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's 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?
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 literature, but in the view of Kahlke and Eva (2018), most of these definitions 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 skillfully analysing, assessing, and reconstructing it.’
They go on to suggest that critical thinking is:
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 this question, Fortepiani (2018) suggests that critical thinkers should be able to:
All of these qualities are important, however, 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) outlines a broad spectrum of characteristics attributed to strong critical thinkers. They include:
Papp et al. (2014) also helpfully suggest that the following five milestones can be used as a guide to help develop competency in critical thinking:
At this stage, the unreflective thinker can’t examine their own actions and cognitive processes and is unaware of different approaches to thinking.
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.
By now, the learner is familiar with their own thinking processes and makes a conscious effort to practice critical thinking.
As an advanced critical thinker, the learner is able to identify different cognitive processes and consciously uses critical thinking skills.
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 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:
(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.
Examples include 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.
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:
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 be taking on new importance.
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