Abstract
Introduction
Critical thinking, defined as the purposeful, self-regulatory judgment involving interpretation, analysis, evaluation, and inference, is a fundamental requirement for education in the healthcare field. Reflection, a metacognitive process that promotes self-awareness and deeper understanding of experiences, is regarded as one of the key strategies that enhances critical thinking disposition by fostering motivation and habitual application of these skills.
Objective
This study aimed to evaluate the effects of daily versus weekly reflection on the critical thinking disposition of nursing students, including its dimensions of engagement, innovativeness, and cognitive maturity.
Methods
This quasi-experimental study with a pretest–posttest design was undertaken at Birjand University of Medical Sciences, Birjand, Iran in 2023. Participants (n = 48; 24 per group) were recruited via census sampling method and randomly assigned into two daily and weekly reflection groups. The intervention was conducted during four weeks of clinical training. Data were collected through a demographic information questionnaire and Ricketts’ critical thinking disposition questionnaire.
Results
No statistically significant differences were observed between the two groups concerning the mean scores for overall disposition towards critical thinking (p = 0.673, Cohen's d = 0.12) and for each of its dimensions: engagement (p = 0.740, Cohen's d = 0.08), innovativeness (p = 0.281, Cohen's d = 0.22), and maturity (p = 0.652, Cohen's d = 0.10) both before and after the intervention. Mean scores slightly increased in both groups post-intervention (daily: +3.2, 95% CI [1.5, 4.9] ; weekly: +2.8, 95% CI [1.0, 4.6]), though not significantly.
Conclusion
Considering that the mean score of critical thinking disposition and each of its dimensions after the 4-week intervention in the two groups had no statistically significant difference, therefore, it is suggested to investigate the long-term effect of daily and weekly reflection in future studies.
Background
In recent years, critical thinking has garnered significant attention from educational institutions. The labor market's demand for specialists with more profound and effective learning has prompted universities to adopt effective methods for training professionals and graduates. This includes an emphasis on enhancing critical thinking skills to foster deeper and more applicable knowledge. (Choy & Cheah, 2009).
Critical thinking fundamentally involves the purposeful use of cognitive skills such as analysis, evaluation, inference, explanation, combined with a disposition or motivation to apply these skills consistently (Facione, 1990). It requires conscious reflection on issues to achieve logical and contextually appropriate outcomes (Ricketts et al., 2018). In medical disciplines like nursing, critical thinking is essential for accurate patient assessments, decision-making in complex scenarios, and adapting to dynamic healthcare environments (Jafari et al., 2020). Nursing students must develop these abilities to handle evolving roles, where critical thinking disposition—the attitudinal inclination towards engaging in critical thought—plays a key role in motivating skill application (Papp et al., 2014).
Critical thinking encompasses two essential components: skill and disposition. Disposition refers to the internal motivation, open-mindedness, and perseverance needed to engage in critical thinking, without which skills alone are insufficient (Bonet et al., 2022). However, recent research has focused more on skill development, with less attention to fostering disposition.
Review of Literature
Limited research on critical thinking disposition indicates a generally low inclination among students, highlighting the need for targeted interventions (Ahmady & Shahbazi, 2020). Educational institutions must prepare expert personnel with strong critical thinking skills and motivation (Jafari et al., 2020). Consequently, they are compelled to implement effective strategies to enhance both the skills and motivation associated with this type of thinking (Ahmady & Shahbazi, 2020). Among the effective strategies in improving the application of critical thinking disposition is the use of reflective exercise, which has attracted the attention of researchers and scholars in recent years (Mamede & Schmidt, 2004).
Reflection links to critical thinking by encouraging nurses to question assumptions, evaluate actions, and integrate experiences into future practice, thereby strengthening dispositional elements like intellectual maturity and engagement (Mann et al., 2009a).
Reflection is a metacognitive process that takes place before, during, and after an experience, aimed at fostering a deeper understanding of oneself and the current context. This process enables individuals to approach similar future situations with greater awareness and consistency compared to previous encounters (Wald & Reis, 2010a). Numerous studies have demonstrated the positive effects of reflective writing and experiential writing assignments on enhancing critical thinking. However, there has been a scarcity of research focusing specifically on the impact of reflective thinking on critical thinking disposition. Reflection aids learners in enhancing their experiences during and after the execution of clinical skills. By critically evaluating their performance, they become aware of learning deficiencies and gain a deeper understanding of their experiences (Mann et al., 2009a; Tabas et al., 2024). The use of reflective techniques enhances an individual's capacity for inference, reinforces and deepens learning, and increases the disposition towards critical thinking (Rønning & Bjørkly, 2019). Most investigations and research in the field of critical thinking have established the necessity of improving critical thinking disposition and underscored the importance of nurses’ skills in applying critical thinking (Khoshgoftar & Barkhordari-Sharifabad, 2023). Additionally, they have emphasized the need for further exploration of the factors that enhance the level of critical thinking disposition, particularly among nursing and medical students (Jafari et al., 2020).
The literature reveals a gap in studies distinguishing critical thinking disposition from skills, with even fewer examining how reflection frequency (e.g., daily for immediate processing vs. weekly for integrative synthesis) influences disposition, theoretically important per metacognitive models (Gibbs, 1988). This is particularly relevant in nursing, where frequent clinical exposures demand tailored reflective strategies.
Based on the literature review conducted on critical thinking disposition, only a limited number of studies were identified. Given the necessity to reform educational systems to enhance critical thinking among students, particularly in the medical sciences, and considering the potential positive impact of reflective exercises on improving thinking disposition, we decided to investigate the effects of daily and weekly reflection on critical thinking disposition in nursing students. This study aimed to evaluate the effects of daily versus weekly reflection on the critical thinking disposition of nursing students, including its dimensions of engagement, innovativeness, and cognitive maturity.
Methods
Study Design
The study employed a quasi-experimental design with two groups, incorporating both pre-test and post-test assessments. This design was chosen over a fully randomized one because students were pre-assigned to apprenticeship groups by the faculty, making random selection infeasible. However, groups were randomly assigned to interventions via a coin toss to minimize bias.
Participants
In this study, the population consisted of all nursing students in their 6th semester at Birjand University of Medical Sciences during the academic year 2022–2023. Participants were selected using a census sampling method, comprising 48 nursing students in their 6th semester. Sixth-semester students were selected as they are in an advanced stage of clinical training, where critical thinking is crucial for integrating theory and practice. It is important to note that random selection of students was not feasible, as they had already been assigned to apprenticeship groups by the faculty. However, the assignment of training groups to the daily and weekly reflection interventions was conducted randomly. A coin toss was used for this purpose: if the coin landed on heads, the group was assigned to the daily reflection intervention; if it landed on tails, the group was assigned to the weekly reflection intervention.
Participants were divided into two main groups: daily reflection (n = 24) and weekly reflection (n = 24). No further subgroups were created. Students were in the internal medicine and surgical wards during their clinical rotations. In the 6th semester, nursing students’ internships consist of 5 days per week, totaling approximately 20 days over the 4-week intervention period.
The inclusion criteria for the study were: 1) willingness to participate in the study, 2) enrollment in the 6th semester of the Bachelor of Nursing program at Birjand University of Medical Sciences, and 3) no prior work experience in any healthcare centers. Guest students from other universities were not included in the study. The exclusion criteria included: 1) the student's unwillingness to continue participation in the study, 2) absence from training sessions, 3) a one-day absence from the internship for the daily reflection group, more than a one-day absence for the weekly reflection group, 4) failure to complete the reflection notebook.
Data Collection Tools
Data collection instruments included a demographic information questionnaire including age, gender, place of residence, grade point average (GPA) and, as a separate instrument, Ricketts critical thinking disposition questionnaire. Rickett's critical thinking disposition inventory encompasses 33 items, across three subscales: innovativeness (11 items: 1, 5, 7, 11, 14, 17, 24, 25, 26, 28, and 29; min 11, max 55), maturity (9 items: 2, 12, 15, 19, 23, 30, 31, 32 and 33; min 9, max 45), and engagement (13 items: 3, 4, 6, 8, 9, 10, 13, 16, 18, 20, 21, 22, and 27; min score 13, max 65). Items are scored on a five-point Likert scale (1 = absolutely disagree to 5 = absolutely agree), with reverse scoring for items 2,12,15,19,23,30,32,33 (5 = absolutely disagree, 1 = absolutely agree). The total score of critical thinking disposition is obtained by summing the three subscale scores. A total score above 135 indicates a strong disposition, 108–135 indicates an average disposition and 108 or less indicates a weak disposition to critical thinking (Rickets, 2003).
The questionnaire was culturally adapted and validated in Iran with Cronbach's alpha 0.85 (Mousazadehet al., 2021). Ricketts’ questionnaire was chosen for its specific focus on disposition (motivation and attitudes) rather than skills, aligning with the study's emphasis on inclination towards critical thinking; it has been validated in nursing contexts. The validity of this questionnaire was confirmed in Iran and its internal consistency has been confirmed by Cronbach's alpha test 0.85 (Mousazadeh et al., 2021).
A separate reflection assessment tool was not used, as the study focused on reflection's impact on critical thinking disposition, not reflection quality itself.
Intervention
To clarify the research objectives, raise awareness about the concepts of reflection and critical thinking, and guide participants through completing Gibbs’ reflective cycle, a one-hour training session was organized, which all participants attended. The one-hour training session included interactive lectures on reflection and critical thinking concepts, practical demonstrations of completing Gibbs’ reflective cycle, and group discussions to clarify objectives like understanding metacognition and applying reflection to clinical scenarios. Both groups were matched in terms of educational content and clinical experiences, ensuring they had similar ward placements.
To facilitate reflective thinking, a reflective notebook based on the steps of the Gibbs model was designed and provided to the students. The notebook included prompts for each of Gibbs’ six steps; supervision involved weekly reviews and feedback sessions to maintain intensity over 4 weeks. This cyclical model consists of six consecutive steps: first, students describe the experience, detailing what occurred; second, they reflect on their feelings about the experience; third, they evaluate both effective and ineffective actions taken; fourth, they analyze the experience to understand underlying factors and context; fifth, they reach conclusions about what they have learned; and finally, they create an action plan for addressing similar situations in the future (Gibbs, 1988). Students recorded their reflections in the provided reflective notebook, based on Gibbs’ reflective cycle, which they completed either in the clinical setting or at home shortly after experiences. Reflections were completed individually by each student; no group presentations were required, as the focus was on personal metacognitive development. Students reflected on clinical experiences such as patient interactions, decision-making during procedures, and ethical dilemmas. Focus on the nursing process (assessment, diagnosis, planning, implementation, evaluation) was emphasized because it is central to nursing practice and directly enhances critical thinking by encouraging systematic analysis and evidence-based reasoning. Reflections were encouraged immediately after clinical events for the daily group (retrospective if needed) and retrospectively at week's end for the weekly group, to balance freshness of memory with integrative analysis. For the daily group, reflections were submitted each internship day; for the weekly group, a compilation was submitted at week's end. Adherence was verified through weekly notebook submissions and reviews by the supervisor, with non-compliance leading to exclusion as per criteria. Students received ongoing supervision and guidance from the research supervisor (a faculty member experienced in reflective practice), including weekly feedback on their reflective writings to ensure quality and adherence. Feedback on reflections was provided weekly by the research supervisor through written comments in the notebooks, focusing on depth, adherence to Gibbs’ cycle, and suggestions for improvement. On average, participants spent between 15 and 20 min preparing each event report, with one group submitting their reports daily and the other group submitting them weekly. After four weeks, both groups completed the Critical Thinking Disposition Questionnaire. A 4-week duration was chosen to allow for enough exposure to reflective practices without extending beyond the semester's structure.
Ethics Considerations
This study was approved by the ethics committee of Birjand University of Medical Sciences (IR.UMS.REC.1401.424) and adhered to the Declaration of Helsinki. The study purpose and importance were explained to participants, who met the inclusion criteria, and their informed consent was obtained. They were also assured that the data was confidential and they could withdraw from the study at any time.
Statistical Analysis
Data analysis was performed by using SPSS version 16 software. The normality of quantitative variables was tested with the Kolmogorov-Smirnov test. Categorical variables were analyzed using chi-squared. Mann–Whitney and t-test were used to compare continuous variables (chosen based on data normality; t-test for normal, Mann–Whitney for non-normal). Effect sizes (Cohen's d) and 95% confidence intervals were calculated to assess magnitude of changes. The significance level was considered at p < 0.05.
Results
A total of 48 nursing students in their sixth semester participated in this research. The age range of the students was between 20 and 27 years, with 41.7% of the participants being male. The majority of participants (66%) had a GPA between 16 and 18 (Table 1).
Demographic Characteristics of Participants in Study Groups.
*Mann-Whitney **t –test ***chi-squared.
In the daily reflection group, 33.3% of participants reported a high interest in nursing, while 54.2% of participants in the weekly reflection group expressed the same level of interest. The results of the Mann–Whitney statistical test indicated that there was no statistically significant difference in interest in nursing between the two groups, confirming their homogeneity (p = 0.587). As Table 1 shows, there was no statistically significant difference between the students in the two groups in the demographic variables studied, and the two groups were homogeneous.
The analysis of the findings revealed that neither daily nor weekly reflection had a significant impact on the disposition to critical thinking. Specifically, there was no statistically significant change in the mean total score for critical thinking disposition before and after the implementation of daily and weekly reflection among the students (daily pre-post change: +3.2, Cohen's d = 0.15, 95% CI [1.5, 4.9], p = 0.12; weekly: +2.8, Cohen's d = 0.13, 95% CI [1.0, 4.6], p = 0.18). This suggests short-term reflection may not suffice for dispositional shifts, potentially due to entrenched attitudes or insufficient intensity. Furthermore, there was no statistically significant difference between the two groups regarding the mean score of critical thinking disposition or any of its dimensions (innovativeness, maturity, and engagement) before and after the intervention. Additionally, Cohen's d effect sizes for all variables following the intervention were 0.2 (a “small” effect size) and less than 0.2, which suggests a negligible effect (Table 2).
Comparison of the Mean Score of Critical Thinking and its Dimensions Before and After the Intervention.
*t-test **Mann–Whitney ***paired t-test.
Discussion
The present study aimed to determine the effect of daily and weekly reflection on nursing students’ disposition towards critical thinking. Daily reflection involves dedicating time each day to think about and analyze experiences, while weekly reflection entails a more focused effort to reflect on the accumulated experiences of the week. The rationale for these intervals draws from reflective practice theory: daily allows for immediate emotional processing and detail retention (G. Gibbs, 1988), while weekly promotes synthesis and pattern recognition over time (Wald & Reis, 2010a), with empirical support from studies showing frequency affects learning depth (Mann et al., 2009a). In terms of differences, daily reflection facilitates immediate processing of experiences, enabling students to grasp the nuances and emotions associated with each day. Conversely, weekly reflection offers a broader perspective by allowing students to connect and integrate experiences over a longer timeframe. This approach may also be more feasible for some students, as it requires less time commitment compared to daily reflection. Daily reflection can be time-consuming, repetitive, and potentially ineffective, posing challenges for busy students. Conversely, the delay in reflection associated with weekly reflection may result in forgetting or overlooking important details, which can lead to missed learning opportunities and may not capture the urgency and emotional intensity of daily experiences. The results of the present study indicated that there was no statistically significant difference in the mean score of critical thinking disposition among nursing students, as well as in each of its dimensions (innovativeness, cognitive maturity, and mental engagement), before and after the intervention between the daily and weekly reflection groups. This null finding implies that short-term reflection alone may not alter deeply ingrained dispositions, potentially requiring integration with direct skills training or longer durations for meaningful change (Khoshgoftar & Barkhordari-Sharifabad, 2023; Rønning & Bjørkly, 2019). Comparatively, similar studies like Tabas et al. (2024) found reflection improved self-regulated learning, but over longer periods and with different outcomes; Bonet et al. (2022) noted disposition changes with intensive group interactions, absent here. This contrasts with the findings of Khalil and Abou Hashish (2022), which reported positive and significant results. In that study, statistically significant changes were observed in the mean disposition scores for critical thinking before and after the intervention, highlighting a discrepancy with the findings of the present study (Khalil & Abou Hashish, 2022). The observed differences in findings may be attributed to the duration of the interventions. Khalil and Abou Hashish (2022) conducted their intervention over a total of ten hours, divided into five sessions of two hours each. In contrast, the current study implemented a single one-hour training session aimed at elucidating the research objectives, enhancing awareness of reflection and critical thinking concepts, conducting research, and completing Gibbs’ cycle. Ricketts et al. (2018) in their article asserts that substantial time investment in education and training is necessary to effectively shift individuals’ mindsets towards critical thinking (Ricketts et al., 2018). The lack of change in critical thinking disposition observed in the current study may be attributed to the brief duration of the intervention. While duration likely contributed to null results, it may interact with factors like supervision intensity; alone, short duration appears insufficient, as longer studies show effects. In their study Zhang et al. (2017) reported findings consistent with those of Khalil and Abou Hashish (2022), which contrasts with the results of the present study. Zhang utilized specialists in reflective thinking training and conducted the intervention over a period of 12 months under rigorous supervision. In their review, they concluded that reflective thinking training significantly enhances students’ critical thinking disposition (Zhang et al., 2017). In this context, the differences in the results obtained may be attributed to two key factors: the duration of the intervention and the meticulous monitoring of how tasks were executed by the students. In the current study, the Gibbs event report was completed over a period of four weeks, which may explain the absence of statistically significant changes in students’ mean disposition towards critical thinking. Conversely, the study conducted by Yeh et al. (2023), demonstrated significant improvements in students’ critical thinking abilities, identifying four common areas of change. Notably, these changes included two major conceptual shifts—self-worth and volunteerism—alongside two key behavioral changes—patience and gratitude (Yeh et al., 2023). The findings of this study were not aligned with those of the present research. One possible explanation for this discrepancy is the 18-week duration of the intervention in the other study.
No significance possibly due to short duration (4 weeks), small sample, or limited intervention intensity; future studies need longer follow-up. Cultural factors in Iran (e.g., hierarchical education) may limit reflection depth, reducing impact on disposition; contextual elements like ward stress could hinder openness to critical thinking.
Strengths and Limitations
The strengths of the present study include the following: Daily and weekly groups were selected based on similar educational content and clinical experiences to control for possible side effects. A one-hour training session was held for all participants to enhance their understanding of reflection and critical thinking concepts and to synchronize the reflection method. Examining the effect of reflection at two different time frequencies can help identify the most effective reflection method. The use of the Gibbs reflection cycle, a well-known and effective model for conducting reflection, is also a strength of this study. The limitations of this study include the implementation of a briefing session and event report over a four-week period, a lack of control over certain aspects of the study environment, and the use of non-random sampling. The small sample size (n = 48) is a main limitation, potentially reducing statistical power to detect small effects. Factors such as varying teaching methods (e.g., didactic vs. interactive) and cultural influences (e.g., collectivist norms affecting self-reflection) may have confounded results by unevenly impacting motivation and openness to critical thinking. Therefore, it is recommended that future research explore the long-term effects of daily and weekly reflection over periods of 8, 12, and 16 weeks. Additionally, increasing the number of training sessions and evaluating the reflection variable using standardized tools would enhance the study's rigor. Employing a random sampling method is also advised to improve the generalizability of the findings. Another limitation of the present study was the reliance on students’ self-assessment of their critical thinking through a questionnaire, despite this being a commonly used approach. Self-reported measures prone to bias; short duration limits long-term insights; generalizability reduced by single-institution sample, affecting external validity to diverse settings.
Implications for Practice
According to the results obtained, daily and weekly reflection alone is not enough to create a significant change in the tendency towards critical thinking. Therefore, in educational and professional environments, it is recommended that this reflection be combined with complementary methods and techniques such as direct critical thinking skills training, active training, and group interactions. Also, paying attention to the duration and quality of reflective interventions is of great importance. Finally, the design of educational programs should be flexible to have a better impact on different aspects of students’ critical thinking.
Conclusion
Despite the potential advantages of daily and weekly reflection, the results of this study revealed that these methods did not significantly impact the critical thinking disposition of nursing students over a four-week period. These findings highlight the complexity involved in fostering critical thinking disposition and suggest that additional factors or interventions—such as the educational environment, training methods, duration of training, and evaluation techniques—are essential for facilitating its development.
Footnotes
Acknowledgements
We extend our thanks to the Vice President of Research and Technology of Birjand University of Medical Sciences and to the nursing students doing their Bachelor’, namely, Elahe Sadat Qaderi, Amir Hossein Moradi and Mohammad Rezaei who participated in the proposal writing stage.
Ethics Declarations
This study was approved by the ethics committee of Birjand University of Medical Sciences (IR.BUMS.REC.1401.424) and adhered to the Declaration of Helsinki. The study purpose and importance were explained to participants, who met the inclusion criteria, and their informed consent was obtained. They were also assured that the data was confidential and they could withdraw from the study at any time.
Author Contributions
Z.A. designed the study. D.O., A.M., H.N., A.M., and A.B. analyzed and interpreted the data. Z.A., D.O., A.M., H.N., A.M., and A.B. drafted the manuscript. Z.A., D.O., A.M., H.N., A.M., and A.B. revised the manuscript. All authors have read and approved the manuscript.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Conflict of Interest
The authors have no conflict of interests.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.