Critical Thinking of Student Nurses during Clinical Accompaniment Lecturer: Nursing Education and Advanced Nursing Dynamics Programme Opsomming Introduction and Problem

Curationis 28(3): 11-19 The purpose o f this study was to investigate the methods o f clinical accompaniment used by clinical facilitators in practice. The findings o f the study also reflected facilitators' perceptions regarding critical thinking and the facilitation thereof. A quantitative research design was used. A literature study was conducted to identify the methods of accompaniment that facilitate critical thinking. Data was collected by means o f a questionnaire developed for that purpose. Making a content-related validity judgm ent, and involving seven clinical facilitators in an academic institution, ensured the validity of the questionnaire. The results of the study indicated that various clinical methods o f accompaniment were used. To a large extent, these methods correlated with those discussed in the literature review. The researcher further concluded that the concepts 'critical thinking' and 'facilitation' w ere not interpreted correctly by the respondents, and would therefore not be implemented in a proper manner in nursing practice. Furthermore, it seem ed evident that tutor-driven learning realised more often than student-driven learning. In this regard, the requirement of outcomes-based education was not satisfied. T he researcher is therefore o f the opinion that a practical program m e for the development of critical thinking skills during clinical accompaniment must be developed within the framework of outcom es-based education. Die doel van hierdie studie was om die metodes van kliniese begeleiding wat deur kliniese fasiliteerders in die praktyk gebruik word, te ondersoek. Die bevindinge van die studie reflekteer ook fasiliteerders se persepsies aangaande kritiese denke en die fasilitering daarvan. 'n Kwantitatiewe navorsingsontwerp is gebruik. 'n Literatuurstudie is uitgevoer om die metodes van begeleiding wat kritiese denke fasiliteer, te identifiseer. Data is deur middel van 'n vraelys wat vir dié doel ontwerp is, ingesamel. Die geldigheid v an d ie v ra e ly s is v e rs e k e r d e u r d ie b e p a lin g van 'n in h o u d v e rw a n te geldigheidsoordeel deur sewe kliniese fasiliteerders van 'n akademiese instelling. Die resultate van die studie het aangetoon dat verskeie kliniese begeleidingsmetodes gebruik is. Hierdie metodes het in 'n groot mate ooreengestem met dié wat in die literatuurstudie bespreek is. Die navorser het voorts tot die slotsom gekom dat die k o n sep te " k ritiese d en k e " en " fa silite …

Die doel van hierdie studie was om die metodes van kliniese begeleiding wat deur kliniese fasiliteerders in die praktyk gebruik word, te ondersoek. Die bevindinge van die studie reflekteer ook fasiliteerders se persepsies aangaande kritiese denke en die fasilitering daarvan. 'n Kwantitatiewe navorsingsontwerp is gebruik. 'n Literatuurstudie is uitgevoer om die metodes van begeleiding wat kritiese denke fasiliteer, te identifiseer. Data is deur middel van 'n vraelys wat vir dié doel ontwerp is, ingesamel. Die geldigheid v an d ie v ra e ly s is v e rs e k e r d e u r d ie b e p a lin g van 'n in h o u d v e rw a n te geldigheidsoordeel deur sewe kliniese fasiliteerders van 'n akademiese instelling. Die resultate van die studie het aangetoon dat verskeie kliniese begeleidingsmetodes gebruik is. Hierdie metodes het in 'n groot mate ooreengestem met dié wat in die literatuurstudie bespreek is. Die navorser het voorts tot die slotsom gekom dat die k o n sep te "k ritiese d en k e" en "fa silite rin g " nie k o rrek deur die resp o n d en te geïnterpreteer is en dus nie op 'n behoorlike wyse in die verpleegpraktyk geimplementeer sal word nie. Dit het voorts duidelik geblyk dat dosent-gedrewe leer meer dikwels realiseer as student-gedrewe leer. In hierdie opsig is daar dus nie aan dié vereiste van uitkomsgebaseerde onderrig voldoen nie. Die navorser is dus van mening dat 'n praktiese program binne die raamwerk van uitkom sgebaseerde onderrig vir die ontw ikkeling van kritiese denkvaardighede gedurende die kliniese begeleiding van studente ontwikkel moet word.

Introduction and problem statement
The most important purpose o f nursing education is to provide students with learning opportunities that will enable them to develop critical thinking skills so th at th ey co u ld becom e c o m p e te n t, in d e p e n d e n t, c ritic a l-th in k in g nurse practitioners. Nursing practice requires a high level of cognitive development and independent thinking. Students who are skilled in problem solving and have learnt to use problem-solving scientifically will b ecom e safe p ra c titio n e rs. P ro b lem s o lv in g te a c h e s stu d e n ts to so lv e in d iv id u a l id e n tifie d p ro b lem s, and requires the ability to make associations (M ashaba& Brink 1994:273).
The importance of informed and skilled n u rse s w ho can th in k c r itic a lly is u n d is p u te d .
By n u rsin g p ra c tic e s ta n d a rd s , k n o w le d g e s h o u ld be implemented and applied to ensure safe and effective nursing care (M ashaba & Brink 1994:44).
Scientific nursing only realises when students correlate nursing practice with nursing theory (Kathol, Geiger & Hartig 1998:31-34). Students must be able to scientifically motivate their actions in nursing practice, and this ability requires analytical critical-thinking skills. Logical critical thinking and a cognitive learning experience require that students actively process information and transform it into new knowledge (Hinchliff 1999:19).
Time spent on nursing education in the clinical field is essential because this is where students experience the science of nursing in real-life situations under the supervision of clinical facilitators. The quality o f learning experiences in this context can be influenced by the methods and the educational approaches used. A ccom panim ent methods currently in use in the clinical field do not seem to enhance and develop the critical thinking skills of students. Furthermore, no concrete programmes are available to guide facilitators regarding the use of strategies that facilitate critical thinking during the clinical accom pani m ent o f s tu d e n ts . T he d y n a m ic s underlying the facilitation o f clinical decision-making processes can thus be described as problematic. The apparent in a b ility o f stu d e n ts to use c ritic a l th in k in g s k ills and u n s a tis fa c to ry performances in this regard can be due to ineffective accompaniment in clinical practice by clinical facilitators. The question now arises: Does student accom panim ent by clinical facilitators lead to the d ev e lo p m e n t o f c ritic a l thinking skills in students?

Research objectives
The objectives o f this study were: • To identify methods o f accom paniment that were described in literature as enhancing the development of critical thinking skills in students; •

Definitions of key concepts Clinical facilitator
T h e c lin ic a l f a c ilita to r p ro v id e s p ro fessional guidance and academ ic leadership to students, m ainly in the clinical field. The role of facilitator is to provide specialist experience during the in te g ra tio n o f th e o ry and p ra c tic e (M ellish& Brink 1990:220).

Student or student nurse
A student or a student nurse is a person who follows a programme o f education and training that was approved by the South African Nursing Council (SANC). Regulation 425, 1982, Article 15(3), and leads to the acquirement of a qualification that gives the keeper thereof the right to register as a nurse (general, psychiatric, community) and a midwife.

Clinical accompaniment
The clinical accompaniment of a student is the process w hereby the student is guided and accom panied by the clinical f a c ilita to r in o rd e r to b e c o m e a p ro fe ssio n a l and in d ep e n d en t nurse practitioner (Klopper 1999:110).

Scientific nursing
Scientific nursing incorporates the safe an d sk ilfu l c a re g iv e n to p a tie n ts according to preset standards. It includes the attainment o f skills such as critical thinking and analytical reasoning and is b a se d upon s c ie n tific k n o w le d g e . S cientific nursing is regulated by the Scope of Practice regulation of the SANC (1984).

Facilitation
For the purposes o f this study, facilitation can be described as the accompaniment o f students in the clinical field with the purpose of enabling them to achieve high levels o f cognitive thinking, reasoning, problem stating and problem solving. S tu d e n ts are e n c o u ra g e d to use inform ation, know ledge, technologies, fa c ts , an d s k ills to e n su re c o rre c t interpretation and management of health processes. It is a goal-driven, dynamic process o f critical reflection in which p a r tic ip a n ts w o rk to g e th e r in an a tm o sp h e re o f le arn in g and m utual respect (Burrows 1997:401).

Critical thinking
Critical thinking is the ability to solve p ro b le m s by u sin g h ig h c o g n itiv e thinking processes whereby information is im plem ented in a creative, logical, analytical and scientific manner. It is thus an o n g o in g , c re a tiv e , lo g ic a l and analytical process (Hansten & Washburn 1999:39).

Research design
A q u an titativ e study was conducted. The research design can be described as descriptive, explorative, and contextual, re fle c tin g th e m e th o d s o f c lin ic a l accom panim ent used by facilitators. The goal o f descriptive studies is to observe, to describe and to docum ent certain aspects of a situation (Polit & Hungler 1997:168)

Research Method
The following phases characterised the research method: • Central concepts were explored through an in-depth literature study.
• M ethods of accom panim ent facilitating the developm ent of critical thinking were identified during the literature study.
• A deductive strategy was followed, and a structured questionnaire was compiled and implemented. The question naire was used as a guideline throughout the interpretation and analysis o f data.

Population and sampling
The Purposive sampling was used. Certain participants in one geographical area were consciously selected to ensure that p a r tic ip a n ts o f a s p e c ific fie ld o f experien ce w ould be inclu d ed . The p a rtic ip a n ts w ere b e lie v e d to have specialised knowledge and insight into certain experiences (De Vos 1998:190). R e g a rd in g in c lu s io n in th e sa m p le population, the following criteria were stipulated: • Registration as a professional nurse with the SANC; • Working in Pretoria at a health or educational facility where training in nursing is provided; • Accepting the responsibility for accompanying students in clinical practice or a speciality field; • Nursing staff subcategories such as enrolled nurses were excluded from the study.

Research setting
Participants' duties included lecturing n u rsin g s tu d e n ts a n d in c lu d e d the clinical accompaniment o f these students in c lin ic a l p ra c tise . N ot one o f the participants was at the time o f the study part of the clinical field. W orking in the clinical setting was not required o f them. Participants included in this study were resp o n sib le for a cco m p an im en t in a variety o f clin ical settin g s. Specific clinical areas were not the focus in this study.

Research instrument
Based on the literature review, closed and open-ended questions were formulated. The validity of a m easuring instrument can be described as the ability o f the instrument to correctly measure specific concepts (De Vos 1998:83).
In this study, the validity o f the content o f the questionnaire (that was based on the literature review ) was ju d g ed by seven academics. They were specialists in fields relevant to that surveyed by the researcher and were well informed about the topic.
In this study, applying a parallel form of reliab ility testing ensured reliability. Parallel test forms are interchangeable versions that are compiled to measure the same construct equally well by means of different contents (Huysamen 1994:120).
In the questionnaire under discussion, r e lia b ility te stin g re a lis e d th ro u g h d iffe re n t q u estio n s te stin g the sam e c o n c e p t. T h is p a ra lle l m e th o d o f reliability testing increased the value of the findings. If the trustworthiness o f a response was questioned, a parallel form o f measurement could be conducted to present the researcher with a comparative result. That was done in this study. Data results of different questions measuring the same concept were compared.

Data collection
O ne hundred and ten (110) question naires were handed out and collected personally, ensuring total anonymity and c o n fid e n tia l h a n d lin g o f co m p le ted q u e s tio n n a ire s . T he re sp o n se rate (questionnaires completed and returned) was fifty-nine per cent 58% (N = 64).
The total amount of questionnaires that could be used was 53% (N=59). In an attem pt to increase response rate the questionnaires were personally handed out and recollected by the researcher. T he response rate o f one in stitu tio n however had remarkable effect as only ten questionnaires were received back. Fifty were handed out. Possible reasons for this poor response could have been busy schedules during exam ination as this was the only available time before the holidays.

Data analysis
The SAS com puter softw are package was employed to obtain both descriptive and statistical sum m arisations o f data, and findings were depicted in tables and graphs and discussed accordingly.

Literature study
The importance o f the development of critical thinking in nursing education is d is c u s s e d in d e ta il th ro u g h o u t the literature. The researcher identified the lack o f practical guidelines regarding clinical accompaniment as an impediment to significant accom panim ent (O liffe 2 0 0 0 :1 ) T he im p o rta n c e o f the development of critical thinking in the education of nursing students must be evident in nursing theory and, especially, nursing practice (Fowler 1998:183).
T he resea rch er realised th ro u g h the literature study that students would not h av e th e a b ility to use s c ie n tific reasoning to ensure correlation o f theory with practice if critical thinking were not developed (Celia & Gorden 2001:13). Im plem enting the correct m ethods of a c c o m p a n im e n t d u rin g c lin ic a l accompaniment of nursing students and using practical exam ples can develop critical thinking. Critical thinking will develop as students broaden their clinical field of experience. Scientific nursing will result. In literature, various methods of a c c o m p a n im e n t, w h ich can be implemented to facilitate critical thinking, are discussed (Hart 2000:31).
Although clinical facilitators seem to be doing their utmost, it is proved that the development o f critical thinking in the clinical field does not realise as desired (Greenwood 2000:428). To think critically means to think further than the obvious and to m ake en lig h ten e d and g o alorientated decisions (Fowler 1998:183). The dynam ic health system s o f today require skilled professionals that have the ability to use critical thinking skills to m ak e a c c u ra te c lin ic a l d e c is io n s (V idebeck 1997:23). T oday's neverending sources of knowledge and everc h a n g in g te c h n o lo g ie s re q u ire professionals that can think critically. The professional nurse needs a wide field of knowledge to use resources effectively, c o o rd in a te a c tio n s and e v a lu a te outcomes. Critical thinking skills enable nurses to deliver quality healthcare in times of scarce resources and finances, and growing responsibilities (Jacobs, Ott, Sullivan, Ulrich & Short 1997:19).
Inexperienced clinical facilitators can negatively affect the implementation of accom panim ent m ethods. In efficien t accompaniment of students can further lead to ineffective learning experiences. F acilitators' scientific know ledge and clinical and didactic skills form part of the challenging requirements o f nursing education (O 'Neill & Dluhy 1997:6). Facilitators should be able to apply their knowledge and skills effectively. This must realise in the class situation as well as in the clinical field where scientific knowledge is applied through the art of nursing (Grealish 2000:231).

Findings: Socio demographic aspects Qualifications
Thirty-two per cent 46%; (n=27) of the respondents did not have a qualification in nursing education. The follow ing demographic information is depicted: 19%; (n= 11) o b tain ed a d ip lo m a in Nursing Education, 27%; (n=16) a Baccalaureus in Nursing Education, 7%; (n=4) a M asters Degree in Nursing Education, 2%; (n = l) a Doctoral Degree in Nursing Education. After obtaining clinical qualifications, the m a s te rin g o f d id a c tic s k ills w as em phasised as essential (Sergiovanni 1995:212).

Clinical experience
The clinical experience of respondents was considered important and relevant, b e c a u se n u rs in g stu d e n ts fo rm perceptions o f their professional and nursing resp o n sib ilities and roles by observing the skills of facilitators at the b edside o f a p atien t. T h erefo re, the importance of a clinically skilled facilitator cannot be stressed enough (Fothergill-Bourbonnais & Higuchi 1995:37).
Forty-nine per cent (49%; n=29) of the respondents had five to ten years o f clinical experience. They may have been able to convey valuable inform ation a cq u ire d th ro u g h ex te n siv e c lin ic a l experience to the benefit of the students. However, clinical experience m ust be re c e n t, as h e a lth c a re m e th o d s and te c h n o lo g ie s c h a n g e c o n tin u o u sly . Com m itm ent to lifelong learning will en sure that clin ical fa c ilita to rs stay a b re a s t o f new m e th o d s an d te c h nologies. Optimally skilled, they will be able to function as role models (Benor & Leviy 1997:206). From own experience, the researcher can conclude that clinical skills can be optimally achieved only if a person is working in the clinical field. If clinical facilitators were educated and train ed b efo re outco m es-b ased e d u cation was introduced in 1999, they would n o t be up to d a te w ith the n ew e st tendencies in education and training, and knowledge would be transferred in the old manner. The facilitating process may not realise and students' thinking abilities m ay n o t be d e v e lo p e d o p tim a lly . However, if facilitators were committed to lifelong learning, they would have the a d v a n ta g e o f c o m b in in g le a rn in g opportunities with specialist experience in an O B E a p p ro a c h . F a c ilita tio n techniques could be integrated into the teaching process, and students' critical thinking skills could be developed. In this scenario, optimal clinical accompaniment will occur.
The follow ing conclusion is made: If didactic knowledge and clinical skills are integrated, and are recent, the facilitator will function as a clinical specialist. The clinical facilitator becomes a role model, and th e c lin ic a l e x p e rie n c e o f the facilitator will lead to the creation of improved clinical learning opportunities and theory-practice correlation will be ensured.

Number of years experience in clinical accompaniment
Forty-two per cent (42%; n=25) o f the re s p o n d e n ts had do n e c lin ic a l accompaniment for a period of ten years, and fifty-five percent (55%; n=33) did it for eight years. These findings imply that a total o f ninety-seven per cent (97%; n = 5 8 ) o b ta in e d th e ir n u rsin g q u a lif ic a tio n s b e fo re O B E w as im plem ented, because they have been doing clinical accompaniment for more than 5 years. Since 1999, changes in H ig h e r E d u c a tio n have re su lte d in changes in the approach tow ards the education and training of student nurses. In the new approach, facilitating the developm ent o f thinking processes in students is preferred above the didactic transference o f knowledge.

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A fter conducting the literature review, the re s e a rc h e r id e n tifie d im p o rta n t c o n c e p ts in th e fie ld o f c lin ic a l accom panim ent. R espondents' percep tions reg ard in g th ese co n cep ts w ere tested through the questionnaire, and the fin d in g s a re d is c u s s e d u n d e r the following headings:

Critical thinking
In this study, the characteristics o f a person with critical thinking abilities, as identified by the respondents, did not c o rre s p o n d to th o se fo u n d in the literature. The methods of accom pani ment used by the respondents in clinical practice did how ever match those found in the literature. However, the successful application o f these m ethods depends upon the innovation and creativity o f c lin ic a l fa c ilita to rs . T h e re fo re , the application o f these m ethods requires clinical facilitators who have insight into the c o n c e p ts 'c ritic a l th in k in g ' and 'facilitation'. It also requires competent facilitators w ith facilitating skills and critical thinking abilities.
If the im p o rta n c e o f sk ills such as a n a ly tic a l th in k in g and s c ie n tific reasoning is negated, they will not be regarded as priorities, and not be pursued in th e le a r n in g s itu a tio n . C lin ic a l facilitators then will attend more to role le a rn in g an d c lin ic a l s k ills , as p s y c h o m o to r a c tiv itie s only. T he im p o rta n c e o f th e d e v e lo p m e n t o f thinking processes that enable students to apply know ledge scientifically will be lo st. S u ch a s itu a tio n w ill p re v e n t students from developing the ability to analytically m otivate and debate their actions. Theory-practice correlation will not occur. Respondents in this study who have indicated clinical skills of far more im p o rta n c e th a n th e o ry -p ra c tic e correlation confirm ed this conclusion. Theory application in the clinical field is essential as it en ab les the student to understand disease processes and their clinical manifestations. Clinical practice must be based on scientific knowledge. S tu d e n ts ' a b ilitie s to use a n a ly tica l thinking will be enhanced if they receive the n ec essary g u id an ce in cog n itiv e developm ent. The quality o f scientific discussions o f identified problems will improve, and significant theory-practice correlation will becom e evident. The nursing o f patients with complex health problem s requires registered nurses that have critical thinking skills as well as a W hile developing analytical thinking processes, reasoning abilities and clinical skills, students learn to prioritise, which ag a in e n h a n c e s th e ir a b ility to systematise in practice. Theory-practice c o rre la tio n then re a lise s . S tu d e n ts develop self-confidence as com petent clinical practitioners, and consequently a c c e p t f a c ilita to r s ' p o s itiv e in p u t. Students mature in their relationship with p re c e p to rs th a t th ey re g a rd as ro le models. Mutual trust and understanding develop. Students are led to professional as w e ll as c o g n itiv e m a tu rity . T he re s p o n d e n ts w ere a sk e d w h ic h c h a r a c te ris tic s th e y re g a rd e d as im p o rta n t in a stu d en t w ith c ritic a l thinking skills. The respondents had to list th e c h a ra c te ristic s ac co rd in g to im p o rta n c e . T h e ir re s p o n s e s are d em onstrated by m eans o f a colum n graph in Figure 1.
Not without some degree o f concern, the researcher inferred from Figure 1 that respondents regarded the following most im portant characteristics o f a critical thinker of lesser importance:

•
Analytical thinking skills; • Scientific reasoning ability; • The ability to correlate theory with practice; and • The ability to prioritise.
This leads to the conclusion that the development of critical thinking skills in students does not realize in practice. The reason being that clinical facilitators do not regard them as important. Therefore the researcher has great uncertainty that the clinical facilitators will have the ability to fa c ilita te c ritic a l th in k in g sk ills effectively.  towards contents and their application. It enables the s tu d e n t to in te g ra te all aspects m entioned above, and to achieve various other outcomes in new situations, contexts and arenas (Olivier 2000:59). It becomes clear that OBE in itself requires the facilitation process because s tu d e n t d riv e n le a rn in g ta k e s p la c e w hen th e s tu d e n t is g u id e d in the learning process.

Facilitation
Referring The respondents were asked to indicate the methods they would use to facilitate a le a rn in g e x p e rie n c e. T he o p tio n s p ro v id e d to th em as w ell as th e ir responses can be seen in Figure 2.
As displayed in Figure 2,60% (n=35) of respondents indicated that they would make the student aware of the problem giving guidance regarding know ledge application and problem solving. Thirtyseven percen t (n=22) o f respondents indicated that they would prefer to let the student work through the data, and identify problems themselves while the facilitator is giving guidance. Only 3% (n=2) of the respondents indicated that they would present a lecture to enhance comprehension. No respondent indicated that s/he would state the problem and give it as an assignment to the students to complete. These results indicate that re s p o n d e n ts ' in sig h t re g a rd in g the process o f facilitation was not sufficient. S tu d e n ts m u st be a b le to id e n tify problem s independently and m ust be guided to do just this in order to be safe clinical practitioners. A possible explanation for the responses in Figure 2 may be that many clinical facilitators did their training before OBE w as in tro d u ced . To m any, stu d en t-d riv en le a rn in g is still an unknow n concept, and students are expected to memorize and reproduce facts rather than apply know ledge with insight. This is greatly problem atic as it is clear that critical thinking is not developed because students do have factual knowledge but will they be able to apply it?
In the literature, the term 'facilitation' was pointed out as a difficult and abstract concept, and described as not easily interpretable. Facilitation and its success d e p e n d u p o n the u n d e rs ta n d in g facilitators have of their new educational role, one o f giving guidance to students r a th e r th a n a tte m p tin g to tra n s fe r k n o w le d g e . F a c ilita tio n is b e in g em phasized as an im portant aspect of OBE, and facilitators have to show a thorough understanding o f this concept • if they want to act as facilitators (Burrows 1997:396).

Methods of clinical accompaniment
T he su rv e y c o n firm e d th at c lin ic a l • facilitators were generally knowledgeable ab o u t th e v a rio u s tra in in g m ethods iden tified in the literature review as methods that facilitated critical thinking. Clinical facilitators were well informed • regarding research tendencies, training methods and strategies. It can be inferred that clinical facilitators are adult learners who believe in continuous development and follow a ph ilo so p h y o f lifelo n g learning. It can how ever be argued that if, as p re v io u sly d iscu ssed , clin ic al f a c ilita to r s d o n 't h av e in s ig h t in concepts critical thinking and facilitation it will not be implem ented correctly.
The following aspects were identified as important during the literature review and analysis of the research findings: Reflection as part of clinical accom panim ent is described as a method that is commonly used in various fields of healthcare training (in the classroom and in nursing practice) (Hyrkas, Tarkka & Paunonen-Ilmonen 2001:504).
Reflection is recommended as a method to overcome the problem o f theory-practice correlation and to develop practice-based nursing knowledge (Smith 1998:891).
Clinical learning activities such as the presentation of patient studies form an important aspect of critical thinking skill development.
Respondents identified the presentation of patient studies as the m ost important strategy for developing critical thinking skills. During patient studies, disease processes are analysed and their clinical manifestations in practice are discovered.
• During the presentation of these studies, students are guided to make use of pathophysiology and theory. Scientific actions are planned after an assessm ent o f the patient has been done. The student learns to think analytically, and to sift and prioritise data that were obtained from medical reports, the findings o f the physical examination and the patient's medical history. Clinical and cognitive skills and theoretical knowledge develop during patient presentations. Holistic nursing occurs, and the student develops as a professional practitioner by being exposed to members o f the multidisciplinary team.
• Legal and ethical aspects are impressed upon students. As registered nurses, students learn to co-ordinate their role as advocate for both the patient and the healthcare system.
• Respondents and the literature identified group work, group discussions and collective learning sessions as important accom panim ent or learning strategies that would stimulate critical thinking par excellence.
• With reference to the facilitation of critical thinking, the lecturing method was given the lowest priority by respondents. However, lectures can be implemented in combination with group discussions, think tanks and collective learning sessions as an equivalent and innovative strategy. Lectures are seldom used during clinical accompanim ent o f students, and are therefore underrated. As mentioned earlier, methods identified by clinical facilitators with regard to the developm ent o f critical thinking skills were in accordance with those identified in the literature. However, the researcher w as not c o n v in c e d th a t th e c o rre c t facilitation techniques were used during the application o f identified methods. It also became evident that the development of critical thinking skills and thinking patterns did not enjoy first priority during the clinical accompaniment o f students. In this study, both these issues could be described as obvious deficiencies.

Evaluation of the study Positive aspects
T he re se a rc h is re le v a n t as c ritic a l thinking is a requirem ent o f scientific nursing. Furtherm ore, the research is important because the developm ent of critical thinking enables the learner to develop into and function as a competent nursing practitioner. A ccom panim ent methods indicated by facilitators were in accordance with those presented in the literature review as methods that facilitate the development of critical thinking. It seem ed, how ever, that these m ethods were not always applied correctly. The respondents will receive feedback regarding the research. This is a positive aspect, as feedback m ay guide th eir attitudes towards clinical accompaniment and impress upon them the necessity of facilitating critical thinking. The researcher had to use the lite ra tu re study as the b asis fo r the compilation of the questionnaire.

Recommendations
One of the aims of this study was to make re c o m m e n d a tio n s re g a rd in g fu rth e r re se a rc h in n u rsin g e d u c a tio n . By implication the conclusion drawn by the researcher during the literature study and data analysis was that clinical facilitators sh o u ld be ab le to th in k c ritic a lly them selves if they w ant to facilitate critical thinking in students. The clinical facilitator's field of knowledge should be extensive to guide students by means of science-based reasoning through the processes of developing correct thinking patterns and mental attitudes. Successful learning activities depend on effective problem stating, and effective problem stating is determined by critical thinking. Therefore, the facilitator's ability to think critically should be em phasized once again. K now ledge and its integration form the basis of critical thinking.
S tu d en ts becom e in v o lv ed in study c o n te n ts w hen th e y a re g u id e d to develop cognitive thinking patterns. The student considers the study content, it b ecom es in teg rated k n ow ledge, and content can now be used meaningfully. F acilitatin g critical thinking im plies enhancing understanding and insight in to p e rfo rm a n c e . It a lso im p lie s accepting responsibility for actions that are b ase d on sc ie n tific and fa c tu a l knowledge.
A further important conclusion was that the concepts 'facilitation' and 'critical thinking' were not understood correctly, and that both would not be treated or applied correctly.
The researcher therefore recommended that a training course be offered that could fill this void. Such a course could take the format of a refresher course for clinical facilitators who w ere trained before OBE was instituted. The course can be propagated for attendance by any person w ho w as resp o n sib le for the clinical accompaniment of students and w ho w o u ld lik e to re c tify ow n deficiencies in this regard. C linical facilitators, who accom pany students in clinical practice, experience a lack of concrete guidelines that can assist them in the developm ent o f students' a b ilities to think c ritic ally (C habeli 1998:39). The rese arc h er therefo re recom m ended that concrete guidelines for student accom panim ent in clinical practice be drawn up. This study can serve as a basis for the development of a practical guide or model that presents specific methods of clinical accom pani m ent o f students in clinical practice.
M oreover, the m odel should include sp e c ific g u id e lin e s th a t c o u ld be implemented to enhance the development o f critical thinking skills. In conclusion, the following aspects are emphasized:

Conclusion
• Nurse educators should be critical thinkers themselves if they want to develop this characteristic in their students.
• Critical thinking is a developmental process that requires thorough planning of learning activities to ensure the correct application of knowledge. It should be included in the curriculum from the first study year onwards, and specific planning should be done to ensure the development and evaluation of critical thinking.
• Scientific knowledge provides the basis for the development of critical thinking.
• The success of learning activities depends on effective problem stating and evaluation.
• Facilitation implies knowledge of the concept, and is a purposeful, dynamic process in which the student is guided to form thinking patterns. This, by implication, means that nurse educators should be lifelong learners who stay abreast of the newest tendencies in nursing education and training (inter alias by attending courses).
• Demands for models o f clinical accompaniment and refresher courses in terms of outcomesbased education should be addressed by further research and additional courses. These are the challenges and responsibilities put to every nurse educator and researcher today.
The developm ent of the critical thinking skill is being emphasized as a requirement fo r th e s a fe , c o m p e te n t, c a p a b le practitioner, and is essential for true independency. Critical thinking is also r e q u ire d d u rin g p ro b le m -s o lv in g , analytical reasoning, data analysis and the draw in g o f conclusions (C habeli 1998:39).
Various authors stress the responsibility o f c lin ic a l fa c ilita to rs reg ard in g the developm ent o f critical thinking through the usage o f specific training methods. The concept 'critical thinking' should be d e fin e d , and th e m e th o d s o f a c c o m p a n im en t th at w ill e n su re its realization should be clearly described.
By facilitating critical thinking in students from their first study year onward and by evaluating its development continuously, students will achieve competent levels o f critical thinking skills (Abegglen & O 'Neill C onger 1997:452). The only re m e d y fo r the g a p s in c lin ic a l accom panim ent is the introduction of u s e fu l p ra c tic a l p ro g ra m s th at are a p p lic a b le to all le v e ls o f stu d e n t accompaniment.