a significant effect on changing nurse’s internal thinking to external thinking style
(15). In the third stage of Gibbs cycle, nurses in test group assessed the scenario
and mentioned all negative and positive points of the case (15). Evaluating all
aspects of situation is effective on changing executive thinking to legislative
thinking style. Up to now we have studied the scenario from different aspects.
While concluding, nurses investigate other related actions. In other words they
reach conclusions on how they could act differently compared to the scenario (1).
This stage has had important effects on changing thinking styles, i.e. changing the
conservative thinking styles to liberal, executive to legislator and internal to
external thinking style. In the sixth stage of Gibbs cycle we began planning of the
scenario for group reflection. We asked what they will do facing such situations
in future (15). Nurses had to think and provide solutions for future planning. This
is partly effective in changing thinking styles from executive to legislative in
function, local to global in levels, internal to external in scope and conservative
too liberal in tendency. Reviewing scenarios, educating critical thinking skills in
two dimensions of mental habits and critical thinking skills and using Rubenfeld
Reflection Study on Thinking Styles
865
and Scheffer’s questions caused nurses to feel the area they work in needs a
change, and they should continuously improve methods that result in better
handling of situations. Researcher recognizes dynamicity of group as the reason
for effectiveness of group reflection. The events of group reflection caused nurses
to see it as a good experience. They listed positive characteristics of reflection as
ensuring, having enough time for reflection, obtaining new perspectives, sharing
with colleagues and more effective relation with patients. These results are backed
by Gustafson’s research (2004) on development of nursing (17). Study of
applying reflection on a daily basis was performed in an orthopedic section by
Moloney (2006) on 16 nursing students. Results of reflection such as
strengthening students in different stages of describing, analyzing, understanding
new insights, learning and evaluating supported the results of this study using
different stages of Gibbs’s cycle (3). Findings of this study are consistent with
research by Lee (2009) in terms of applying group reflection in scientific studies,
clarifying researchers’ interpretations and internal discussions, clarifying
presumptions, values and beliefs, gathering information and analysis throughout
the research procedure as a result of free relations and group coherence,
discussion and studying ideas with regard to research results (16). Implementing
17 scenarios in two dimensions of critical thinking and mental habits during group
reflection played an important role in effectiveness of intervention. Clinical
scenarios devised for heart care simulates the situations for nurses’ analysis and
decision making. Questions by Rubenfeld and Scheffer were essential in
promoting critical thinking (2). These questions challenged critical thinking and
allowed nurses to consider different solutions for problems and motivated nurses
to examine their value systems. Questions were asked in regard to different
perspectives and probabilities. Questions were devised for each aspect in the
corresponding scenario of group reflection so that nurses would provide logical
reasoning for their answers. They needed to think beyond the obvious matters in
clinical situations. Clinical scenarios helped them consider different views,
compare various probabilities, think beyond the obvious and finally change
thinking styles. Nurses’ interest in providing reasonable, logical and systematic
methods which result in quality patient care is another factor for effectiveness.
They were free to choose intellectual reasoning and systematic methods in
problem solving. Critical thinking was an active process that obligated nurses to
transfer data, choose essential factors and then evaluate to create a vital decision
making procedure. They could make their decision based on deep understanding
and logical conclusions. Legislative, liberal and monarchic people act in a
Jurnal Fikrah
866
creative and untraditional manner. These two characteristics display self-
confidence. Studying scenarios related to self-confidence by using corresponding
questions for the purpose of critical thinking development has been effective in
changing these styles. To be inquisitive, the person must be pioneer (monarchic)
and then decide what information he/she needs. Then he/she must analyze the
information (legislator) and the curious person must consult with others (external)
to have a correct understanding of the information. It seems there is a considerable
relationship between curiosity and thinking styles. This relation for changes in
thinking styles of the first category has been verified in a study by Zhang (2003)
(12). Analyst people are recognized by their persistence to enter logical
discussions to solve problems (2). People with legislator thinking styles like to be
involved in analytic matters (20). The person studies aspects of an issue (local)
and obtains new viewpoints (liberal) and provides logical orders for different
aspects of that matter. Therefore there is probably a relationship between
analytical situation and legislator, local and liberal thinking styles. Zhang ‘s study
supports effect of intervention program on scores for curiosity from mental habits
and analysis from thinking skills and also significance of liberal and legislative
thinking styles (12). Educating information seeking, intellectual coherence,
contextual perspective, logical reasoning and distinction by group reflection have
been effective in changing thinking styles from executive to legislative in
function, anarchic to monarchic in form, internal to external in scope and
conservative too liberal in tendency. Using each skill in two dimensions of mental
habits and thinking skills has been effective in people’s tendency towards judicial
in function and oligarchic in form. Based on the finding s of this research, results
don’t indicate significant difference. While so many people use a certain situation
of thinking style, so many of them at the same time use combined methods. The
person who has combined method creates new ideas and beliefs. Thus, an exact
estimate can be beyond the facts that we find in the questionnaires. Although
many people use a single thinking style in a situation, some consider
combinations and other procedures. A person with mixed method creates new
ideas when dealing with situations. Therefore an exact assessment of thinking
styles can go above a questionnaire. Also a person can use a combination of two
or more categories of thinking styles, meaning that the person might not have
dominant thinking style for the questionnaire. This can display judicial,
hierarchic, oligarchic, anarchic, local, internal and conservative to be
insignificant.
Reflection Study on Thinking Styles
861
Conclusion
Now nurses need professional yet unfamiliar situations or places. Therefor they
must be ready to work as secure, creative, worthy and intuitive nurses in an
environment where information and treatment situations are constantly changing.
Everyday nurses deal with a rich collection of data and information for simulation
and conform their knowledge for solving problems and explaining the situation.
Nursing decisions continually face situations where there is no clue or correct
answer. Therefor thinking and its enhancement and changing thinking styles
related to positive characteristics such as deeper approach to learning, high self-
confidence, higher cognitive levels and open personality can help nurses deal with
complicated clinical situations. Thinking styles are very important. Some might
be accused of weakness, since their thinking style is inconsistent with
environment. Instead of focusing on their abilities in environments matching their
thinking style, they are eliminated. Since thinking styles are not static, by using
new education approaches we can draw attention to using different thinking styles
matching the situation people are in. We should mention that if we don’t consider
thinking styles, we face risk of losing smart people because of concepts such as
gifted or intelligent. As a matter of fact, some intelligent people would be
excluded due to the thinking styles that we prefer.
REFERENCES
[1] Maddison Ch. Reflective Practice in Nursing: The Growth of the Professional
Practitioner. 3rd edition. 2004
[2] Rubenfeld Mg، Scheffer BK. Critical thinking in nursing: an interactive
approach، 2nd ed. USA: Lippincott Williams and Wilkins; 2006;p: 276-81
[3] Moloney J. using reflection in every day orthopedic nursing practice. Journal
of orthopedic nursing. 2006;(10):49-55
[4] Dewey J. How we think: a restatement of the relation of reflective thinking to
the educative process. Health Boston. English national Board for nursing to
the context of project. London: English national board; 2000
[5] Boyd E.M، False A.W. reflective learning: key to learning from experience.
Journal Of Humanistic Psychology1983;23(2):99-117
[6] Burton BA. Reflection: nursing،s practice and education panacea?. Journal of
Advanced Nursing. 2000;31(5):1009-1017
[7] Moattari M. Views of Nursing Students about Reflection: A Qualitative Study.
Journal of Medical Education. 2007;11(1)
Jurnal Fikrah
861
[8] Sternberg R J، Wagner R K. Thinking styles inventory. Unpublished test. Yale
university;1992
[9] Zhang، L. F. Thinking styles and the big five personality traits revisited.
Personality and Individual Differences. 2006;40:1177-1187
[10] Barkley E، Cross K. collaborative learning technique.1st ed.USA: Jossey-
bass; 2004;p:98-110
[11] Valioolah F، Kadivar P. assessment of internal integrity of inventory of
thinking styles. Journal of Psychology. Tabriz University.2007;2(6):83-109
[12] Zhang L. contribution of thinking styles to critical thinking disposition.
Journal of Psychology. 2003;137(6):517-544
[13] Black A، McCoach D. Validity Study of the Thinking Styles Inventory.
Journal for the Education of the Gifted. 2008;32(2):180-210
[14] Gibbs G. Learning by doing. A guide to teaching and learning methods.
Oxford Polytechnic: Further Education Unit;1984
[15] Young P، Jeong B. Gibbs reflection. Journal of Online learning & Teaching.
2011;7(1)
[16] Lee N PhD، Using group reflection in an action research study. Nurse
Researcher. 2009;10(3):54-67
[17] Gustafson C. reflection: the way to professional development? Journal Of
clinical Nursing. 2004;13(3):271-280
[18] Platzer H، Blake D، & Ashford D. barriers to learning from reflection: a study
of the use of group work with post registration nurses. Journal of Advance
Nursing. 2000;22:1001-1008
[19] Sternberg، Robert J.، Henry L. Roediger III، and Diane F. Halpern، eds.
Critical thinking in psychology. New York: Cambridge Univ. Press;2007
[20] Zhang L F، Sachs J. Assessing thinking styles in the theory of mental self-
government: A HONG KONG validity study. Psychological Reports. 1997;
81: 915-28