Critical Thinking Skills of Allied Health Science Students: A Structured Inquiry

by Marcia Y. Sharp, EdD, RHIA; Rebecca B. Reynolds, EdD, RHIA, FAHIMA; and Keisha N. Brooks, MS, CT(ASCP)

Abstract

This study examines the critical thinking skills of health informatics and allied health students. The Health Sciences Reasoning Test was utilized to investigate the critical thinking skills of 57 graduating seniors in the class of 2011 at a university in the southeastern United States. Results indicate that 64.9 percent of the participants had weak critical thinking skills, 31.6 percent of the participants had moderate critical thinking skills, and 3.5 percent of the participants had strong critical thinking skills. Baccalaureate participants’ critical thinking skills were lower than master’s and entry-level master’s participants. Entry-level master’s students scored higher than master’s level students. This research adds to the body of literature surrounding the critical thinking skills of allied health students and provides new information to deans, administrators, and educators that may be useful when evaluating students’ critical thinking skills. As accrediting agencies and policymakers continue to raise the bar and place more accountability on higher education institutions, it is important that attention remain on graduating students who can think critically. The results of the study will help to establish a foundation for allied health science programs to determine the level of critical thinking skills that their graduates possess. Results of the study can provide a starting point for faculty to make changes in the curriculum to improve students’ critical thinking skills.

Introduction

Critical thinking is a major educational outcome required of higher education institutions. Today, more than ever, educational programs are challenged to develop students’ critical thinking skills. In light of the shifting scope of practice in various healthcare settings, allied health professionals must be capable of adapting to these ever-changing demands. Because of the demands placed on healthcare institutions to deliver quality patient care in an interdisciplinary environment, the development of critical thinking skills among allied health students is essential.

Every day allied health professionals must gather, analyze, and process information to make sound, logical decisions. Often the decisions are complex and require multiple levels of decision making. Regardless of the magnitude of the decisions to be made, it is essential that allied health students have the clinical reasoning and critical thinking skills to make good decisions. But do these students have critical thinking skills and the abilities to apply those skills in many different contexts? Can deans, program directors, and department chairs at colleges and universities be assured that they are graduating students who can think critically in complex situations? As accrediting agencies and policy makers continue to raise the bar and place more accountability on higher education institutions, it is important that attention remain on graduating students who can think critically. It is up to us, as educators, to ensure that we are teaching, evaluating, and assessing students’ critical thinking skills.

Much research on critical thinking has been conducted, examining strategies used to integrate critical thinking into the curriculum, single courses on critical thinking, and the use of concept maps as critical thinking techniques.^1–5 A few studies among allied health professions such as dental hygiene, occupational therapy, and physical therapy have been conducted, assessing the critical thinking skills of students. Each discipline conducted studies with only students from that field; no studies that had an interdisciplinary approach were found. The researcher did not find any studies that included health informatics and information management (HIIM) professionals, medical laboratory technicians, or cytotechnologists. As the healthcare industry moves away from silos in treating patients to a more interdisciplinary team approach, so should higher education institutions move toward an interdisciplinary approach in teaching and research. This study is an attempt to include students from different disciplines, such as dental hygiene, medical technology, HIIM, and cytotechnology, and add to the body of knowledge by assessing the critical thinking skills of students enrolled in these allied health programs collectively. Rather than looking at a single discipline, this study aimed to determine whether there are differences in the critical thinking skills of students in various allied health programs.

The primary purpose of this study was to determine the critical thinking skill level of allied health students at a university in the southeastern United States, as measured by the Health Sciences Reasoning Test (HSRT). The questions the investigators sought to answer were as follows:

1. What is the critical thinking skill level of allied health students at this university (strong, moderate, or weak)?
2. Are there differences in critical thinking skills based on the allied health students’ programs?
3. Are there differences in critical thinking skills between programs taught at different academic levels (baccalaureate, entry-level master’s, and master’s)?

Background/Literature Review

The following excerpt outlines the history of critical thinking:

Although the principles of Critical Thinking underpin much of Western philosophy, it did not come to the forefront as a specific concept until the late Nineteenth Century. Philosophical discussion of critical inquiry surfaced in the 1870’s in the United States, when Charles Sanders Peirce, who believed that logic is the scientific method that will lead to truth, originated the concept of pragmatism. Pragmatism stresses the relation of theory to practice (or what Paulo Freire called “praxis,” meaning reflection and action upon the world in order to change it). . . . John Dewey, [the noted educator] who argued for a model of critical thinking based on a theory of knowing that is continuous[,] . . . adopted Peirce’s notion of meaning, and focused on the connection that thinking has with experience, doing, and the consequences of action. Dewey subscribed to the philosophical school known as pragmatism, and described his approach to inquiry as “reflective thinking,” to distinguish it from ordinary thinking.⁶

Various sources have defined and explained critical thinking as follows:

• Critical thinking is the process by which one penetrates beyond the surface of a problem, recognizes how the problem can be solved, and possesses the content knowledge needed to solve the problem.⁷
• “Critical thinking is reflective reasoning about beliefs and actions. It is a way of deciding whether a claim is always true, sometimes true, partly true, or false. . . . Critical thinking clarifies goals, examines assumptions, discerns hidden values, evaluates evidence, accomplishes actions, and assesses conclusions.”⁸
• “It is a part of formal education and is increasingly significant as students progress through university to graduate education. . . . Critical thinking is considered important in the academic fields because it enables one to analyze, evaluate, explain, and restructure [one’s] thinking, thereby decreasing the risk of adopting, acting on, or thinking with, a false belief.”⁹

Although no single definition of critical thinking exists, much research has been conducted on critical thinking. The critical thinking research in the higher education arena has been broad and extensive, while research on the allied health professions lags behind. The results of this study will help to establish a foundation for allied health programs to determine the level of critical thinking skills their graduates possess. This study can inform deans, program directors, and department chairs, as well as faculty, on the extent to which critical thinking is demonstrated in their program’s graduates. Results of the study can provide a foundation for faculty to make changes in the curriculum to improve students’ critical thinking skills.

Critical thinking is not only essential but an expectation of healthcare professionals. “Critical thinking is increasingly being recognized as the cognitive engine driving the processes of knowledge development and professional judgment in a wide variety of professional practice fields.”¹⁰ The depth and breadth of information that healthcare practitioners are expected to master is voluminous. The two major disciplines in healthcare are medicine and nursing. Some studies related to critical thinking exist within the medicine discipline, but most studies have been conducted in nursing.

Equally important to the healthcare industry, but often overlooked, are the allied health professions. Allied health professionals are “involved with the delivery of health or related services pertaining to the identification, evaluation and prevention of diseases and disorders; dietary and nutrition services; rehabilitation and health systems management, among others.”¹¹ Studies related to critical thinking were found in radiographic technology, occupational therapy, physical therapy, and dental hygiene professions.^12–15 The majority of these studies evaluated critical thinking skills as an outcome measure based on licensure examination scores.

Despite widespread attention to critical thinking, studies have shown that schools neither challenge students to think critically about academic subjects nor help them develop the reasoning skills needed to succeed in the 21st century.^{16, 17} “On average, gains in critical thinking, complex reasoning and writing skills (i.e., general collegiate skills) during the first two years of college are either exceedingly small or empirically non-existent for a large proportion of students.”¹⁸ In a study conducted by Arum and Roksa (2011),¹⁹ “Forty-five percent of our students did not demonstrate any significant improvement in CLA [Collegiate Learning Assessment] performance during the first two years of college.”²⁰ This study reports that many college students graduate without knowing how to sift fact from opinion, make a clear written argument, or objectively review conflicting reports of a situation or event.²¹

Method

This quantitative research study is both descriptive and exploratory. Institutional review board approval was obtained from the university. A commercial survey tool, the HSRT, was used to investigate the critical thinking skills of allied health students. The instrument gathers information regarding demographic variables and an overall critical thinking score. The data were subsequently analyzed with SPSS version 19.0.

Participants

The participants in the study consisted of cytotechnology, dental hygiene, HIIM, and medical technology students graduating in the class of 2011 from an allied health college in an academic health science center in the southeastern United States. The college also includes audiology and speech language pathology, occupational therapy, and physical therapy programs. Because of the various schedules of the programs, students were selected for participation from the programs where students were available on-campus for the researcher to meet with, to increase the response rate. A total of 63 students from cytotechnology (n = 2), dental hygiene (n = 33), HIIM (n = 20), and medical technology (n = 8) constituted the research population for this survey.

Instrument

Data were collected through the administration of the HSRT. The HSRT is a commercially available survey instrument, developed by Noreen and Peter Facione and designed specifically for health science professionals, workers, and students.²² The instrument has been used in research studies attempting to predict critical thinking skills needed for professional licensure exams, disposition toward critical thinking among various allied health disciplines, and association of critical thinking skills and clinical performance. It is being used worldwide at high-ranking health science education programs to measure critical thinking skills and habits of mind in students and practicing professionals.²³ The HRST is a multiple-choice test that targets core critical thinking skills of health science professionals and health science students. It measures five subscale critical thinking areas, including analysis and interpretation, inference, evaluation and explanation, deductive reasoning, and inductive reasoning.²⁴ Questions invite test takers to draw inferences, make interpretations, analyze information, draw warranted inferences, identify claims and reasons, and evaluate the quality of arguments. The HSRT has an overall internal consistency value of .81 with Kuder-Richardson formula 20, and an overall .81 reliability coefficient.²⁵ The total score is a measure of overall critical thinking skills, and the maximum score is 33. According to the HSRT test manual, total HSRT scores of 25 or above represent strong critical thinking skills, scores ranging from 15 to 24 are considered midrange and represent competence in critical thinking skills in most situations, and scores of 14 or below represent fundamental weaknesses in critical thinking skills.²⁶

Procedures

After training on how to administer the instrument was conducted, dates were arranged with dental hygiene and medical technology students to take the paper version of the assessment. Because the HIIM students are online students, they were given the same assessment online. The cytotechnology students were in the process of finishing clinical rotations, so the researcher decided that they should take the online assessment as well. An e-mail message that explained the study, asked for consent, and provided the instructions for accessing the HSRT was sent to the online students. To improve participation rates, the researcher sent a follow-up e-mail to online participants one week later, after the initial e-mail request. Dental hygiene and medical technology students, who were face-to-face students, completed the assessment in person on a scheduled data collection date. Completion of either assessment, paper or online, took approximately 45 to 50 minutes.

Variables

Independent variables included age, gender, grade point average (GPA), program, academic level, and educational degree the student was currently seeking. Age was defined as the student’s current age. Gender was defined as the student’s birth gender (female, male). Grade point average was the student’s overall GPA prior to being accepted to the program. This variable was self-reported and was based on a 4.00 scale. Program was defined as the current allied health program the student was enrolled in (cytotechnology, dental hygiene, HIIM, and medical technology). Academic level was defined as the highest education level obtained prior to acceptance in the current allied health program (some college hours but no degree yet, associate’s degree, bachelor’s degree, master’s degree, doctoral [terminal] degree, or other). Degree the student was currently seeking was defined as the degree that the student was currently attending school to obtain (bachelor’s degree, master’s degree, entry-level master’s degree). Entry-level master’s degree programs do not require completion of a baccalaureate degree before matriculating to the masters level. The dependent variables in the study were the HSRT total score and the five HSRT scale subscores: analysis and interpretation, inference, evaluation and explanation, deductive reasoning, and inductive reasoning.

Reliability

Cronbach’s alpha was used to assess the internal reliability or consistency of the scales that made up the total HSRT score. An internal reliability test for the five scales—analysis and interpretation, inference, evaluation and explanation, inductive reasoning, and deductive reasoning—was conducted and yielded an alpha value of .85. According to Pallant (2007), an alpha value of .70 or greater is an acceptable measure.²⁷

Descriptive statistics were used to describe the critical thinking skill level of allied health students overall. Analysis of variance (ANOVA) was used to determine if any differences in HSRT scores between groups of students were statistically significant (p < .05).

 Results

This study was conducted with a sample of 63 graduating students. A total of 57 students (90 percent response rate) volunteered to take the assessments. The face-to-face sessions resulted in a 91 percent response rate from dental hygiene students and a 75 percent response rate from medical technology students. The e-mail requests asking students to take the online version of the HSRT resulted in a 100 percent response rate from the cytotechnology students and a 95 percent response rate from the HIIM students.

The critical thinking skill level of the participating students was assessed through descriptive analysis, which indicated that 64.9 percent (n = 37) of allied health science students showed weak critical thinking skills, 31.6 percent (n = 18) showed moderate critical thinking skills, and 3.5 percent (n = 2) showed strong critical thinking skills (see Table 1).

One-way ANOVA was used to determine if there were any statistically significant differences in critical thinking skills based on allied health program. Results displayed in Table 2 indicated a statistically significant difference at the p < .05 level in critical thinking scores for the different programs, F (3, 53) = 28.708, p = .00. Post hoc analysis using the Tukey test indicated that the mean score for dental hygiene students (M = 7.73) was significantly different from that of cytotechnology students (M = 19.50) and HIIM students (M =18.68). HIIM students’ mean score (M = 18.68) was significantly different from that of dental hygiene students (M = 7.73) and medical technology students (M = 10.33). The mean score of medical technology students (M = 10.33) was significantly different from that of cytotechnology students (M = 19.50) and HIIM students (M = 18.68).

One-way ANOVA was used to determine if there were any statistically significant differences in critical thinking skills of students in programs taught at different academic levels (baccalaureate, entry-level master’s, and master’s). The descriptive statistics are listed in Table 3. Results depicted in Table 4 indicated a statistically significant difference at the p < .05 level in critical thinking scores for the different academic levels.

Discussion

The results of the study indicated that 64.9 percent of allied health science students participating in the study had weak critical thinking skills, 31.6 percent had moderate critical thinking skills, and 3.5 percent had strong critical thinking skills. This finding is consistent with Arum and Roksa’s 2011 study, which indicated that students’ critical thinking and critical reasoning skills were relatively weak or nonexistent.²⁸

This study found statistically significant differences in critical thinking skills based on program type. The dental hygiene mean score (M = 7.73) was significantly different from the cytotechnology mean score (M = 19.50) and the HIIM mean score (M =18.68). The HIIM mean score (M = 18.68) was significantly different from the dental hygiene mean score (M = 7.73) and the medical technology mean score (M = 10.33). The medical technology mean score (M = 10.33) was significantly different from the cytotechnology mean score (M = 19.50) and the HIIM mean score (M = 18.68). No other studies investigating multiple programs at once have been published to allow for comparison.

ANOVA indicated differences in critical thinking based on academic level (Table 4). Bachelor participants’ critical thinking skills were lower than those of master’s and entry-level master’s participants. Surprisingly, entry-level master’s students scored higher than master’s-level students. This finding could be a result of the small sample of entry-level master’s students. This result is consistent with findings in a nursing study that found significant differences between the development of critical thinking skills among graduates of diploma, associate, and baccalaureate educational programs.²⁹ The nursing study also found that students prepared at the baccalaureate level demonstrated higher levels of critical thinking ability than those at the diploma or associate level.³⁰ King and Kitchener (1994) also found that more formal education is a powerful predictor of critical and reflective thinking.³¹

Limitations

There are several limitations to this study. First, the study is limited to one academic health science center located in the southeastern United States, which reduces the generalizability of the results. While results of this study may be typical for allied health students at this location, they may not be indicative of allied health students elsewhere in the region or in other regions of the United States. Second, participants were limited to only those students enrolled and expected to graduate in the spring of 2011, so the demographics and backgrounds of these participants may not be typical of those expected to graduate at other times. This study was also constrained by the collection of data at one point in the students’ academic careers—that is, upon exit from the students’ academic program. While the results of this study cannot be generalized to all allied health students, the study nonetheless contributes to the body of research concerning the importance of improving critical thinking skills among allied health students.

Recommendations

Recognizing the importance of critical thinking, universities and colleges are implementing critical thinking assessments and outcome measures of critical thinking throughout their academic programs. For deans and college administrators, the results of the study provide support to introduce programs to improve critical thinking skills. Several institutions, such as George Mason University, the University of Tennessee at Chattanooga, and El Paso Community College, have instituted critical thinking programs to provide an avenue for students and faculty to focus on critical thinking outcome measures. These avenues include, but are not limited to, programs such as critical thinking across the curriculum, critical thinking across the disciplines, and specific courses on critical thinking.

For program directors and department chairs in the allied health areas, the ability of students to pass national board examinations is an important outcome measure. However, equally important is the ability of allied health students to demonstrate adequate critical thinking and reasoning skills. Therefore, program directors and department chairs should assess students’ critical thinking skills upon entering, midway through, and upon exiting their respective programs and make necessary changes to ensure students are graduating with adequate critical thinking skills.

There is no “magic trick” or “quick fix” instructional model that instructors can apply in a few courses to increase critical thinking skills; rather, the careful integration of deep thinking and thought-provoking assignments by educators is essential for developing students’ critical thinking skills. Activities used to foster critical thinking skills include evaluating alternatives to a problem, identifying credible sources, organizing an essay, predicting what will happen next, defending an argument, and self-evaluating the learning process through reflective analysis.

Conclusion

The findings of this research suggest the need for improvements in the critical thinking skills of allied health students. Results from the study provide a foundation for faculty to be aware of the potential lack of critical thinking skills in students and to make curricular changes in an attempt to improve students’ critical thinking skills. Several remaining questions offer future research possibilities. Critical thinking research should be expanded to other allied health programs throughout the United States and include longitudinal studies to identify if critical thinking skills change during students’ academic careers. A future research study could examine other allied health disciplines to identify if a relationship between students’ critical thinking skills and pass rate on their disciplines’ national board examinations exists.

The literature that currently exists recognizes the importance of critical thinking and the evaluation of students’ critical thinking skills. When assessing the critical thinking skills of college students, one must also consider the critical thinking skills of college educators. The ability to think critically and the ability to teach critical thinking skills warrant an investigation into how the two areas can be successfully merged. The information gathered from an assessment of critical thinking skills among college educators could help inform college administrators, deans, program directors, department chairs, and faculty on how to better train educators to teach critical thinking skills to their students.

Marcia Y. Sharp, EdD, RHIA, is an associate professor in the Department of Health Informatics and Information Management at the University of Tennessee Health Science Center in Memphis, TN.

Rebecca B. Reynolds, EdD, RHIA, FAHIMA, is chair and associate professor in the Department of Health Informatics and Information Management at the University of Tennessee Health Science Center in Memphis, TN.

Keisha N. Brooks, MS, CT (ASCP), is an assistant professor of clinical laboratory sciences at the University of Tennessee Health Science Center in Memphis, TN.

Notes

1. Kurfiss, J. Critical Thinking Theory, Research, Practice, and Possibilities (ASHE-ERIC Higher Education Report No. 2). Washington, DC: Association for the Study of Higher Education, 1988.
2. Halpern, D. F. “Students Need Reality Checks.” Education Digest 63 (1997): 24–26.
3. Irvine, L. M. “Can Concept Mapping Be Used to Promote Meaningful Learning in Nurse Education?” Journal of Advanced Nursing 21 (1995): 1175–79.
4. Baugh, N. G., and K. G. Mellott. “Clinical Concept Mapping as Preparation for Student Nurses’ Clinical Experiences.” Journal of Nurse Education 23 (1998): 35–41.
5. Clayton, L. H. “Concept Mapping: An Effective, Active Teaching-Learning Method.” Nursing Education Perspectives 27, no. 4 (2006): 197–203.
6. Damji, S., M. Dell’Anno, M. McGrath, and J. Warden. “What Is Critical Thinking and How Can It Be Promoted by Adult Educators?” December 2001. Available at http://fcis.oise.utoronto.ca/~daniel_sc/faqs/qa10.html.
7. Willingham, D. T. “Critical Thinking: Why Is It So Hard to Teach?” American Educator 31, no. 2 (2007): 8–19.
8. Wikipedia. “Critical Thinking.” Available at en.wikipedia.org/wiki/Critical_thinking(accessed April 1, 2013).
9. Ibid.
10. Facione, N. C., and P. A. Facione. “Externalizing the Critical Thinking in Knowledge Development and Clinical Judgment.” Nursing Outlook 44 (1996): 129–36.
11. Association of Schools of Allied Health Professions. “Allied Health Professionals.” Avaliable at http://www.asahp.org/definition.htm.
12. Bartlett, D. J., and P. D. Cox. “Measuring Change in Students’ Critical Thinking Ability: Implications for Healthcare Education.” Journal of Allied Health 31 (2002): 64–69.
13. Velde, B., P. P. Wittman, and P. Vos. “Development of Critical Thinking in Occupational Therapy Students.” Occupational Therapy International 13, no. 1 (2006): 49–60.
14. Williams, K. B., C. Schmidt, T. S. Tilliss, K. Wilkins, and D. R. Glasnapp. “Predictive Validity of Critical Thinking Skills and Disposition for the National Board Dental Hygiene Examination: A Preliminary Investigation.” Journal of Dental Education 70 (2006): 536–44.
15. Zettergren, K. K., and R. Beckett. “Changes in Critical Thinking Scores: An Examination of One Group of Physical Therapy Students.” Journal of Physical Therapy Education 18, no. 2 (2004): 73–79.
16. Halpern, D. F. “Students Need Reality Checks.”
17. Arum, Richard, and Josipa Roksa. Academically Adrift: Limited Learning on College Campuses. Chicago, IL: University of Chicago Press, 2011.
18. Learning in Higher Education. “Core Findings.” Social Science Research Council. 2011. Avaliable at http://highered.ssrc.org/?page_id=33.
19. Arum, Richard, and Josipa Roksa. Academically Adrift: Limited Learning on College Campuses.
20. Learning in Higher Education. “Core Findings.” Social Science Research Council. 2011. Avaliable at http://highered.ssrc.org/?page_id=33.
21. Arum, Richard, and Josipa Roksa. Academically Adrift: Limited Learning on College Campuses.
22. Insight Assessment. “Health Sciences Reasoning Test (HSRT).” Available at http://www.insightassessment.com/Products/Critical-Thinking-Skills-Tests/Health-Sciences-Reasoning-Test-HSRT/(language)/eng-US.Facione, Noreen C., and Peter A. Facione. The Health Sciences Reasoning Test. Millbrae,CA: California Academic Press, 2005.
23. Facione, Noreen C., and Peter A. Facione. The Health Sciences Reasoning Test Manual. 2011 ed. Millbrae, CA: California Academic Press, 2011.
24. Insight Assessment. “Health Sciences Reasoning Test (HSRT).”
25. Facione, Noreen C., and Peter A. Facione. The Health Sciences Reasoning Test Manual. 2011 ed. Millbrae, CA: California Academic Press, 2011.
26. Ibid.
27. Pallant, J. SPSS Survival Manual: A Step-by-Step Guide to Data Analysis Using SPSS Version 15. 3rd ed. Berkshire, England: Open University Press, 2007.
28. Arum, Richard, and Josipa Roksa. Academically Adrift: Limited Learning on College Campuses.
29. Fero, L. J., C. M. Witsberger, S. W. Wesmiller, T. G. Zullo, and L. A. Hoffman. “Critical Thinking Ability of New Graduate and Experienced Nurses.” Journal of Advanced Nursing 65, no. 1 (2009): 139–48.
30. Ibid.
31. King, P., and K. Kitchener. Developing Reflective Judgment: Understanding and Promoting Intellectual Growth and Critical Thinking in Adolescents and Adults. San Francisco, CA: Jossey-Bass, 1994.