Critical thinking: concept analysis from the perspective of Rodger's evolutionary method of concept analysis

ABSTRACT Objective: to analyze the concept of critical thinking (CT) in Rodger's evolutionary perspective. Method: documentary research undertaken in the Cinahl, Lilacs, Bdenf and Dedalus databases, using the keywords of 'critical thinking' and 'Nursing', without limitation based on year of publication. The data were analyzed in accordance with the stages of Rodger's conceptual model. The following were included: books and articles in full, published in Portuguese, English or Spanish, which addressed CT in the teaching and practice of Nursing; articles which did not address aspects related to the concept of CT were excluded. Results: the sample was made up of 42 works. As a substitute term, emphasis is placed on 'analytical thinking', and, as a related factor, decision-making. In order, the most frequent preceding and consequent attributes were: ability to analyze, training of the student nurse, and clinical decision-making. As the implications of CT, emphasis is placed on achieving effective results in care for the patient, family and community. Conclusion: CT is a cognitive skill which involves analysis, logical reasoning and clinical judgment, geared towards the resolution of problems, and standing out in the training and practice of the nurse with a view to accurate clinical decision-making and the achieving of effective results.


Introduction
The concept of critical thinking (CT) has, over the last two decades, been one of the most discussed in the area of the teaching and clinical practice of Nursing (1)(2) .
However, as a transversal domain, it extends to the various areas in which people work, from the most simple and routine, to the most complex and painstaking professional and academic tasks (3)(4) .
The literature on CT has its roots in two academic disciplines: philosophy and psychology (4)(5)(6) . However, one can also observe a third axis in the field of education (4,6) . In philosophy, one seeks to define the hypothetical critical thinker based on her qualities and characteristics (4,6) , while psychology seeks to describe the critical thinker based on her skills or actions (4) . In the ambit of education, there is a focus on the teaching and assessment of CT skills. As a result, there is a lack of consensus regarding the concept of CT in the literature, especially in the area of Nursing, which is influenced by these three axes.
In the area of healthcare -including nursing -the aging of the population, the increase in the complexity of illnesses and consequently in the care required, as well as the demand for services, require a professional with skills in CT, problem resolution and decisionmaking, and who is capable of appropriately accessing information, leading to safe, efficacious clinical practice which is based in scientific evidence (3,(7)(8) .
CT is an essential tool for the teaching and care practice of the nurse, and must not be confused with intelligence, but, rather, understood as a skill which can be learned (9)(10) . This being the case, because of the importance of the need to train professional nurses able to think critically, the Red Iberoamericana de Investigación en Educación en Enfermería (RIIEE) addressed this issue in its multicentric investigation project (11) carried out in 16 countries in Ibero-America, this study being part of this investigation.
Researching CT in conjunction with an international investigation network (11) encouraged the authors to undertake the present work, as, as has been observed in the literature in Nursing (4,7,(11)(12) , the term CT presents variations, causing frequent disagreements, which indicates the need for refining and clarifying the concept.
As a result, this study's objective is to analyze the concept of critical thinking in the teaching and clinical practice of Nursing, in the perspective of Rodger's evolutionary model of concept analysis (13) . The rationale for this study of the conceptual analysis of CT, specific to Nursing, is that it promotes clarification for future studies in the ambit of these professionals' academic and clinical practice.

Method
A documentary study (14) based on the evolutionary model of concept analysis proposed by Rodgers (13) . This model understands the concept as a reverberation of the phenomena, which are dynamic, as they change over time and have a direct relationship with the context of their use. They have an inductive, nonsequential and descriptive character, indicating systematic rigor, considering a definition which presents conceptual problems (13) .
The process of analysis of the concept took place based on its substitute terms and related concepts, attributes, antecedents, and implications, and involves five stages (13) . In the first stage, the concept of interest was identified (13) , in the present study, CT, including the expressions and substitute terms used for the concept in the literature.
In the second stage, undertaken in February 2015, the authors proceeded to consult with the Cinahl, Lilacs and Bdenf databases (13) , due to these being considered to be important in the context of the Brazilian and foreign scientific production, in the ambit of Nursing. Use was also made of the Dedalus database, for obtaining textbooks of Nursing from the Collective Catalog of the Libraries of the University of São Paulo.
As a specific descriptor for CT was not found, the same was inserted in the search as a keyword, along with the descriptor 'Nursing'. The works were identified using the search strategy of critical thinking AND nursing and its variations for Portuguese and Spanish, without limiting the search by year of publication. A total of 529 works were located in the databases mentioned.
In the third stage, for collection of the relevant data, identification of the attributes, and the contextual basis of the concept (13) , the following were defined as inclusion criteria: textbooks and articles of Nursing published in full, published in English, Portuguese or Spanish, and which addressed CT in the teaching and clinical practice of Nursing. The following were defined as exclusion criteria: duplicated studies and those which did not address aspects related to the concept of CT.
In the fourth stage, for analysis of the data and identification of their characteristics (13) , firstly the reading of the titles of the works selected in the second stage was undertaken, based in the criteria of inclusion and exclusion. A total of 481 works was obtained. Next, the abstracts were read in order to select those which addressed the issue of CT in the context of Nursing.   (the Figure 1 continue in the next page...) The identification of the substitute terms represents the first approximation with the concept to be analyzed (13) , for understanding the origin, development, functions and interconnections of a concept with other similar words or expressions. The substitute terms for CT identified were: analytical thinking (15) critical-creative thinking (16) (12%), nonlinear thinking (17) (9.5%) and critical-holistic thinking (16) (9.5%).
Differently from the substitute terms, the concepts related to CT (Table 1) have a link and closeness to it, but are not synonymous with it.   The antecedents, like the consequences of a concept, are conditioned to a contextual basis, in this case, the concept of CT in Nursing. In addition to this, they are related to the situational, temporal, sociocultural and course-related contexts of the profession at the present time (13) . The antecedents are considered the events, situations or phenomena which precede the concept investigated, while the consequences are situations which result from the occurrence of the concept in question (Table 3).
(continue...) important aspects for the development of the concept over time (13) . In accordance with the frequency as certained in the works, the implications and hypotheses are listed in Table 4. The implications and hypotheses represent, respectively, the results and possibilities to be achieved (13) by a critical thinker in the ambit of Nursing and are

Substitute terms and related factors/concepts
The concept of CT remains little clarified in the Nursing literature (1,16) , it being possible to identify a number of close words/expressions which are capable of representing or even explaining attributes and skills of an ideal critical thinker. In this regard, it becomes important to make it clear that substitute terms figure as expressions with meanings which are similar to the concept of CT. This aspect was discussed in one review study (16) , which indicated that clinical reasoning and CT are, often, used as synonymous terms inappropriately, as CT involves skills and attitudes which are necessary for the development of clinical reasoning.
Based on the empirical material researched, the most frequent substitute term was analytical thinking, followed by critical-creative thinking. These substitute terms, to the contrary of clinical reasoning, are synonyms, as they present a semantic interconnection with CT. As a result, when a nurse assesses a patient's health problem, observing, examining, recognizing and raising hypotheses regarding health problems, she is using analytical thinking, which can also be termed CT (17) .
On the other hand, the related factors (Table 1) have a correlation of cause or effect with the concept.
For CT, the main related factors identified are aptitudes which are necessary for undertaking the stages of the Nursing process, such as decision-making (16) , clinical judgment (18)(19) and clinical reasoning (11) . This Rev. Latino-Am. Enfermagem 2016;24:e2785 relationship is not one of mere causality, it having been demonstrated in one study (20) that CT skills establish a relationship between themselves and, in the same way, with the stages of the diagnostic process in Nursing.
Furthermore, CT involves skills and attitudes which are fundamental for achieving excellent goals of diagnostic accuracy. It is emphasized that, as a structural element of CT, clinical reasoning leads to clinical judgment, resulting in clinical decision-making (12,15,20) .
Another term which has been described many times coupled with CT, nearly forming a single term, is the concept of reflexive thinking (11,(15)(16) . The reasoning for this may be related to the fact that some authors consider reflection to be a skill of the critical thinker. Based on the hypothesis that reflection leads to critical thinking, one experimental study (21) , using reflexive writing, was undertaken with 70 undergraduate students of nursing.
As a result, a significant increase was observed in the CT skills among the students of the experimental group.
It is, therefore, relevant to undertake studies of this issue, as they assist in the process of understanding and evolution of the concepts.

Attributes of the concept of CT
The attributes bring together a real definition of the concept, different from the nominal definition provided in dictionaries, which simply substitute one word or expression with another which is synonymous (13) . As a result, the attributes are an integral part of a concept, corresponding to its characteristics. The sum of these attributes typifies and characterizes the concept. As presented in Table 2, the attributes which qualify CT are made up of skills and dispositions.
It is inferred, based on these results, that in the literature there is a major influence of the Delphi Report (22) , a consensus undertaken at the beginning of the 1990s by an interdisciplinary group of specialists in CT from the area of the humanities, social sciences, and education, defining the essential characteristics of the ideal critical thinker. The report (22) describes a significant proportion of the attributes identified in this study, such that these constitute the characteristics examined in most of the psychometric scales for assessing the development of CT.
In the literature analyzed, the skill mentioned most frequently for a critical thinker was "analysis" (11,15,19,22) or the ability to break something down in order to achieve an understanding of a given situation. It is believed that this skill is essential in academic and professional activity in Nursing, in that the understanding of the whole is limited to analysis of the parts, whether in the learning of a technique or in taking the patient history.
The most frequent disposition was "openmindedness" (19,22) or impartiality in assessment, overcoming preconceptions in a rational way for prudent judgment and later decision-making. However, as studies indicate (4,6,20) , these skills and dispositions must be constantly exercised, given that the human mind tends to base its decisions on patterns of the cause-andeffect type, often intuitively, without careful examination of the possible alternatives.
As a result, for the improvement in the attributes of CT, the student or professional of Nursing must adopt a stance of seeking, in a careful, rational and active way, the improvement of the cognitive and affective aspects which are inherent to her professional and personal activities (21,23) . Based on this definition, it may be perceived that CT is a practical activity based on the sensible search for reason, through skills and dispositions, it being essential for the individual to have an inclination or attitude for carrying these out (20) . In this process, the importance of thinking about thought (metacognition) (4) is underlined as a necessary path to developing CT skills.

Antecedents of the Concept
Based on the categories presented in Table 3, the emphasis on the development of CT in the teaching and training of the student of Nursing is clear (11,16) , as well as the importance of the Teaching Policies, in particular the Brazilian National Curricular Guidelines (DCNs)of the undergraduate courses in Nursing (11,(24)(25) as phenomena which have leveraged the discussions and highlighted the importance of training nurses in the skill of thinking critically.
In Brazil, the DCNs (25) bestow curricular flexibility, which viabilizes pedagogical projects geared towards specific goals or demands. As a result, there is the possibility of a teaching permeated by CT, as it progresses towards problematizing training, linking teaching, work and community.
Another aspect also evidenced as a predecessor of CT was the seeking of better results in clinical practice (14,18,22) and the scientific and technological advance (25)(26) , which represent an important challenge at the time of writing, as a result of the competencies and skills which are necessary and required for the students and nurses in order to respond efficaciously to the complexity of the health systems. In this regard, studies (16,19,23) indicate that the rapid technological and in health management (15,23,27) . Besides this, the nurse's decision-making must take into account the evidence deriving from professional experience, the scientific literature and the patient's requirements, with a view to the safety and quality of the health services.

Consequences of the concept of CT
The consequences of a concept are closely related to the antecedents and must follow them (13) . As a result, the consequences presented in Table 4 are considered to be situations which result from the occurrence of CT.
Hence, they trigger actions in practice and/or teaching.
The latter two, although distinct, are fundamental in the nurse's practice and lead to clinical decisionmaking. Clinical reasoning involves mental processes applied in the activities of the nurse who, based on a judgment based on knowledge, will take an appropriate decision. In this process of intellectual action, which results in clinical intervention, CT acts as a regulator of the patterns of thinking (8,12) . It thus covers an attitude of being disposed to considering, in a conscious way, the problems which arise in the ambit of the clinical experience or of teaching.
For effective decision-making based in CT, therefore, persistent effort is required for examining any situation or supposed form of knowledge in the light of evidence which supports new conclusions in regard to it (10,15) . One study (23) which assessed the structural elements of CT in 20 nurses from emergency services corroborated these findings, as it emphasized the importance of CT for clinical decision-making, as well as its interconnection in the managerial, multi-professional and teaching ambits. It is relevant to emphasize that the first three consequent terms identified previously also appeared as related concepts in Table 1, reinforcing the tenuous interconnections with CT.

Implications and hypotheses of the concept of CT
The main implications and hypotheses listed in Table   4 (19,(26)(27) .
One longitudinal Australian study (28)  Rev. Latino-Am. Enfermagem 2016;24:e2785 As indicated by the works analyzed (15,23,26) , it is believed that, as she progresses in the dimensions of CT, the student or nurse can achieve greater professional satisfaction and autonomy in her work process. Among various factors analyzed in one study (29) , the nurses reported that they achieved greater professional satisfaction as they achieved greater autonomy. In this regard, CT and its structural elements are intermediary tools which lead the professional to assertiveness in her clinical actions, creating safety, autonomy and satisfaction.

Conclusion
The concept analysis, based in Rodger's evolutionary As limitations of the study, the fact is highlighted that studies were selected from Latin American databases, with the exception of Cinahl. However, the study met the needs of the multicentric RIIEE project.
As a consequence, broader studies become important, considering that the concept changes over time.
Furthermore, it is necessary to develop the clarification of the concept of CT in other areas of knowledge.