Critical thinking skills have been linked to improved patient outcomes, better quality patient care and improved safety outcomes in healthcare (Jacob et al. 2017).
Given this it is necessary for educators in healthcare to stimulate and lead further dialogue about how these skills are taught, assessed, and integrated into the design and development of staff and nurse education and training programs (Papp et al. 2014).
So, what exactly is critical thinking and how can healthcare educators cultivate it amongst their staff?
What is Critical Thinking?
In general terms ‘critical thinking’ is often used, and perhaps confused, with problem-solving and clinical decision-making skills.
In practice however, problem-solving tends to focus on the identification and resolution of a problem, whilst critical thinking goes beyond this to incorporate asking skilled questions and critiquing solutions.
Several formal definitions of critical thinking can be found in the literature, but in the view of Kahlke and Eva (2018), most of them have limitations. That said, Papp et al. (2014) offer a useful starting point, suggesting that critical thinking is:
‘The ability to apply higher order cognitive skills and the disposition to be deliberate about thinking that leads to action that is logical and appropriate.’
The Foundation for Critical Thinking (2017) expands on this and suggests that:
‘Critical thinking is that mode of thinking, about any subject, content, or problem, in which the thinker improves the quality of his or her thinking by skilfully analysing, assessing, and reconstructing it’.
They go on to suggest that critical thinking is:
Key Qualities and Characteristics of a Critical Thinker
Given that critical thinking is a process that encompasses conceptualisation, application, analysis, synthesis, evaluation, and reflection, what qualities should be expected from a critical thinker?
In answering Fortepiani (2018), suggests that critical thinkers should be able to:
Formulate clear and precise questions;
Gather, assess, and interpret relevant information;
Reach relevant well-reasoned conclusions and solutions;
Think open-mindedly, recognising their own assumptions; and
Communicate effectively with others on solutions to complex problems.
All of these qualities are important but good communication skills are generally considered to be the bedrock of critical thinking. Why? Because they help to create a dialogue that invites questions, reflections and an open-minded approach, as well as generating a positive learning environment needed to support all forms of communication.
Lippincott Solutions (2018) also outlines a broad spectrum of characteristics attributed to strong critical thinkers. They include:
Inquisitiveness with regard to a wide range of issues;
A concern to become and remain well-informed;
Alertness to opportunities to use critical thinking;
Self-confidence in one’s own abilities to reason;
Open mindedness regarding divergent world views;
Flexibility in considering alternatives and opinions;
Understanding the opinions of other people;
Fair-mindedness in appraising reasoning;
Honesty in facing one’s own biases, prejudices, stereotypes, or egocentric tendencies; and
A willingness to reconsider and revise views where honest reflection suggests that change is warranted.
Papp et al. (2014) also helpfully suggests that the following 5 milestones can be used as a guide to help developing competency in critical thinking.
Stage 1: Unreflective Thinker
At this stage, the unreflective thinker can’t examine their own actions and cognitive processes and is unaware of different approaches to thinking.
Stage 2: Beginning Critical Thinker
Here the learner begins to think critically and starts to recognise cognitive differences in other people. However, external motivation is needed to sustain reflection on the learners’ own thought processes.
Stage 3: Practicing Critical Thinker
By now the learner is familiar with their own thinking processes and makes a conscious effort to practice critical thinking.
Stage 4: Advanced Critical Thinker
As an advanced critical thinker, the learner is able to identify different cognitive processes and consciously uses critical thinking skills.
Stage 5: Accomplished Critical Thinker
At this stage, the skilled critical thinker can take charge of their thinking and habitually monitors, revises, and rethinks approaches for continual improvement of their cognitive strategies.
A common challenge for many educators and facilitators in healthcare is encouraging students to move away from passive learning and encouraging movement towards active learning situations that require critical thinking skills.
Just as there are similarities among the definitions of critical thinking across subject areas and levels, there are also several generally recognised hallmarks of teaching for critical thinking. These include:
Promoting interaction among students as they learn;
Asking open ended questions that do not assume one right answer;
Allowing sufficient time to reflect on the questions asked, or problems posed; and
Teaching for transfer. Helping learners to see how a newly acquired skill can apply to other situations and experiences.
Lippincott Solutions (2018)
Snyder and Snyder (2008) also make the point that it’s helpful for educators and facilitators to be aware of any initial resistance that learners may have and try to guide them through the process. They should aim to create a learning environment where learners can feel comfortable thinking through an answer rather than simply having an answer given to them.
For example, using peer coaching techniques, mentoring or preceptorship to engage students in active learning and critical thinking skills. Or integrating project-based learning activities that require students to apply their knowledge in a realistic healthcare environment.
Carvalhoa et al. (2017) also advocate problem-based learning as a widely used and successful way of stimulating critical thinking skills in the learner. This view is echoed by Tsui-Mei (2015), who notes that critical thinking, systematic analysis and curiosity significantly improve after practice-based learning.
Integrating Critical Thinking Skills into Curriculum Design
Most educators agree that critical thinking can’t easily be developed if the program curriculum is not designed to support it. This means that a deep understanding of the nature and value of critical thinking skills needs to be present from the outset of the curriculum design process, and not just bolted on as an afterthought.
In the view of Fortepiani (2018), critical thinking skills can be summarised by the statement that “thinking is driven by questions”, which means that teaching materials need to be designed in such a way as to encourage students to expand their learning by asking questions that generate further questions and stimulate the thinking process. Ideal questions are those that:
Challenge assumptions and points of view;
Question the source of information; and
Explore variable interpretations and potential implications of information.
To put it another way, asking questions with limiting, thought stopping answers inhibits the development of critical thinking. This means that educators must ideally be critical thinkers themselves.
Drawing these threads together, The Foundation for Critical Thinking (2017) offers us a simple reminder that even though it’s human nature to be ‘thinking’ most of the time, most thoughts, if not guided and structured tend to be biased, distorted, partial, uninformed, or even prejudiced.
They also note that the quality of work depends precisely on the quality of the practitioners’ thought processes. Given that practitioners are being asked to meet the challenge of ever more complex care, the importance of cultivating critical thinking skills, alongside advanced problem-solving skills seems to take on a new importance.
Carvalhoa, D. P.S.R.P., Azevedoa, I. C., Cruza, G.K.P. et al. (2017) ‘Strategies used for the promotion of critical thinking in nursing undergraduate education: A systematic review’, Nurse Education Today , 57(), pp. 103-10 [Online]. Available at: https://www.sciencedirect.com/science/article/pii/S0260691717301715(Accessed: 7.12.18).
Fortepiani, L. A. (2018) https://blog.lifescitrc.org/pecop/2017/01/16/critical-thinking-or-traditional-teaching-for-health-professions/, Available at: https://blog.lifescitrc.org/pecop/2017/01/16/critical-thinking-or-traditional-teaching-for-health-professions/(Accessed: 7.12.18).
Jacob, E., Duffield, C. and Jacob, D (2017) ‘A protocol for the development of a critical thinking assessment tool for nurses using a Delphi technique’, Journal of Advanced Nursing, 73(8 ), pp. 1982-1988 [Online]. Available at: https://doi.org/10.1111/jan.13306(Accessed: 7.12.18).
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Lippincott Solutions (2018) Turning New Nurses Into Critical Thinkers, Available at: http://lippincottsolutions.lww.com/blog.entry.html/2018/06/05/turning_new_nursesi-UnqI.html(Accessed: 10.12.18).
Papp, K. K., Huang, G. C., Lauzon, C. et al. (2014) ‘Milestones of Critical Thinking: A Developmental Model for Medicine and Nursing’, Academic Medicine , 89(5), pp. 715-720 [Online]. Available at: https://journals.lww.com/academicmedicine/Fulltext/2014/05000/Milestones_of_Critical_Thinking___A_Developmental.14.aspx(Accessed: 7.12.18).
Snyder, L. G. and Snyder, M. J. (2008) ‘Teaching Critical Thinking and Problem Solving Skills’, The Delta Pi Epsilon Journal, L(2), pp. 90-99 [Online]. Available at: https://tccl.arcc.albany.edu/knilt/images/a/a5/Teaching_critical_thinking.pdf(Accessed: 7.12.18).
The Foundation for Critical Thinking (2017) Defining Critical Thinking, Available at: http://www.criticalthinking.org/pages/defining-critical-thinking/766(Accessed: 7.12.18).
Tsui-Mei, H., Lee-Chun, H. and Chen-Ju MSN, K. (2015) ‘ How Mental Health Nurses Improve Their Critical Thinking Through Problem-Based Learning’, Journal for Nurses in Professional Development , 31(3), pp. 170-175 [Online]. Available at: https://journals.lww.com/jnsdonline/Abstract/2015/05000/How_Mental_Health_Nurses_Improve_Their_Critical.8.aspx(Accessed: 7.12.18).