الفهرس 
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Abstract
Today, nursing experts believe that critical thinking is an integral part of education at any level especially for undergraduate students. Since Critical Thinking is the kind of thinking that leads to the best solution, analysis, evaluation, selection and applications. Critical thinking is a careful, reasonable and reflective way of thinking in which the person does not simply accept all arguments and conclusions exposed to but rather has an attitude involving questioning such arguments and conclusions. It means making reasoned judgments that are logical and well-thought-out. CT is a major requirement to make better decisions and self-efficacy, which consider an act of deliberately analyzing information so that one can make better clinical decisions.
Aim of the study
Investigate the effect of implementing critical thinking training program on internship nursing student’s clinical decision making abilities and perceived self-efficacy.
Setting This study was conducted at two settings; the first setting was Faculty of Nursing – Alexandria University; due to it continuously aim to enhance/improve teaching process to acquire the international accreditation. The second setting was Alexandria Main University Hospital. It considered the main hospital that nursing students receive their internship training and they spend about nine months in its critical units. Also, it considers the first stakeholders setting contact with newly graduate students.
Subject
The study sample included one group who were newly graduated from Bachelor Degree of Nursing Science (BScs). A purposive sampling included the participants who were newly graduated 2020 – 2021 before they started their internship from the previously mentioned faculty. A sample size of 65 participants.
Inclusion criteria:
The nurse interns who did not have record of psychological disorders and using its related drugs as it effects on their mental ability.
The nurse interns who graduated from BScs of nursing of academic year 2020 – 2021,
The nurse interns who are receive the internship training at Main University Hospital at the time of data collection,
The nurse interns who are willing to participate in the study.
Exclusion criteria:
The nurse interns who received internship training in operating theater (OR) at the time of data collection,
The nurse interns who were received additional courses or training programs regarding CT and CDM before.
Tools
Five tools were utilized in this study for data collection:
Tool (1): Nursing interns’ knowledge regarding Critical Thinking (CT) questionnaire
It was developed by the researcher based on review of related literature (Abd Elgawad et al., 2021; Abdel-Wahid & Attia, 2020; Alfaro-Lefevre, 2019c) to assess Nurse Interns’ knowledge regarding CT. It consists of 10 open ended questions for example (Define CT?, what are the importance of CT….etc). Responses were measured as follows; complete true answer score =3, incomplete true answer score =2 and incorrect answer =1. The overall score range from 10 – 30, ≤60% (≤18 score) indicates low CT knowledge, from 61-75% (19 – ≤22 score) indicates moderate CT knowledge and more than 75% (>22 score) indicates high CT knowledge.
Tool (2): Yoon’s Critical Thinking Disposition (YCTD) Questionnaire
This tool was developed by Yoon (2004) revised by author (2008) and validated by Shin et al., (2015). It was adapted by the researcher to assess the level of CT disposition as perceived by nurse interns. It consists of 27 items classified into seven dimensions namely; self-confidence (4 items), eagerness/curiosity (5 items), fairness (4 items), objectivity (3 items), prudence (4 items), healthy skepticism (4 items) and systematicity (3 items). Responses were measured on a five point Likert scale ranging from (1) strongly disagree to (5) strongly agree. Reverse coding items (No. 17 & 20) were done. The overall score range from 27 - 135, ˂ 60% (˂ 81 score) indicates weak disposition, from 60% - 80% (81 – 108 score) indicates positive inclination and ˃ 80% (˃ 108 score) strong disposition of CT.
Tool (3): Clinical Decision Making Questionnaire
It consists of three parts; part A, was developed by Center for Nursing Education and Testing C-NET (1973) and updated by C-NET (2020). It was adopted by the researcher to assess the Clinical decision making abilities among nurse interns. It consists of 30 multiple choice scenarios were classified into two dimensions as follow; recognizing the emergency situation (11 items) and clinical decision making and intervention (19 items). Responses were measured as follows; the correct answer score =2 and incorrect answer score =1. The overall score range from 30 – 60, ˂ 60% (˂ 36 score) indicates low CDM abilities, from 60% - 80% (36 - 48 score) indicates moderate CDM abilities and ˃ 80% (˃ 48 score) indicates high CDM abilities.
Part B, was developed by the researcher based on review of related literature (Abd Elgawad et al., 2021; Abdel-Wahid & Attia, 2020; Alfaro-Lefevre, 2019c) to assess Nurse Interns’ ability to give rational for own decision. It consists of one open ended question follow each multiple choice questions from part A; the question was (Why you choose this answer?). Responses were measured as follows; complete true answer score =3, incomplete true answer score = 2 and incorrect answer = 1. The overall score range from 30 – 90, ≤60% (≤54 score) indicates low ability to give rational for own decision, from 61-75% (55 – ≤68
score) indicates moderate ability to give rational for own decision and more than 75% (>68 score) indicates high ability to give rational for own decision.
Part C, was developed by the researcher based on review of related literature (Abd Elgawad et al., 2021; Alizadeh et al., 2020; Chesser, 2016) to assess Nurse Interns’ confidence level in their own decision. It consists of one question of five point Likert scale follow each multiple choice questions; the question was (To what extent you confident of your decision/answer?). Responses were measured on a five point Likert scale ranging from (1) not confident to (5) very confident. The overall score range from 30 - 150, ˂ 60% (˂ 90 score) indicates low confidence level, from 60% - 80% (90 - 120 score) indicates moderate confidence level and ˃ 80% (˃ 120 score) high confidence level of own decision/answer.
Tool (4): Perceived Self-Efficacy (SE) Questionnaire
It was developed by Schwarzer & Jerusalem (1979) and validated by Abou-Elala (2012) and Salanova, et al., (2012). It was adapted by the researcher to assess the study participants’ perceived self-efficacy level. It consists of 10 items measured on four point Likert scale ranged from (4) = exactly true to (1) = not at all true. The overall score range from 10 – 40, ˂ 50% (˂ 20 score) indicates low perceived self-efficacy, from 50% - 75% (20 - 30 score) indicates moderate perceived self-efficacy and ˃ 75% (˃ 30 score) indicates high perceived self-efficacy. For example, it is easy for me to stick to my aims and accomplish my goals.
Tool (5): Training Program Effectiveness Feedback Questionnaire
It was developed by the researcher based on the review of related literature (Abdel-Wahid & Attia, 2020; Algahtani et al., 2020) to evaluate effectiveness of training program (strength and weakness points) from intern nurses’ point of view. It consists of includes 21 items classified into six dimensions namely; searching (3 items), content (6 items), environments (3 items), presentation (6 items), organization of teamwork (2 items) and general satisfaction (1 item). Responses were measured as follows; present and complete =2, present incomplete =1 and not present =0. The overall score range from 0 – 42, ≤ 60% (≤ 25 score) indicates poor, from 61% - 75% (26 – ≤ 31 score) indicates neutral and ˃ 75% (˃ 31 score) indicates good training program.
Method
1. An approval was obtained from the Research Ethical Committee at the Faculty of Nursing, Alexandria University to approve the protocol.
2. An official communication was released from the management of the Faculty of Nursing, Alexandria University to the hospital authority to get an agreement to conduct the study.
3. The researcher took permission from the hospital administrator who permitted the intern nurses for cooperation with the researcher.
4. The five tools were tested for its face and content validity by a jury of seven experts from the Faculty of Nursing, Alexandria University.
5. Scale- Content Validity Index/ Average done for three tools were developed by the researcher; CDM Questionnaire (three parts), Nurse Interns’ knowledge regarding CT questionnaire and Training Program Effectiveness Feedback Tool.
6. The study tools were tested for their reliability using cronbach’s alpha coefficient and all tools were reliable.
7. A pilot study was carried out on 10 % of nurse - interns (n=7) rather than the study subjects in order to check and ensure clarity of tools, their applicability, feasibility, identify obstacles and problems that may be encountered during the training program and data collection.
Data Collection
In this study, the data collection framework of ADDIE model was adapted by the researcher. Data were collected as following these steps:
I. Assessment Phase (from 4 May 2021 to 10 July 2021)
This phase done as follows:
a) Assess internship nursing student’s CT by using (YCTD) (tool II) was self-administered to the participant’s pre the training program.
b) Assess internship nursing student’s CDM abilities by using Clinical Decision Making (tool III) was self-administered to the participant’s pre the training program.
c) Assess internship nursing student’s perceived self-efficacy (tool IV) was self-administered to the participant’s pre the training program.
II. Planning stage (from 4 May 2021 to 10 July 2021)
Based on the previous phase the planning phase included:
a) General and specific objectives according to program content as definition of CT and CDM, CT skills, models, dimensions and tools.
b) The study subjects was divided into (4) groups (17, 16, 16 and 16 in each group) according recommended social distance. The training program was carried out for 6 working days 2 hrs/day total 12hr/group before the formal internship program.
c) Teaching strategies of the program were blended learning through face to face and Microsoft team.
d) Audiovisual material as PowerPoint and videos were used based on learning content.
e) Avenue place of conducting the program was at class 8th fourth floor.
III. Implementation phase (from 25 July to 15 September 2021)
1. select the subjects through recruitment as follow:
An advertisement Posted through the faculty official page on face-book and Microsoft team about the CT training program.
Application form was filled on voluntary base by the nurse-interns need who accepted to participate in the training program.
Electronic selection of study subjects based on inclusion criteria.
2. Conducted CT training program as pre-identified planning.
3. Suitable teaching strategies and instructional materials were used.
IV. Evaluation phase (from 16 September to 20 September 2021)
Evaluation of CT training program was carried out as follow:
1. Evaluation of the training program effectiveness through tools (I, II, III, IV) provided to study subjects immediately after completing the training program and after one month to assess their CT, CDM and Perceived SE.
2. Evaluation of the training program from participant’s point of view through (tool V) to study subjects immediately after completing the training program.
The following were the main results of the present study:
- The median age of nursing interns was (22 year) and 89.2 % of nursing interns were single, with female making up the bulk of this group (83.1%).
- There was statistically significant difference between the knowledge of nurse interns’ before and immediate after application the CT training program (p<0.001*).
- The nurse interns’ mean scores for critical thinking disposition had increased substantially before and after the CT training sessions (p<0.001*).
- The mean percent scores for clinical decision-making abilities among nursing interns significantly enhanced both immediately after and after one month later the application of critical thinking training program.
- The mean percent scores of nursing interns regarding the Self-Efficacy level had significantly increased (P<0.001*) both immediately after and one month after the implementation of the critical thinking training program.
- Almost all nurse interns had high mean percent score regarding their opinion of CT training program (98.94 ± 2.63). While, all participants satisfied from content, environment and general satisfaction.
The finding of this study results in the following recommendations:
- Develop a project proposal for applying CT for all nursing interns.
- Develop a training program about CT tools as concept mapping for newly graduate students.
- For undergraduate and graduate nursing students, concepts of CT, CDM and SE were applied in theoretical and practical courses, both in terms of knowledge and behavior, in order to foster positive attitudes and understanding of thought differences among nursing students throughout the educational process.
- By creating a variety of training programs and interactive communication workshops, nursing educators can increase their knowledge of the value of CT, become more capable at making decisions, and be inspired to help nursing students develop their CT skills.
Carry out group discussions, engage in cross-cultural peer exchange of ideas and experiences, learn from current case studies, and use reliable technological resources and CT skills to solve problems.
- Provide continuous in-service educational programs and training programs for intern nurses related to CT, CDM and SE during internship year especially during orientations.