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1. Accepted
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been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/jan.13306
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DR ELISABETH RUTH JACOB (Orcid ID : 0000-0002-3506-8422)
PROFESSOR CHRISTINE DUFFIELD (Orcid ID : 0000-0001-6534-8743)
Received Date : 14-Dec-2016
Revised Date : 23-Feb-2017
Accepted Date : 06-Mar-2017
Article type : Protocol
TITLE PAGE
Full Title: A protocol for the development of a critical thinking assessment tool for nurses using a
Delphi technique
Running Head: Critical thinking assessment protocol
Author Details: Elisabeth JACOB1
, Christine DUFFIELD2
, Darren JACOB3
.
1. Elisabeth JACOB, PhD, RN, MEd.
Dr, Associate Dean Nursing
School of Nursing and Midwifery
Edith Cowan University, Australia
e.jacob@ecu.edu.au

2. Accepted
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2. Christine DUFFIELD, RN, MHP, PhD
Professor,
School of Nursing and Midwifery
University of Technology Sydney/ Edith Cowan University,
3. Darren JACOB, RN, MN, GradDipNsg(ED)
School of Nursing and Midwifery
Mr, Registered Nurse, Research Assistant,
Joondalup Health Campus/ Edith Cowan University, Australia
Acknowledgements: Not applicable
Conflict of Interest Statement: No conflict of interest has been declared by the authors.
Funding Statement: This study is funded by the West Australian Nurses Memorial Charity. The
funders had no input into study design and the decision to submit the protocol for publication.
ABSTRACT
Aim: The aim of this study is to develop an assessment tool to measure the critical thinking ability of
nurses.
Background: As an increasing number of complex patients are admitted to hospitals, the importance
of nurses recognising changes in health status and picking up on deterioration is more important. To
detect early signs of complication requires critical thinking skills. Registered nurses are expected to
commence their clinical careers with the necessary critical thinking skills to ensure safe nursing

3. Accepted
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practice. Currently there is no published tool to assess critical thinking skills which is context specific
to Australian nurses.
Design: A modified Delphi study will be used for the project.
Methods: This study will develop a series of unfolding case scenarios using national health data with
multiple choice questions to assess critical thinking. Face validity of the scenarios will be determined
by an expert reference group of clinical and academic nurses. A Delphi study will determine the
answers to scenario questions. Panel members will be expert clinicians and educators from two states
in Australia. Rasch analysis of the questionnaire will assess validity and reliability of the tool.
Funding for the study and ethical approval were obtained in March and November 2016 respectively.
Discussion: Patient outcomes and safety are directly linked to nurses’ critical thinking skills. This
study will develop an assessment tool to provide a standardised method of measuring nurses’ critical
thinking skills across Australia. This will provide health care providers with greater confidence in the
critical thinking level of graduate registered nurses.
Key words: critical thinking, nurse, nursing, assessment, education, Delphi panel.
SUMMARY STATEMENT
‘Why the study is needed’
• Critical thinking is an essential skill for registered nurses to enable detection of changes in
patients’ conditions and effectively manage changing circumstances, yet no standardised
critical thinking tool is available which is context specific and relevant to Australian nurses to
assess this skill.
• Development of this assessment tool will provide a consistent method of measuring critical
thinking skills with measurable outcomes for all education providers.

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• A standardised tool will enable health care personnel to have greater confidence that new
graduate registered nurses will have an appropriate skill level to provide the required level of
care and ensure patient safety.
INTRODUCTION
Increasingly patients admitted to hospital are more complex with shorter lengths of stay, requiring
nurses to be more alert than ever before to changes in patients’ conditions (Beck 2009 , Castledine
2010). To manage complex patient presentations in fast paced environments, where clinical
information is available in piecemeal or delayed steps (West et al. 2012), requires nurses to quickly
and expertly recognise complications, picking up on what are often subtle signs of deterioration.
Nurses are often the first health care personnel to detect early signs of complications (Clarke & Aiken
2003 , Kutney-Lee et al. 2009) and to do so quickly and effectively requires advanced critical
thinking skills (Carter et al. 2015 , Perez et al. 2015). Differences in patient outcomes have been
attributed to nurses’ surveillance, a skill which is influenced by the level of nurse (enrolled or
registered nurse), their education, clinical expertise and years of experience (Kutney-Lee et al. 2009).
Registered nurses are expected to graduate from their undergraduate courses with the necessary
critical thinking skills to ensure safe nursing practice (Jacob et al. 2014).
Critical thinking has been defined as ‘weighing up the arguments and evidence for and against’
Cottrell 2008 (as cited by Whiffin & Hasselder 2013 p.831). It is described as the process of raising
questions, defining problems, gathering and assessing information and coming to well-reasoned
conclusions after looking at all alternatives (ISNA 2015). Other terms used for critical thinking
include clinical reasoning, clinical judgement, problem-solving, clinical decision making and the
nursing process (Perez et al. 2015). These processes are all linked to making professional judgements,
resolution of problems, or facilitating decision making. Critical thinking is a complex process
involving both cognitive abilities and attitudinal disposition (Nair & Leeseberg-Stamler 2013 , Perez

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et al. 2015) and is recognised as one of the main goals of higher education (Kerkman & Johnson
2014). Cognitive skills are thought to include operational skills such as the ability to interpret,
analyse, evaluate and infer whereas dispositional dimensions refer to a quest for thinking (Facione
1990) and include truth seeking, open mindedness, analyticity, self-confidence, inquisitiveness and
maturity of judgement (Carter et al. 2015). Professional critical thinking is different to other critical
thinking in that it is based on professional knowledge and directed towards clinical practice
(Castledine 2010).
As nursing has evolved as a profession and education of nurses moved into the higher education
sector there is less unquestioning obedience to the doctor and ‘his’ (usually) opinion (Castledine
2010). Critical thinking is now accepted as an essential part of nursing practice (Castledine 2010,
Pucer et al. 2014) and nurses are expected to use these skills to make appropriate professional
judgments in the face of complex patient care needs and changing clinical circumstances (Feng et al.
2010). Critical thinking is based on the best available evidence from patient assessment, scientific
knowledge and nursing research. These skills are developed over time through professional
knowledge, expertise and experience (Kutney-Lee et al. 2009). Development of these skills is
recognised as a priority for undergraduate nursing degree preparation (Carter et al. 2015).
This research aims to develop an assessment tool to evaluate the critical thinking skills of nurses in
Australia. Measurement of critical thinking ability will establish the effectiveness of student learning
to guide the development of teaching strategies to prepare students for practice.
BACKGROUND
Critical thinking skills are directly related to the identification of deteriorating patients and patient
safety (Feng et al. 2010, Robert & Petersen 2013). Undergraduate nursing education programs
internationally and in Australia are required to prepare students to think critically (ANMC 2002,
NMBA 2006, Wangensteen et al. 2011, Carter et al. 2016). These skills are expected to develop over
the course of an undergraduate degree as students improve their knowledge and understanding of

6. Accepted
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nursing science, practice and theoretical concepts (Jacob et al. 2014). There is wide acknowledgement
that the ability to think critically develops over time (Feng et al. 2010 , Wangensteen et al. 2011) and
is also related to experience in clinical practice and exposure to different environments (Feng et al.
2010 , Wangensteen et al. 2011). Therefore it is anticipated that students in the third (final) year of
their program should have greater critical thinking skills than commencing students.
Different approaches to teaching critical thinking include using case scenarios, concept mapping,
simulation, problem-based learning, interactive videodisc systems, reflective journaling, questioning
and role modelling (Feng et al. 2010 , Chan 2013 , Yeo 2014 , Przybyl et al. 2015 , Carter et al.
2016). Results from research on each of these different teaching methods is varied, although most
studies show some increase in critical thinking regardless of the method (Carter et al. 2016). A recent
systematic literature review found that most studies into teaching critical thinking in nursing have
small numbers of participants with limitations in terms of methodological rigour (Carter et al. 2016).
Despite being identified as a critical skill for nurses, measurement of higher order cognitive skills
remains inconsistent or neglected in nursing education (Walsh & Seldomridge 2006). Measurement of
critical thinking is necessary to both identify deficits and development areas for students and to
demonstrate the effectiveness of teaching methods (Carter et al. 2015). In the US and UK, many
universities assess students throughout their undergraduate program to demonstrate changes in critical
thinking to validate program outcomes required for accreditation (Newton & Moore 2013 , Robert &
Petersen 2013). Standardised tests are popular due to established reliability, validity and ease of
administration (Walsh & Seldomridge 2006). Tests such as ‘The Scale of Judgmental Ability in
Nursing’ (Seidl & Sauter 1990), ‘Watson-Glaser Critical Thinking Appraisal' (WGCTA) (Watson &
Glaser 2002), ‘Content Analysis Method’ (Newman et al. 1995) and the ‘California Critical Thinking
Disposition Inventory’ (CCTDI) and ‘Californian Critical Thinking Skills Test’ (CCTST) (Facione &
Facione 1996) are regularly used in the USA and UK. These tools use different measures to determine
critical thinking ability such as rating tools using rubrics and Likert scales to assess verbal responses,
evaluation of written responses to scenarios or multiple choice questions. They differ in the number
of questions (25-80 items) and length of completion time (15 -240 minutes) and whether they assess

7. Accepted
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generic critical thinking or nursing sensitive skills required for patient care (Perez et al. 2015).
Differences also exist in terms of which facets of critical thinking are measured, with some focusing
on cognitive thinking skills while others focus on disposition. Difficulties have also been identified in
using the above tools due to the time required for marking written answers, differences in assessor
evaluations, assessments via use of written assignments only, assessment of online student cohorts
and comparisons of groups, with recommendations for tools to be refined or new ones developed
(Landis et al. 2007). Carter et al. (2015) found limited reporting of reliability, little emphasis on
validity and inconsistent results across studies using commercially available tools for measuring
critical thinking (CCTDI, CCTST, WGCTA) (Carter et al. 2015).
Walsh and Seldomridge (2006) suggest that educators are still attempting to establish reliable and
valid methods for assessing changes to critical thinking in nursing students. For critical thinking tests
to be reliable and valid they need to be both discipline and context specific for nursing (Walsh &
Seldomridge 2006, Feng et al. 2010, Newton & Moore 2013, Robert & Petersen 2013, Carter et al.
2015, Perez et al. 2015). Hence for a test to be appropriate for the Australian nursing audience, it must
be specific and relevant to Australian nurses to cater for differences in terminology, workforce
structures, role expectations and national standards.
Assessment of critical thinking skills in undergraduate nurses in Australia requires no standardised
approach across universities. Assessment of student ability to meet the required standards of practice
as a registered nurse is at the discretion of each educational provider, with no external checks such as
national registration exams or cross institutional grading required to ensure students have these skills.
Once students complete an accredited nursing program they are eligible for registration as a nurse.
Perhaps as a consequence, concerns have been expressed as to whether Australian graduates indeed
possess critical thinking skills (Levett-Jones et al. 2010). Importantly for this study, Perez et al.
(2015) determined that the standardised instruments currently available to measure critical thinking
are not sensitive for measurement in the nursing discipline because they fail to link theoretical
concepts to the current health-care system and clinical environment.

8. Accepted
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THE STUDY
Aim
This research will develop an assessment tool to assess critical thinking skills in nurses in Australia.
The objectives of the study are:
• To develop an assessment tool to measure critical thinking skills in nurses using national data
and an expert reference group to develop case studies
• Use a Delphi technique to determine the correct responses to multiple choice questions related
to the case studies
• Pilot the tool with nursing students at one Australian university
Design
The research will use a mixed methods approach to develop a critical thinking assessment tool
specific to the Australian nursing context. The tool will use unfolding case scenarios to stimulate
critical thinking with a series of multiple choice questions (MCQ) related to assessment and patient
management. The reasons for the use of case scenarios and multiple choice questions for the
assessment are explained further.
Case scenarios
Case scenarios are recognised as a method of education that encourages critical thinking and active
learner engagement by mimicking real life situations (West et al. 2012). Case scenarios are
descriptions of actual patient situations, commonly involving a decision, challenge, opportunity,
problem or an issue faced by a person (Popil 2011). They are specifically designed to provoke
students’ thinking and are useful in developing and assessing critical thinking, as most clinical
problems have many solutions (Popil 2011). Unfolding case scenarios provide students with

9. Accepted
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increasing data as the scenario is revealed, allowing them to analyse and respond to each situation
before moving forward with additional information in the same case (West et al. 2012). This provides
a way of simulating real life situations where information related to patients may not be available or
be delayed and yet nurses are required to assess and make decisions regarding patient care on the
information at hand. ‘Case studies challenge learners to analyse problems and make decisions based
on limited, ambiguous, conflicting and at times incorrect information that simulates real life
situations’ (West et al. 2012, p.577). This approach is thought to enable the incorporation of
theoretical knowledge into clinical situations and help bridge the theory practice divide in nurse
education (Popil 2011). Students at different levels of learning and critical thinking ability will
demonstrate different abilities to connect theory and practice and translate previous learning into
current experience (West et al. 2012). It is anticipated that there will be differences in critical thinking
ability between students at different years in their undergraduate nursing degree and years of
experience.
It is important for realism that the patient scenarios mimic the clinical environment and include issues
that the students are likely to encounter (Gilbroy & Kane 2004, West et al. 2012). The case scenarios
will include any specialised information, such as diagnosis, vital signs, family support and current
situation, needed to enable the students to choose the relevant data to provide a correct response for
each multiple-choice question. To ensure the case scenarios are realistic and meet current clinical
needs, cases will be developed using government data to reflect the most common types of
presentations, age and gender that would be experienced in an acute health service in Australia. An
acute health focus was chosen as the majority of clinical placements undertaken by nursing students
are in these areas. The case studies will be designed around real clinical situations and developmental
in approach, progressing from simple to complex in terms of decision-making (West et al. 2012). This
approach to scenario development aligns with elaboration theory which suggests that different
complexity exists for any real-world case scenario and so questions should progress from simplest to
more complex (Haji et al. 2015). This is done to ensure students are not overwhelmed during the
testing (Haji et al. 2015). More than one case scenario will be developed as recommended by West et

10. Accepted
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al., (2012) to enable different clinical scenarios and situations to be explored. Five case scenarios will
be developed for this study and they will be reviewed by two experienced clinicians and two nursing
academics to provide face validity. This will ensure that the scenarios are relevant to clinical practice
and contain the necessary information to answer the questions provided.
Multiple Choice Questions
Multiple-choice questions (MCQ) require students to use critical thinking skills to evaluate different
response options and determine which best solves the problem (Kerkman & Johnson 2014).
Integration of critical thinking in MCQ is acknowledged to be challenging but can be achieved if
principles of higher order thinking are incorporated by question developers (Tractenberg et al. 2013).
As suggested by Tractenberg et al. (2013), development of the MCQs will be undertaken through
collaboration between an assessment expert with specific training in question writing and a clinical
nurse with expertise in nursing. Rasch modelling will be used to determine the reliability and validity
of the assessment tool and as a method of estimating item difficulties to assist with scoring of
questions (Tractenberg et al. 2013).
To prevent student overload (Gilboy et al. 2004), 25 MCQs in total will be developed for the tool.
Between three to nine questions are expected for each case scenario, depending on the focus. In
developing the MCQ answers, varied ways of caring for patients will be supplied, providing students
with a choice of answers to enable critical thinking skills to be revealed (Walsh & Seldomridge 2006).
The questions will vary in difficulty and complexity. The variation in question difficulty enables
students to demonstrate their level of proficiency at critical thinking, allowing maximum performance
by students with more advanced critical thinking skills. It is expected that the amount of nursing
knowledge and clinical exposure students have had will influence their ability to undertake critical
thinking regarding the situation. Rules for delivery recommended by Gilboy et al. (2004) will be
adopted for the assessment, such as students cannot go back to a previous question and change their

11. Accepted
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answers and a specified time is allowed for each answer. The online platform Qualtrics 360 (Qualtrics
2016) will be used for development of the assessment tool.
Modified Delphi technique
A consensus methodology with an expert working group using a modified Delphi technique will be
used to determine the importance, accuracy and relevance of each of the suggested answers to the
MCQ questions. A Delphi consultation is a method for gathering opinions where participants do not
meet. The use of group consensus overcomes limitations of the test that may be due to the particular
bias of the individual designers (Haji et al. 2015) and results in a ‘generalised expert opinion’.
Advantages of using a Delphi technique include ensuring panellists’ anonymity, reduced influence
from dominant participants, ease of administration of questionnaires through electronic media,
participant able to provide input from geographically diverse areas and participants are able to take
time to consider answers rather than respond immediately to questions (Haji et al. 2015). The use of
subject matter experts enables identification of critical content points and enables refinement of the
tool to meet expected levels of critical thinking. This will ensure content validity, reliability and
consistency of the tool, confirm clarity of the question and ensure correct answers.
Panel Members
The participants for the Delphi study will be experienced clinicians and academic nurses. Expert panel
members are defined as a person who has extensive knowledge and/or experience in nursing practice
or nursing education. Persons with at least 5 years of clinical or teaching experience in their specialty
area or nurse education will be considered experts (Paul 2014). Purposive sampling will be used to
ensure an adequate number of participants. Individuals considered clinical nursing education experts
will initially be nominated by the researchers. Each nominee will be contacted electronically with
information regarding the study and expected time commitments for the study, expected to be no

12. Accepted
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more than three rounds. A panel of 10-15 experts is considered adequate to balance representativeness
from different clinical settings (Haji et al., 2015). Panellists will be provided with an identification
number to ensure confidentiality through the process.
The surveys will be sent to panellists using an electronic link to Qualtrics software, Version
November 2016. Part one of the survey will include the instructions for completion of the survey and
demographic data, such as clinical specialty, years of experience in clinical nurse education. The
second part of the survey will ask panellists to rank the MCQ answers provided for each question
from least correct to most correct for given case scenarios. Free text boxes will be included at the end
of each question to enable comments from panellists or suggestions for revisions. Panellists will be
given two weeks to complete each round. The questionnaire will then be revised based on feedback
regarding accuracy and clarity of questions. Following the initial round, participants will be sent a
report outlining their individual scores, the group scores and the mean standard deviation for each
question. In following rounds panellists will be sent a revised questionnaire reflecting suggested
revisions and again asked to rank the answers, taking into consideration their previous responses and
the mean responses from the panel. Panellists who disagree with the consensus decision will be asked
to justify their response. Consensus will be defined based on the consistency of opinion amongst
panellists of 80% agreement for each item (Paul 2014). It is anticipated that no more than three rounds
of surveys will be required for the study.
Piloting of tool
Following development of the critical thinking tool, it will be piloted using student nurses at one
campus of an Australian university. The sample will consist of students at the beginning and end of
their three years of university study. Power analysis at alpha level of 0.1 and power level of 80%
suggests a total sample size of 82 participants is required if the effect size is moderate, or a total
sample size of 34 participants if the effect size is high. The sub sampling by category is calculated
based on a 2:1 ratio (i.e. two participants in year 1 cohort for every participant in year 3 cohort). This

13. Accepted
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translates into 55 year 1 and 27 year 3 participants for a moderate effect size, or 23 year 1 and 11 year
3 participants for a high effect size. Use of the two different levels of undergraduate degree students
will enable identification of whether the tool identifies differences in critical thinking skills between
students in the different year levels. Students will be recruited using an online platform through the
University and the unit coordinators will alert students to the presence of the study in both stage one
and stage six of the Bachelor of Nursing program. Participation in the study will be anonymous by
clicking on a link to the Qualtrics program through the email. Completing the survey will be seen as
informed consent. The students’ previous level of education, years of nursing experience, previous
educational level and age will also be collected to determine if these factors influenced the level of
critical thinking level obtained by the student.
Data analysis
Data from the Delphi study will be undertaken using statistical analysis through the Qualtrics
program. All panellists’ opinions will be weighted equally. A mean of all responses for each question
will be determined. Consensus will be determined when a minimum of 80% of respondents agree for
a given question.
Data analysis for the student pilot will be undertaken using both statistical methods and content
analysis. IBM SPSS Version 19 (IBM 2010) will be used for all quantitative analysis. Descriptive
statistics will be used to describe student cohorts, including mean and standard deviation or median
and interquartile range for continuous variables such as age, time at university; and percentages for
categorical variables such as age and student type. Data will be analysed and compared using t-test
analysis to determine if difference in critical thinking is found between the two groups of nurses.
Open ended questions will be analysed using content analysis methods.

14. Accepted
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ETHICAL CONSIDERATIONS
Ethics approval was granted in 2016 from the University (Project No. 15626). Implied consent will be
obtained from Delphi participants through completing the surveys. No person participating in the
study will be named in any reports from the findings. Students participating in the pilot will be
anonymous and provide implied consent by completion of the survey.
VALIDITY AND RELIABILITY
Content validity, reliability and consistency of the tool will be assessed through the Delphi study
process. Rasch modelling will determine the reliability and validity of the assessment tool as a
method of estimating item difficulty for scoring of questions (Tractenberg et al. 2013).
DISCUSSION
Critical thinking skills are directly linked to patient outcomes and patient safety (Robert & Petersen
2013). The outcome of this study will be the development of a tool to assess critical thinking skills of
nurses in Australia. This will benefit the Australian community in several ways. Currently there is no
contexts specific assessment tool available to assess individual nurses’ critical thinking skill level that
is used throughout Australia. With national nursing registration but no national standard or method for
assessment of critical thinking skills, it is difficult to ensure that on graduation, nurses have the same
skill level, or indeed any skill in this area.
Limitations
Limitations of this study include that only one university will be used in the development of the tool.
It expected that following development, the tool will be further tested on students at different
universities and in other states of Australia.

15. Accepted
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CONCLUSION
Development of this assessment tool will provide a consistent method of measuring critical thinking
skills with measurable outcomes for all education providers. Importantly, health care facilities should
have greater confidence that new graduate registered nurses will have an appropriate skill level of
nurses to provide the required level of care. The research will also enable differences in the critical
thinking skill level of the different level of nursing care provider to be assessed.
Author Contributions:
All authors have agreed on the final version and meet at least one of the following criteria
(recommended by the ICMJE*):
1) substantial contributions to conception and design, acquisition of data, or analysis and
interpretation of data;
2) drafting the article or revising it critically for important intellectual content.
* http://www.icmje.org/recommendations/
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16. Accepted
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17. Accepted
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18. Accepted
Article
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