critical thinking definition in medical terminology

Medical Student Guide For Critical Thinking

Critical thinking is an essential cognitive skill for every individual but is a crucial component for healthcare professionals such as doctors, nurses and dentists. It is a skill that should be developed and trained, not just during your career as a doctor, but before that when you are still a medical student.

To be more effective in their studies, students must think their way through abstract problems, work in teams and separate high quality from low quality information. These are the same qualities that today's medical students are supposed to possess regardless of whether they graduate in the UK or study medicine in Europe .

In both well-defined and ill-defined medical emergencies, doctors are expected to make competent decisions. Critical thinking can help medical students and doctors achieve improved productivity, better clinical decision making, higher grades and much more.

This article will explain why critical thinking is a must for people in the medical field.

Definition of Critical Thinking

You can find a variety of definitions of Critical Thinking (CT). It is a term that goes back to the Ancient Greek philosopher Socrates and his teaching practice and vision. Critical thinking and its meaning have changed over the years, but at its core always will be the pursuit of proper judgment.

We can agree on one thing. Critical thinkers question every idea, assumption, and possibility rather than accepting them at once.

The most basic definition of CT is provided by Beyer (1995):

"Critical thinking means making reasoned judgements."

In other words, it is the ability to think logically about what to do and/or believe. It also includes the ability to think critically and independently. CT is the process of identifying, analysing, and then making decisions about a particular topic, advice, opinion or challenge that we are facing.

Steps to critical thinking

There is no universal standard for becoming a critical thinker. It is more like a unique journey for each individual. But as a medical student, you have already so much going on in your academic and personal life. This is why we created a list with 6 steps that will help you develop the necessary skills for critical thinking.

1. Determine the issue or question

The first step is to answer the following questions:

• What is the problem?
• Why is it important?
• Why do we need to find a solution?
• Who is involved?

By answering them, you will define the situation and acquire a deeper understanding of the problem and of any factors that may impact it.

Only after you have a clear picture of the issue and people involved can you start to dive deeper into the problem and search for a solution.

2. Research

Nowadays, we are flooded with information. We have an unlimited source of knowledge – the Internet.

Before choosing which medical schools to apply to, most applicants researched their desired schools online. Some of the areas you might have researched include:

• If the degree is recognised worldwide
• Tuition fees
• Living costs
• Entry requirements
• Competition for entry
• Number of exams
• Programme style

Having done the research, you were able to make an informed decision about your medical future based on the gathered information. Our list may be a little different to yours but that's okay. You know what factors are most important and relevant to you as a person.

The process you followed when choosing which medical school to apply to also applies to step 2 of critical thinking. As a medical student and doctor, you will face situations when you have to compare different arguments and opinions about an issue. Independent research is the key to the right clinical decisions. Medical and dentistry students have to be especially careful when learning from online sources. You shouldn't believe everything you read and take it as the absolute truth. So, here is what you need to do when facing a medical/study argument:

• Gather relevant information from all available reputable sources
• Pay attention to the salient points
• Evaluate the quality of the information and the level of evidence (is it just an opinion, or is it based upon a clinical trial?)

Once you have all the information needed, you can start the process of analysing it. It’s helpful to write down the strong and weak points of the various recommendations  and identify the most evidence-based approach.

Here is an example of a comparison between two online course platforms , which shows their respective strengths and weaknesses.

When recommendations or conclusions are contradictory, you will need to make a judgement call on which point of view has the strongest level of evidence to back it up. You should leave aside your feelings and analyse the problem from every angle possible. In the end, you should aim to make your decision based on the available evidence, not assumptions or bias.

4. Be careful about confirmation bias

It is in our nature to want to confirm our existing ideas rather than challenge them. You should try your best to strive for objectivity while evaluating information.

Often, you may find yourself reading articles that support your ideas, but why not broaden your horizons by learning about the other viewpoint?

By doing so, you will have the opportunity to get closer to the truth and may even find unexpected support and evidence for your conclusion.

Curiosity will keep you on the right path. However, if you find yourself searching for information or confirmation that aligns only with your opinion, then it’s important to take a step back. Take a short break, acknowledge your bias, clear your mind and start researching all over.

5. Synthesis

As we have already mentioned a couple of times, medical students are preoccupied with their studies. Therefore, you have to learn how to synthesise information. This is where you take information from multiple sources and bring the information together. Learning how to do this effectively will save you time and help you make better decisions faster.

You will have already located and evaluated your sources in the previous steps. You now have to organise the data into a logical argument that backs up your position on the problem under consideration.

6. Make a decision

Once you have gathered and evaluated all the available evidence, your last step  is to make a logical and well-reasoned conclusion.

By following this process you will ensure that whatever decision you make can be backed up if challenged

Why is critical thinking so important for medical students?

The first and most important reason for mastering critical thinking is that it will help you to avoid medical and clinical errors during your studies and future medical career.

Another good reason is that you will be able to identify better alternative options for diagnoses and treatments. You will be able to find the best solution for the patient as a whole which may be different to generic advice specific to the disease.

Furthermore, thinking critically as a medical student will boost your confidence and improve your knowledge and understanding of subjects.

In conclusion, critical thinking is a skill that can be learned and improved.  It will encourage you to be the best version of yourself and teach you to take responsibility for your actions.

Critical thinking has become an essential for future health care professionals and you will find it an invaluable skill throughout your career.

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Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr.

Patient Safety and Quality: An Evidence-Based Handbook for Nurses.

Chapter 6 clinical reasoning, decisionmaking, and action: thinking critically and clinically.

Patricia Benner ; Ronda G. Hughes ; Molly Sutphen .

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This chapter examines multiple thinking strategies that are needed for high-quality clinical practice. Clinical reasoning and judgment are examined in relation to other modes of thinking used by clinical nurses in providing quality health care to patients that avoids adverse events and patient harm. The clinician’s ability to provide safe, high-quality care can be dependent upon their ability to reason, think, and judge, which can be limited by lack of experience. The expert performance of nurses is dependent upon continual learning and evaluation of performance.

• Critical Thinking

Nursing education has emphasized critical thinking as an essential nursing skill for more than 50 years. 1 The definitions of critical thinking have evolved over the years. There are several key definitions for critical thinking to consider. The American Philosophical Association (APA) defined critical thinking as purposeful, self-regulatory judgment that uses cognitive tools such as interpretation, analysis, evaluation, inference, and explanation of the evidential, conceptual, methodological, criteriological, or contextual considerations on which judgment is based. 2 A more expansive general definition of critical thinking is

. . . in short, self-directed, self-disciplined, self-monitored, and self-corrective thinking. It presupposes assent to rigorous standards of excellence and mindful command of their use. It entails effective communication and problem solving abilities and a commitment to overcome our native egocentrism and sociocentrism. Every clinician must develop rigorous habits of critical thinking, but they cannot escape completely the situatedness and structures of the clinical traditions and practices in which they must make decisions and act quickly in specific clinical situations. 3

There are three key definitions for nursing, which differ slightly. Bittner and Tobin defined critical thinking as being “influenced by knowledge and experience, using strategies such as reflective thinking as a part of learning to identify the issues and opportunities, and holistically synthesize the information in nursing practice” 4 (p. 268). Scheffer and Rubenfeld 5 expanded on the APA definition for nurses through a consensus process, resulting in the following definition:

Critical thinking in nursing is an essential component of professional accountability and quality nursing care. Critical thinkers in nursing exhibit these habits of the mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, openmindedness, perseverance, and reflection. Critical thinkers in nursing practice the cognitive skills of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting, and transforming knowledge 6 (Scheffer & Rubenfeld, p. 357).

The National League for Nursing Accreditation Commission (NLNAC) defined critical thinking as:

the deliberate nonlinear process of collecting, interpreting, analyzing, drawing conclusions about, presenting, and evaluating information that is both factually and belief based. This is demonstrated in nursing by clinical judgment, which includes ethical, diagnostic, and therapeutic dimensions and research 7 (p. 8).

These concepts are furthered by the American Association of Colleges of Nurses’ definition of critical thinking in their Essentials of Baccalaureate Nursing :

Critical thinking underlies independent and interdependent decision making. Critical thinking includes questioning, analysis, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application, and creativity 8 (p. 9).

Course work or ethical experiences should provide the graduate with the knowledge and skills to:

• Use nursing and other appropriate theories and models, and an appropriate ethical framework;
• Apply research-based knowledge from nursing and the sciences as the basis for practice;
• Use clinical judgment and decision-making skills;
• Engage in self-reflective and collegial dialogue about professional practice;
• Evaluate nursing care outcomes through the acquisition of data and the questioning of inconsistencies, allowing for the revision of actions and goals;
• Engage in creative problem solving 8 (p. 10).

Taken together, these definitions of critical thinking set forth the scope and key elements of thought processes involved in providing clinical care. Exactly how critical thinking is defined will influence how it is taught and to what standard of care nurses will be held accountable.

Professional and regulatory bodies in nursing education have required that critical thinking be central to all nursing curricula, but they have not adequately distinguished critical reflection from ethical, clinical, or even creative thinking for decisionmaking or actions required by the clinician. Other essential modes of thought such as clinical reasoning, evaluation of evidence, creative thinking, or the application of well-established standards of practice—all distinct from critical reflection—have been subsumed under the rubric of critical thinking. In the nursing education literature, clinical reasoning and judgment are often conflated with critical thinking. The accrediting bodies and nursing scholars have included decisionmaking and action-oriented, practical, ethical, and clinical reasoning in the rubric of critical reflection and thinking. One might say that this harmless semantic confusion is corrected by actual practices, except that students need to understand the distinctions between critical reflection and clinical reasoning, and they need to learn to discern when each is better suited, just as students need to also engage in applying standards, evidence-based practices, and creative thinking.

The growing body of research, patient acuity, and complexity of care demand higher-order thinking skills. Critical thinking involves the application of knowledge and experience to identify patient problems and to direct clinical judgments and actions that result in positive patient outcomes. These skills can be cultivated by educators who display the virtues of critical thinking, including independence of thought, intellectual curiosity, courage, humility, empathy, integrity, perseverance, and fair-mindedness. 9

The process of critical thinking is stimulated by integrating the essential knowledge, experiences, and clinical reasoning that support professional practice. The emerging paradigm for clinical thinking and cognition is that it is social and dialogical rather than monological and individual. 10–12 Clinicians pool their wisdom and multiple perspectives, yet some clinical knowledge can be demonstrated only in the situation (e.g., how to suction an extremely fragile patient whose oxygen saturations sink too low). Early warnings of problematic situations are made possible by clinicians comparing their observations to that of other providers. Clinicians form practice communities that create styles of practice, including ways of doing things, communication styles and mechanisms, and shared expectations about performance and expertise of team members.

By holding up critical thinking as a large umbrella for different modes of thinking, students can easily misconstrue the logic and purposes of different modes of thinking. Clinicians and scientists alike need multiple thinking strategies, such as critical thinking, clinical judgment, diagnostic reasoning, deliberative rationality, scientific reasoning, dialogue, argument, creative thinking, and so on. In particular, clinicians need forethought and an ongoing grasp of a patient’s health status and care needs trajectory, which requires an assessment of their own clarity and understanding of the situation at hand, critical reflection, critical reasoning, and clinical judgment.

Critical Reflection, Critical Reasoning, and Judgment

Critical reflection requires that the thinker examine the underlying assumptions and radically question or doubt the validity of arguments, assertions, and even facts of the case. Critical reflective skills are essential for clinicians; however, these skills are not sufficient for the clinician who must decide how to act in particular situations and avoid patient injury. For example, in everyday practice, clinicians cannot afford to critically reflect on the well-established tenets of “normal” or “typical” human circulatory systems when trying to figure out a particular patient’s alterations from that typical, well-grounded understanding that has existed since Harvey’s work in 1628. 13 Yet critical reflection can generate new scientifically based ideas. For example, there is a lack of adequate research on the differences between women’s and men’s circulatory systems and the typical pathophysiology related to heart attacks. Available research is based upon multiple, taken-for-granted starting points about the general nature of the circulatory system. As such, critical reflection may not provide what is needed for a clinician to act in a situation. This idea can be considered reasonable since critical reflective thinking is not sufficient for good clinical reasoning and judgment. The clinician’s development of skillful critical reflection depends upon being taught what to pay attention to, and thus gaining a sense of salience that informs the powers of perceptual grasp. The powers of noticing or perceptual grasp depend upon noticing what is salient and the capacity to respond to the situation.

Critical reflection is a crucial professional skill, but it is not the only reasoning skill or logic clinicians require. The ability to think critically uses reflection, induction, deduction, analysis, challenging assumptions, and evaluation of data and information to guide decisionmaking. 9 , 14 , 15 Critical reasoning is a process whereby knowledge and experience are applied in considering multiple possibilities to achieve the desired goals, 16 while considering the patient’s situation. 14 It is a process where both inductive and deductive cognitive skills are used. 17 Sometimes clinical reasoning is presented as a form of evaluating scientific knowledge, sometimes even as a form of scientific reasoning. Critical thinking is inherent in making sound clinical reasoning. 18

An essential point of tension and confusion exists in practice traditions such as nursing and medicine when clinical reasoning and critical reflection become entangled, because the clinician must have some established bases that are not questioned when engaging in clinical decisions and actions, such as standing orders. The clinician must act in the particular situation and time with the best clinical and scientific knowledge available. The clinician cannot afford to indulge in either ritualistic unexamined knowledge or diagnostic or therapeutic nihilism caused by radical doubt, as in critical reflection, because they must find an intelligent and effective way to think and act in particular clinical situations. Critical reflection skills are essential to assist practitioners to rethink outmoded or even wrong-headed approaches to health care, health promotion, and prevention of illness and complications, especially when new evidence is available. Breakdowns in practice, high failure rates in particular therapies, new diseases, new scientific discoveries, and societal changes call for critical reflection about past assumptions and no-longer-tenable beliefs.

Clinical reasoning stands out as a situated, practice-based form of reasoning that requires a background of scientific and technological research-based knowledge about general cases, more so than any particular instance. It also requires practical ability to discern the relevance of the evidence behind general scientific and technical knowledge and how it applies to a particular patient. In dong so, the clinician considers the patient’s particular clinical trajectory, their concerns and preferences, and their particular vulnerabilities (e.g., having multiple comorbidities) and sensitivities to care interventions (e.g., known drug allergies, other conflicting comorbid conditions, incompatible therapies, and past responses to therapies) when forming clinical decisions or conclusions.

Situated in a practice setting, clinical reasoning occurs within social relationships or situations involving patient, family, community, and a team of health care providers. The expert clinician situates themselves within a nexus of relationships, with concerns that are bounded by the situation. Expert clinical reasoning is socially engaged with the relationships and concerns of those who are affected by the caregiving situation, and when certain circumstances are present, the adverse event. Halpern 19 has called excellent clinical ethical reasoning “emotional reasoning” in that the clinicians have emotional access to the patient/family concerns and their understanding of the particular care needs. Expert clinicians also seek an optimal perceptual grasp, one based on understanding and as undistorted as possible, based on an attuned emotional engagement and expert clinical knowledge. 19 , 20

Clergy educators 21 and nursing and medical educators have begun to recognize the wisdom of broadening their narrow vision of rationality beyond simple rational calculation (exemplified by cost-benefit analysis) to reconsider the need for character development—including emotional engagement, perception, habits of thought, and skill acquisition—as essential to the development of expert clinical reasoning, judgment, and action. 10 , 22–24 Practitioners of engineering, law, medicine, and nursing, like the clergy, have to develop a place to stand in their discipline’s tradition of knowledge and science in order to recognize and evaluate salient evidence in the moment. Diagnostic confusion and disciplinary nihilism are both threats to the clinician’s ability to act in particular situations. However, the practice and practitioners will not be self-improving and vital if they cannot engage in critical reflection on what is not of value, what is outmoded, and what does not work. As evidence evolves and expands, so too must clinical thought.

Clinical judgment requires clinical reasoning across time about the particular, and because of the relevance of this immediate historical unfolding, clinical reasoning can be very different from the scientific reasoning used to formulate, conduct, and assess clinical experiments. While scientific reasoning is also socially embedded in a nexus of social relationships and concerns, the goal of detached, critical objectivity used to conduct scientific experiments minimizes the interactive influence of the research on the experiment once it has begun. Scientific research in the natural and clinical sciences typically uses formal criteria to develop “yes” and “no” judgments at prespecified times. The scientist is always situated in past and immediate scientific history, preferring to evaluate static and predetermined points in time (e.g., snapshot reasoning), in contrast to a clinician who must always reason about transitions over time. 25 , 26

Techne and Phronesis

Distinctions between the mere scientific making of things and practice was first explored by Aristotle as distinctions between techne and phronesis. 27 Learning to be a good practitioner requires developing the requisite moral imagination for good practice. If, for example, patients exercise their rights and refuse treatments, practitioners are required to have the moral imagination to understand the probable basis for the patient’s refusal. For example, was the refusal based upon catastrophic thinking, unrealistic fears, misunderstanding, or even clinical depression?

Techne, as defined by Aristotle, encompasses the notion of formation of character and habitus 28 as embodied beings. In Aristotle’s terms, techne refers to the making of things or producing outcomes. 11 Joseph Dunne defines techne as “the activity of producing outcomes,” and it “is governed by a means-ends rationality where the maker or producer governs the thing or outcomes produced or made through gaining mastery over the means of producing the outcomes, to the point of being able to separate means and ends” 11 (p. 54). While some aspects of medical and nursing practice fall into the category of techne, much of nursing and medical practice falls outside means-ends rationality and must be governed by concern for doing good or what is best for the patient in particular circumstances, where being in a relationship and discerning particular human concerns at stake guide action.

Phronesis, in contrast to techne, includes reasoning about the particular, across time, through changes or transitions in the patient’s and/or the clinician’s understanding. As noted by Dunne, phronesis is “characterized at least as much by a perceptiveness with regard to concrete particulars as by a knowledge of universal principles” 11 (p. 273). This type of practical reasoning often takes the form of puzzle solving or the evaluation of immediate past “hot” history of the patient’s situation. Such a particular clinical situation is necessarily particular, even though many commonalities and similarities with other disease syndromes can be recognized through signs and symptoms and laboratory tests. 11 , 29 , 30 Pointing to knowledge embedded in a practice makes no claim for infallibility or “correctness.” Individual practitioners can be mistaken in their judgments because practices such as medicine and nursing are inherently underdetermined. 31

While phronetic knowledge must remain open to correction and improvement, real events, and consequences, it cannot consistently transcend the institutional setting’s capacities and supports for good practice. Phronesis is also dependent on ongoing experiential learning of the practitioner, where knowledge is refined, corrected, or refuted. The Western tradition, with the notable exception of Aristotle, valued knowledge that could be made universal and devalued practical know-how and experiential learning. Descartes codified this preference for formal logic and rational calculation.

Aristotle recognized that when knowledge is underdetermined, changeable, and particular, it cannot be turned into the universal or standardized. It must be perceived, discerned, and judged, all of which require experiential learning. In nursing and medicine, perceptual acuity in physical assessment and clinical judgment (i.e., reasoning across time about changes in the particular patient or the clinician’s understanding of the patient’s condition) fall into the Greek Aristotelian category of phronesis. Dewey 32 sought to rescue knowledge gained by practical activity in the world. He identified three flaws in the understanding of experience in Greek philosophy: (1) empirical knowing is the opposite of experience with science; (2) practice is reduced to techne or the application of rational thought or technique; and (3) action and skilled know-how are considered temporary and capricious as compared to reason, which the Greeks considered as ultimate reality.

In practice, nursing and medicine require both techne and phronesis. The clinician standardizes and routinizes what can be standardized and routinized, as exemplified by standardized blood pressure measurements, diagnoses, and even charting about the patient’s condition and treatment. 27 Procedural and scientific knowledge can often be formalized and standardized (e.g., practice guidelines), or at least made explicit and certain in practice, except for the necessary timing and adjustments made for particular patients. 11 , 22

Rational calculations available to techne—population trends and statistics, algorithms—are created as decision support structures and can improve accuracy when used as a stance of inquiry in making clinical judgments about particular patients. Aggregated evidence from clinical trials and ongoing working knowledge of pathophysiology, biochemistry, and genomics are essential. In addition, the skills of phronesis (clinical judgment that reasons across time, taking into account the transitions of the particular patient/family/community and transitions in the clinician’s understanding of the clinical situation) will be required for nursing, medicine, or any helping profession.

Thinking Critically

Being able to think critically enables nurses to meet the needs of patients within their context and considering their preferences; meet the needs of patients within the context of uncertainty; consider alternatives, resulting in higher-quality care; 33 and think reflectively, rather than simply accepting statements and performing tasks without significant understanding and evaluation. 34 Skillful practitioners can think critically because they have the following cognitive skills: information seeking, discriminating, analyzing, transforming knowledge, predicating, applying standards, and logical reasoning. 5 One’s ability to think critically can be affected by age, length of education (e.g., an associate vs. a baccalaureate decree in nursing), and completion of philosophy or logic subjects. 35–37 The skillful practitioner can think critically because of having the following characteristics: motivation, perseverance, fair-mindedness, and deliberate and careful attention to thinking. 5 , 9

Thinking critically implies that one has a knowledge base from which to reason and the ability to analyze and evaluate evidence. 38 Knowledge can be manifest by the logic and rational implications of decisionmaking. Clinical decisionmaking is particularly influenced by interpersonal relationships with colleagues, 39 patient conditions, availability of resources, 40 knowledge, and experience. 41 Of these, experience has been shown to enhance nurses’ abilities to make quick decisions 42 and fewer decision errors, 43 support the identification of salient cues, and foster the recognition and action on patterns of information. 44 , 45

Clinicians must develop the character and relational skills that enable them to perceive and understand their patient’s needs and concerns. This requires accurate interpretation of patient data that is relevant to the specific patient and situation. In nursing, this formation of moral agency focuses on learning to be responsible in particular ways demanded by the practice, and to pay attention and intelligently discern changes in patients’ concerns and/or clinical condition that require action on the part of the nurse or other health care workers to avert potential compromises to quality care.

Formation of the clinician’s character, skills, and habits are developed in schools and particular practice communities within a larger practice tradition. As Dunne notes,

A practice is not just a surface on which one can display instant virtuosity. It grounds one in a tradition that has been formed through an elaborate development and that exists at any juncture only in the dispositions (slowly and perhaps painfully acquired) of its recognized practitioners. The question may of course be asked whether there are any such practices in the contemporary world, whether the wholesale encroachment of Technique has not obliterated them—and whether this is not the whole point of MacIntyre’s recipe of withdrawal, as well as of the post-modern story of dispossession 11 (p. 378).

Clearly Dunne is engaging in critical reflection about the conditions for developing character, skills, and habits for skillful and ethical comportment of practitioners, as well as to act as moral agents for patients so that they and their families receive safe, effective, and compassionate care.

Professional socialization or professional values, while necessary, do not adequately address character and skill formation that transform the way the practitioner exists in his or her world, what the practitioner is capable of noticing and responding to, based upon well-established patterns of emotional responses, skills, dispositions to act, and the skills to respond, decide, and act. 46 The need for character and skill formation of the clinician is what makes a practice stand out from a mere technical, repetitious manufacturing process. 11 , 30 , 47

In nursing and medicine, many have questioned whether current health care institutions are designed to promote or hinder enlightened, compassionate practice, or whether they have deteriorated into commercial institutional models that focus primarily on efficiency and profit. MacIntyre points out the links between the ongoing development and improvement of practice traditions and the institutions that house them:

Lack of justice, lack of truthfulness, lack of courage, lack of the relevant intellectual virtues—these corrupt traditions, just as they do those institutions and practices which derive their life from the traditions of which they are the contemporary embodiments. To recognize this is of course also to recognize the existence of an additional virtue, one whose importance is perhaps most obvious when it is least present, the virtue of having an adequate sense of the traditions to which one belongs or which confront one. This virtue is not to be confused with any form of conservative antiquarianism; I am not praising those who choose the conventional conservative role of laudator temporis acti. It is rather the case that an adequate sense of tradition manifests itself in a grasp of those future possibilities which the past has made available to the present. Living traditions, just because they continue a not-yet-completed narrative, confront a future whose determinate and determinable character, so far as it possesses any, derives from the past 30 (p. 207).

It would be impossible to capture all the situated and distributed knowledge outside of actual practice situations and particular patients. Simulations are powerful as teaching tools to enable nurses’ ability to think critically because they give students the opportunity to practice in a simplified environment. However, students can be limited in their inability to convey underdetermined situations where much of the information is based on perceptions of many aspects of the patient and changes that have occurred over time. Simulations cannot have the sub-cultures formed in practice settings that set the social mood of trust, distrust, competency, limited resources, or other forms of situated possibilities.

One of the hallmark studies in nursing providing keen insight into understanding the influence of experience was a qualitative study of adult, pediatric, and neonatal intensive care unit (ICU) nurses, where the nurses were clustered into advanced beginner, intermediate, and expert level of practice categories. The advanced beginner (having up to 6 months of work experience) used procedures and protocols to determine which clinical actions were needed. When confronted with a complex patient situation, the advanced beginner felt their practice was unsafe because of a knowledge deficit or because of a knowledge application confusion. The transition from advanced beginners to competent practitioners began when they first had experience with actual clinical situations and could benefit from the knowledge gained from the mistakes of their colleagues. Competent nurses continuously questioned what they saw and heard, feeling an obligation to know more about clinical situations. In doing do, they moved from only using care plans and following the physicians’ orders to analyzing and interpreting patient situations. Beyond that, the proficient nurse acknowledged the changing relevance of clinical situations requiring action beyond what was planned or anticipated. The proficient nurse learned to acknowledge the changing needs of patient care and situation, and could organize interventions “by the situation as it unfolds rather than by preset goals 48 (p. 24). Both competent and proficient nurses (that is, intermediate level of practice) had at least two years of ICU experience. 48 Finally, the expert nurse had a more fully developed grasp of a clinical situation, a sense of confidence in what is known about the situation, and could differentiate the precise clinical problem in little time. 48

Expertise is acquired through professional experience and is indicative of a nurse who has moved beyond mere proficiency. As Gadamer 29 points out, experience involves a turning around of preconceived notions, preunderstandings, and extends or adds nuances to understanding. Dewey 49 notes that experience requires a prepared “creature” and an enriched environment. The opportunity to reflect and narrate one’s experiential learning can clarify, extend, or even refute experiential learning.

Experiential learning requires time and nurturing, but time alone does not ensure experiential learning. Aristotle linked experiential learning to the development of character and moral sensitivities of a person learning a practice. 50 New nurses/new graduates have limited work experience and must experience continuing learning until they have reached an acceptable level of performance. 51 After that, further improvements are not predictable, and years of experience are an inadequate predictor of expertise. 52

The most effective knower and developer of practical knowledge creates an ongoing dialogue and connection between lessons of the day and experiential learning over time. Gadamer, in a late life interview, highlighted the open-endedness and ongoing nature of experiential learning in the following interview response:

Being experienced does not mean that one now knows something once and for all and becomes rigid in this knowledge; rather, one becomes more open to new experiences. A person who is experienced is undogmatic. Experience has the effect of freeing one to be open to new experience … In our experience we bring nothing to a close; we are constantly learning new things from our experience … this I call the interminability of all experience 32 (p. 403).

Practical endeavor, supported by scientific knowledge, requires experiential learning, the development of skilled know-how, and perceptual acuity in order to make the scientific knowledge relevant to the situation. Clinical perceptual and skilled know-how helps the practitioner discern when particular scientific findings might be relevant. 53

Often experience and knowledge, confirmed by experimentation, are treated as oppositions, an either-or choice. However, in practice it is readily acknowledged that experiential knowledge fuels scientific investigation, and scientific investigation fuels further experiential learning. Experiential learning from particular clinical cases can help the clinician recognize future similar cases and fuel new scientific questions and study. For example, less experienced nurses—and it could be argued experienced as well—can use nursing diagnoses practice guidelines as part of their professional advancement. Guidelines are used to reflect their interpretation of patients’ needs, responses, and situation, 54 a process that requires critical thinking and decisionmaking. 55 , 56 Using guidelines also reflects one’s problem identification and problem-solving abilities. 56 Conversely, the ability to proficiently conduct a series of tasks without nursing diagnoses is the hallmark of expertise. 39 , 57

Experience precedes expertise. As expertise develops from experience and gaining knowledge and transitions to the proficiency stage, the nurses’ thinking moves from steps and procedures (i.e., task-oriented care) toward “chunks” or patterns 39 (i.e., patient-specific care). In doing so, the nurse thinks reflectively, rather than merely accepting statements and performing procedures without significant understanding and evaluation. 34 Expert nurses do not rely on rules and logical thought processes in problem-solving and decisionmaking. 39 Instead, they use abstract principles, can see the situation as a complex whole, perceive situations comprehensively, and can be fully involved in the situation. 48 Expert nurses can perform high-level care without conscious awareness of the knowledge they are using, 39 , 58 and they are able to provide that care with flexibility and speed. Through a combination of knowledge and skills gained from a range of theoretical and experiential sources, expert nurses also provide holistic care. 39 Thus, the best care comes from the combination of theoretical, tacit, and experiential knowledge. 59 , 60

Experts are thought to eventually develop the ability to intuitively know what to do and to quickly recognize critical aspects of the situation. 22 Some have proposed that expert nurses provide high-quality patient care, 61 , 62 but that is not consistently documented—particularly in consideration of patient outcomes—and a full understanding between the differential impact of care rendered by an “expert” nurse is not fully understood. In fact, several studies have found that length of professional experience is often unrelated and even negatively related to performance measures and outcomes. 63 , 64

In a review of the literature on expertise in nursing, Ericsson and colleagues 65 found that focusing on challenging, less-frequent situations would reveal individual performance differences on tasks that require speed and flexibility, such as that experienced during a code or an adverse event. Superior performance was associated with extensive training and immediate feedback about outcomes, which can be obtained through continual training, simulation, and processes such as root-cause analysis following an adverse event. Therefore, efforts to improve performance benefited from continual monitoring, planning, and retrospective evaluation. Even then, the nurse’s ability to perform as an expert is dependent upon their ability to use intuition or insights gained through interactions with patients. 39

Intuition and Perception

Intuition is the instant understanding of knowledge without evidence of sensible thought. 66 According to Young, 67 intuition in clinical practice is a process whereby the nurse recognizes something about a patient that is difficult to verbalize. Intuition is characterized by factual knowledge, “immediate possession of knowledge, and knowledge independent of the linear reasoning process” 68 (p. 23). When intuition is used, one filters information initially triggered by the imagination, leading to the integration of all knowledge and information to problem solve. 69 Clinicians use their interactions with patients and intuition, drawing on tacit or experiential knowledge, 70 , 71 to apply the correct knowledge to make the correct decisions to address patient needs. Yet there is a “conflated belief in the nurses’ ability to know what is best for the patient” 72 (p. 251) because the nurses’ and patients’ identification of the patients’ needs can vary. 73

A review of research and rhetoric involving intuition by King and Appleton 62 found that all nurses, including students, used intuition (i.e., gut feelings). They found evidence, predominately in critical care units, that intuition was triggered in response to knowledge and as a trigger for action and/or reflection with a direct bearing on the analytical process involved in patient care. The challenge for nurses was that rigid adherence to checklists, guidelines, and standardized documentation, 62 ignored the benefits of intuition. This view was furthered by Rew and Barrow 68 , 74 in their reviews of the literature, where they found that intuition was imperative to complex decisionmaking, 68 difficult to measure and assess in a quantitative manner, and was not linked to physiologic measures. 74

Intuition is a way of explaining professional expertise. 75 Expert nurses rely on their intuitive judgment that has been developed over time. 39 , 76 Intuition is an informal, nonanalytically based, unstructured, deliberate calculation that facilitates problem solving, 77 a process of arriving at salient conclusions based on relatively small amounts of knowledge and/or information. 78 Experts can have rapid insight into a situation by using intuition to recognize patterns and similarities, achieve commonsense understanding, and sense the salient information combined with deliberative rationality. 10 Intuitive recognition of similarities and commonalities between patients are often the first diagnostic clue or early warning, which must then be followed up with critical evaluation of evidence among the competing conditions. This situation calls for intuitive judgment that can distinguish “expert human judgment from the decisions” made by a novice 79 (p. 23).

Shaw 80 equates intuition with direct perception. Direct perception is dependent upon being able to detect complex patterns and relationships that one has learned through experience are important. Recognizing these patterns and relationships generally occurs rapidly and is complex, making it difficult to articulate or describe. Perceptual skills, like those of the expert nurse, are essential to recognizing current and changing clinical conditions. Perception requires attentiveness and the development of a sense of what is salient. Often in nursing and medicine, means and ends are fused, as is the case for a “good enough” birth experience and a peaceful death.

• Applying Practice Evidence

Research continues to find that using evidence-based guidelines in practice, informed through research evidence, improves patients’ outcomes. 81–83 Research-based guidelines are intended to provide guidance for specific areas of health care delivery. 84 The clinician—both the novice and expert—is expected to use the best available evidence for the most efficacious therapies and interventions in particular instances, to ensure the highest-quality care, especially when deviations from the evidence-based norm may heighten risks to patient safety. Otherwise, if nursing and medicine were exact sciences, or consisted only of techne, then a 1:1 relationship could be established between results of aggregated evidence-based research and the best path for all patients.

Evaluating Evidence

Before research should be used in practice, it must be evaluated. There are many complexities and nuances in evaluating the research evidence for clinical practice. Evaluation of research behind evidence-based medicine requires critical thinking and good clinical judgment. Sometimes the research findings are mixed or even conflicting. As such, the validity, reliability, and generalizability of available research are fundamental to evaluating whether evidence can be applied in practice. To do so, clinicians must select the best scientific evidence relevant to particular patients—a complex process that involves intuition to apply the evidence. Critical thinking is required for evaluating the best available scientific evidence for the treatment and care of a particular patient.

Good clinical judgment is required to select the most relevant research evidence. The best clinical judgment, that is, reasoning across time about the particular patient through changes in the patient’s concerns and condition and/or the clinician’s understanding, are also required. This type of judgment requires clinicians to make careful observations and evaluations of the patient over time, as well as know the patient’s concerns and social circumstances. To evolve to this level of judgment, additional education beyond clinical preparation if often required.

Sources of Evidence

Evidence that can be used in clinical practice has different sources and can be derived from research, patient’s preferences, and work-related experience. 85 , 86 Nurses have been found to obtain evidence from experienced colleagues believed to have clinical expertise and research-based knowledge 87 as well as other sources.

For many years now, randomized controlled trials (RCTs) have often been considered the best standard for evaluating clinical practice. Yet, unless the common threats to the validity (e.g., representativeness of the study population) and reliability (e.g., consistency in interventions and responses of study participants) of RCTs are addressed, the meaningfulness and generalizability of the study outcomes are very limited. Relevant patient populations may be excluded, such as women, children, minorities, the elderly, and patients with multiple chronic illnesses. The dropout rate of the trial may confound the results. And it is easier to get positive results published than it is to get negative results published. Thus, RCTs are generalizable (i.e., applicable) only to the population studied—which may not reflect the needs of the patient under the clinicians care. In instances such as these, clinicians need to also consider applied research using prospective or retrospective populations with case control to guide decisionmaking, yet this too requires critical thinking and good clinical judgment.

Another source of available evidence may come from the gold standard of aggregated systematic evaluation of clinical trial outcomes for the therapy and clinical condition in question, be generated by basic and clinical science relevant to the patient’s particular pathophysiology or care need situation, or stem from personal clinical experience. The clinician then takes all of the available evidence and considers the particular patient’s known clinical responses to past therapies, their clinical condition and history, the progression or stages of the patient’s illness and recovery, and available resources.

In clinical practice, the particular is examined in relation to the established generalizations of science. With readily available summaries of scientific evidence (e.g., systematic reviews and practice guidelines) available to nurses and physicians, one might wonder whether deep background understanding is still advantageous. Might it not be expendable, since it is likely to be out of date given the current scientific evidence? But this assumption is a false opposition and false choice because without a deep background understanding, the clinician does not know how to best find and evaluate scientific evidence for the particular case in hand. The clinician’s sense of salience in any given situation depends on past clinical experience and current scientific evidence.

Evidence-Based Practice

The concept of evidence-based practice is dependent upon synthesizing evidence from the variety of sources and applying it appropriately to the care needs of populations and individuals. This implies that evidence-based practice, indicative of expertise in practice, appropriately applies evidence to the specific situations and unique needs of patients. 88 , 89 Unfortunately, even though providing evidence-based care is an essential component of health care quality, it is well known that evidence-based practices are not used consistently.

Conceptually, evidence used in practice advances clinical knowledge, and that knowledge supports independent clinical decisions in the best interest of the patient. 90 , 91 Decisions must prudently consider the factors not necessarily addressed in the guideline, such as the patient’s lifestyle, drug sensitivities and allergies, and comorbidities. Nurses who want to improve the quality and safety of care can do so though improving the consistency of data and information interpretation inherent in evidence-based practice.

Initially, before evidence-based practice can begin, there needs to be an accurate clinical judgment of patient responses and needs. In the course of providing care, with careful consideration of patient safety and quality care, clinicians must give attention to the patient’s condition, their responses to health care interventions, and potential adverse reactions or events that could harm the patient. Nonetheless, there is wide variation in the ability of nurses to accurately interpret patient responses 92 and their risks. 93 Even though variance in interpretation is expected, nurses are obligated to continually improve their skills to ensure that patients receive quality care safely. 94 Patients are vulnerable to the actions and experience of their clinicians, which are inextricably linked to the quality of care patients have access to and subsequently receive.

The judgment of the patient’s condition determines subsequent interventions and patient outcomes. Attaining accurate and consistent interpretations of patient data and information is difficult because each piece can have different meanings, and interpretations are influenced by previous experiences. 95 Nurses use knowledge from clinical experience 96 , 97 and—although infrequently—research. 98–100

Once a problem has been identified, using a process that utilizes critical thinking to recognize the problem, the clinician then searches for and evaluates the research evidence 101 and evaluates potential discrepancies. The process of using evidence in practice involves “a problem-solving approach that incorporates the best available scientific evidence, clinicians’ expertise, and patient’s preferences and values” 102 (p. 28). Yet many nurses do not perceive that they have the education, tools, or resources to use evidence appropriately in practice. 103

Reported barriers to using research in practice have included difficulty in understanding the applicability and the complexity of research findings, failure of researchers to put findings into the clinical context, lack of skills in how to use research in practice, 104 , 105 amount of time required to access information and determine practice implications, 105–107 lack of organizational support to make changes and/or use in practice, 104 , 97 , 105 , 107 and lack of confidence in one’s ability to critically evaluate clinical evidence. 108

When Evidence Is Missing

In many clinical situations, there may be no clear guidelines and few or even no relevant clinical trials to guide decisionmaking. In these cases, the latest basic science about cellular and genomic functioning may be the most relevant science, or by default, guestimation. Consequently, good patient care requires more than a straightforward, unequivocal application of scientific evidence. The clinician must be able to draw on a good understanding of basic sciences, as well as guidelines derived from aggregated data and information from research investigations.

Practical knowledge is shaped by one’s practice discipline and the science and technology relevant to the situation at hand. But scientific, formal, discipline-specific knowledge are not sufficient for good clinical practice, whether the discipline be law, medicine, nursing, teaching, or social work. Practitioners still have to learn how to discern generalizable scientific knowledge, know how to use scientific knowledge in practical situations, discern what scientific evidence/knowledge is relevant, assess how the particular patient’s situation differs from the general scientific understanding, and recognize the complexity of care delivery—a process that is complex, ongoing, and changing, as new evidence can overturn old.

Practice communities like individual practitioners may also be mistaken, as is illustrated by variability in practice styles and practice outcomes across hospitals and regions in the United States. This variability in practice is why practitioners must learn to critically evaluate their practice and continually improve their practice over time. The goal is to create a living self-improving tradition.

Within health care, students, scientists, and practitioners are challenged to learn and use different modes of thinking when they are conflated under one term or rubric, using the best-suited thinking strategies for taking into consideration the purposes and the ends of the reasoning. Learning to be an effective, safe nurse or physician requires not only technical expertise, but also the ability to form helping relationships and engage in practical ethical and clinical reasoning. 50 Good ethical comportment requires that both the clinician and the scientist take into account the notions of good inherent in clinical and scientific practices. The notions of good clinical practice must include the relevant significance and the human concerns involved in decisionmaking in particular situations, centered on clinical grasp and clinical forethought.

The Three Apprenticeships of Professional Education

We have much to learn in comparing the pedagogies of formation across the professions, such as is being done currently by the Carnegie Foundation for the Advancement of Teaching. The Carnegie Foundation’s broad research program on the educational preparation of the profession focuses on three essential apprenticeships:

To capture the full range of crucial dimensions in professional education, we developed the idea of a three-fold apprenticeship: (1) intellectual training to learn the academic knowledge base and the capacity to think in ways important to the profession; (2) a skill-based apprenticeship of practice; and (3) an apprenticeship to the ethical standards, social roles, and responsibilities of the profession, through which the novice is introduced to the meaning of an integrated practice of all dimensions of the profession, grounded in the profession’s fundamental purposes. 109

This framework has allowed the investigators to describe tensions and shortfalls as well as strengths of widespread teaching practices, especially at articulation points among these dimensions of professional training.

Research has demonstrated that these three apprenticeships are taught best when they are integrated so that the intellectual training includes skilled know-how, clinical judgment, and ethical comportment. In the study of nursing, exemplary classroom and clinical teachers were found who do integrate the three apprenticeships in all of their teaching, as exemplified by the following anonymous student’s comments:

With that as well, I enjoyed the class just because I do have clinical experience in my background and I enjoyed it because it took those practical applications and the knowledge from pathophysiology and pharmacology, and all the other classes, and it tied it into the actual aspects of like what is going to happen at work. For example, I work in the emergency room and question: Why am I doing this procedure for this particular patient? Beforehand, when I was just a tech and I wasn’t going to school, I’d be doing it because I was told to be doing it—or I’d be doing CPR because, you know, the doc said, start CPR. I really enjoy the Care and Illness because now I know the process, the pathophysiological process of why I’m doing it and the clinical reasons of why they’re making the decisions, and the prioritization that goes on behind it. I think that’s the biggest point. Clinical experience is good, but not everybody has it. Yet when these students transition from school and clinicals to their job as a nurse, they will understand what’s going on and why.

The three apprenticeships are equally relevant and intertwined. In the Carnegie National Study of Nursing Education and the companion study on medical education as well as in cross-professional comparisons, teaching that gives an integrated access to professional practice is being examined. Once the three apprenticeships are separated, it is difficult to reintegrate them. The investigators are encouraged by teaching strategies that integrate the latest scientific knowledge and relevant clinical evidence with clinical reasoning about particular patients in unfolding rather than static cases, while keeping the patient and family experience and concerns relevant to clinical concerns and reasoning.

Clinical judgment or phronesis is required to evaluate and integrate techne and scientific evidence.

Within nursing, professional practice is wise and effective usually to the extent that the professional creates relational and communication contexts where clients/patients can be open and trusting. Effectiveness depends upon mutual influence between patient and practitioner, student and learner. This is another way in which clinical knowledge is dialogical and socially distributed. The following articulation of practical reasoning in nursing illustrates the social, dialogical nature of clinical reasoning and addresses the centrality of perception and understanding to good clinical reasoning, judgment and intervention.

Clinical Grasp *

Clinical grasp describes clinical inquiry in action. Clinical grasp begins with perception and includes problem identification and clinical judgment across time about the particular transitions of particular patients. Garrett Chan 20 described the clinician’s attempt at finding an “optimal grasp” or vantage point of understanding. Four aspects of clinical grasp, which are described in the following paragraphs, include (1) making qualitative distinctions, (2) engaging in detective work, (3) recognizing changing relevance, and (4) developing clinical knowledge in specific patient populations.

Making Qualitative Distinctions

Qualitative distinctions refer to those distinctions that can be made only in a particular contextual or historical situation. The context and sequence of events are essential for making qualitative distinctions; therefore, the clinician must pay attention to transitions in the situation and judgment. Many qualitative distinctions can be made only by observing differences through touch, sound, or sight, such as the qualities of a wound, skin turgor, color, capillary refill, or the engagement and energy level of the patient. Another example is assessing whether the patient was more fatigued after ambulating to the bathroom or from lack of sleep. Likewise the quality of the clinician’s touch is distinct as in offering reassurance, putting pressure on a bleeding wound, and so on. 110

Engaging in Detective Work, Modus Operandi Thinking, and Clinical Puzzle Solving

Clinical situations are open ended and underdetermined. Modus operandi thinking keeps track of the particular patient, the way the illness unfolds, the meanings of the patient’s responses as they have occurred in the particular time sequence. Modus operandi thinking requires keeping track of what has been tried and what has or has not worked with the patient. In this kind of reasoning-in-transition, gains and losses of understanding are noticed and adjustments in the problem approach are made.

We found that teachers in a medical surgical unit at the University of Washington deliberately teach their students to engage in “detective work.” Students are given the daily clinical assignment of “sleuthing” for undetected drug incompatibilities, questionable drug dosages, and unnoticed signs and symptoms. For example, one student noted that an unusual dosage of a heart medication was being given to a patient who did not have heart disease. The student first asked her teacher about the unusually high dosage. The teacher, in turn, asked the student whether she had asked the nurse or the patient about the dosage. Upon the student’s questioning, the nurse did not know why the patient was receiving the high dosage and assumed the drug was for heart disease. The patient’s staff nurse had not questioned the order. When the student asked the patient, the student found that the medication was being given for tremors and that the patient and the doctor had titrated the dosage for control of the tremors. This deliberate approach to teaching detective work, or modus operandi thinking, has characteristics of “critical reflection,” but stays situated and engaged, ferreting out the immediate history and unfolding of events.

Recognizing Changing Clinical Relevance

The meanings of signs and symptoms are changed by sequencing and history. The patient’s mental status, color, or pain level may continue to deteriorate or get better. The direction, implication, and consequences for the changes alter the relevance of the particular facts in the situation. The changing relevance entailed in a patient transitioning from primarily curative care to primarily palliative care is a dramatic example, where symptoms literally take on new meanings and require new treatments.

Developing Clinical Knowledge in Specific Patient Populations

Extensive experience with a specific patient population or patients with particular injuries or diseases allows the clinician to develop comparisons, distinctions, and nuanced differences within the population. The comparisons between many specific patients create a matrix of comparisons for clinicians, as well as a tacit, background set of expectations that create population- and patient-specific detective work if a patient does not meet the usual, predictable transitions in recovery. What is in the background and foreground of the clinician’s attention shifts as predictable changes in the patient’s condition occurs, such as is seen in recovering from heart surgery or progressing through the predictable stages of labor and delivery. Over time, the clinician develops a deep background understanding that allows for expert diagnostic and interventions skills.

Clinical Forethought

Clinical forethought is intertwined with clinical grasp, but it is much more deliberate and even routinized than clinical grasp. Clinical forethought is a pervasive habit of thought and action in nursing practice, and also in medicine, as clinicians think about disease and recovery trajectories and the implications of these changes for treatment. Clinical forethought plays a role in clinical grasp because it structures the practical logic of clinicians. At least four habits of thought and action are evident in what we are calling clinical forethought: (1) future think, (2) clinical forethought about specific patient populations, (3) anticipation of risks for particular patients, and (4) seeing the unexpected.

Future think

Future think is the broadest category of this logic of practice. Anticipating likely immediate futures helps the clinician make good plans and decisions about preparing the environment so that responding rapidly to changes in the patient is possible. Without a sense of salience about anticipated signs and symptoms and preparing the environment, essential clinical judgments and timely interventions would be impossible in the typically fast pace of acute and intensive patient care. Future think governs the style and content of the nurse’s attentiveness to the patient. Whether in a fast-paced care environment or a slower-paced rehabilitation setting, thinking and acting with anticipated futures guide clinical thinking and judgment. Future think captures the way judgment is suspended in a predictive net of anticipation and preparing oneself and the environment for a range of potential events.

Clinical forethought about specific diagnoses and injuries

This habit of thought and action is so second nature to the experienced nurse that the new or inexperienced nurse may have difficulty finding out about what seems to other colleagues as “obvious” preparation for particular patients and situations. Clinical forethought involves much local specific knowledge about who is a good resource and how to marshal support services and equipment for particular patients.

Examples of preparing for specific patient populations are pervasive, such as anticipating the need for a pacemaker during surgery and having the equipment assembled ready for use to save essential time. Another example includes forecasting an accident victim’s potential injuries, and recognizing that intubation might be needed.

Anticipation of crises, risks, and vulnerabilities for particular patients

This aspect of clinical forethought is central to knowing the particular patient, family, or community. Nurses situate the patient’s problems almost like a topography of possibilities. This vital clinical knowledge needs to be communicated to other caregivers and across care borders. Clinical teaching could be improved by enriching curricula with narrative examples from actual practice, and by helping students recognize commonly occurring clinical situations in the simulation and clinical setting. For example, if a patient is hemodynamically unstable, then managing life-sustaining physiologic functions will be a main orienting goal. If the patient is agitated and uncomfortable, then attending to comfort needs in relation to hemodynamics will be a priority. Providing comfort measures turns out to be a central background practice for making clinical judgments and contains within it much judgment and experiential learning.

When clinical teaching is too removed from typical contingencies and strong clinical situations in practice, students will lack practice in active thinking-in-action in ambiguous clinical situations. In the following example, an anonymous student recounted her experiences of meeting a patient:

I was used to different equipment and didn’t know how things went, didn’t know their routine, really. You can explain all you want in class, this is how it’s going to be, but when you get there … . Kim was my first instructor and my patient that she assigned me to—I walked into the room and he had every tube imaginable. And so I was a little overwhelmed. It’s not necessarily even that he was that critical … . She asked what tubes here have you seen? Well, I know peripheral lines. You taught me PICC [peripherally inserted central catheter] lines, and we just had that, but I don’t really feel comfortable doing it by myself, without you watching to make sure that I’m flushing it right and how to assess it. He had a chest tube and I had seen chest tubes, but never really knew the depth of what you had to assess and how you make sure that it’s all kosher and whatever. So she went through the chest tube and explained, it’s just bubbling a little bit and that’s okay. The site, check the site. The site looked okay and that she’d say if it wasn’t okay, this is what it might look like … . He had a feeding tube. I had done feeding tubes but that was like a long time ago in my LPN experiences schooling. So I hadn’t really done too much with the feeding stuff either … . He had a [nasogastric] tube, and knew pretty much about that and I think at the time it was clamped. So there were no issues with the suction or whatever. He had a Foley catheter. He had a feeding tube, a chest tube. I can’t even remember but there were a lot.

As noted earlier, a central characteristic of a practice discipline is that a self-improving practice requires ongoing experiential learning. One way nurse educators can enhance clinical inquiry is by increasing pedagogies of experiential learning. Current pedagogies for experiential learning in nursing include extensive preclinical study, care planning, and shared postclinical debriefings where students share their experiential learning with their classmates. Experiential learning requires open learning climates where students can discuss and examine transitions in understanding, including their false starts, or their misconceptions in actual clinical situations. Nursing educators typically develop open and interactive clinical learning communities, so that students seem committed to helping their classmates learn from their experiences that may have been difficult or even unsafe. One anonymous nurse educator described how students extend their experiential learning to their classmates during a postclinical conference:

So for example, the patient had difficulty breathing and the student wanted to give the meds instead of addressing the difficulty of breathing. Well, while we were sharing information about their patients, what they did that day, I didn’t tell the student to say this, but she said, ‘I just want to tell you what I did today in clinical so you don’t do the same thing, and here’s what happened.’ Everybody’s listening very attentively and they were asking her some questions. But she shared that. She didn’t have to. I didn’t tell her, you must share that in postconference or anything like that, but she just went ahead and shared that, I guess, to reinforce what she had learned that day but also to benefit her fellow students in case that thing comes up with them.

The teacher’s response to this student’s honesty and generosity exemplifies her own approach to developing an open community of learning. Focusing only on performance and on “being correct” prevents learning from breakdown or error and can dampen students’ curiosity and courage to learn experientially.

Seeing the unexpected

One of the keys to becoming an expert practitioner lies in how the person holds past experiential learning and background habitual skills and practices. This is a skill of foregrounding attention accurately and effectively in response to the nature of situational demands. Bourdieu 29 calls the recognition of the situation central to practical reasoning. If nothing is routinized as a habitual response pattern, then practitioners will not function effectively in emergencies. Unexpected occurrences may be overlooked. However, if expectations are held rigidly, then subtle changes from the usual will be missed, and habitual, rote responses will inappropriately rule. The clinician must be flexible in shifting between what is in background and foreground. This is accomplished by staying curious and open. The clinical “certainty” associated with perceptual grasp is distinct from the kind of “certainty” achievable in scientific experiments and through measurements. Recognition of similar or paradigmatic clinical situations is similar to “face recognition” or recognition of “family resemblances.” This concept is subject to faulty memory, false associative memories, and mistaken identities; therefore, such perceptual grasp is the beginning of curiosity and inquiry and not the end. Assessment and validation are required. In rapidly moving clinical situations, perceptual grasp is the starting point for clarification, confirmation, and action. Having the clinician say out loud how he or she is understanding the situation gives an opportunity for confirmation and disconfirmation from other clinicians present. 111 The relationship between foreground and background of attention needs to be fluid, so that missed expectations allow the nurse to see the unexpected. For example, when the background rhythm of a cardiac monitor changes, the nurse notices, and what had been background tacit awareness becomes the foreground of attention. A hallmark of expertise is the ability to notice the unexpected. 20 Background expectations of usual patient trajectories form with experience. Tacit expectations for patient trajectories form that enable the nurse to notice subtle failed expectations and pay attention to early signs of unexpected changes in the patient's condition. Clinical expectations gained from caring for similar patient populations form a tacit clinical forethought that enable the experienced clinician to notice missed expectations. Alterations from implicit or explicit expectations set the stage for experiential learning, depending on the openness of the learner.

Learning to provide safe and quality health care requires technical expertise, the ability to think critically, experience, and clinical judgment. The high-performance expectation of nurses is dependent upon the nurses’ continual learning, professional accountability, independent and interdependent decisionmaking, and creative problem-solving abilities.

This section of the paper was condensed and paraphrased from Benner, Hooper-Kyriakidis, and Stannard. 23 Patricia Hooper-Kyriakidis wrote the section on clinical grasp, and Patricia Benner wrote the section on clinical forethought.

• Cite this Page Benner P, Hughes RG, Sutphen M. Clinical Reasoning, Decisionmaking, and Action: Thinking Critically and Clinically. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 6.
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Critical thinking in clinical medicine: what is it?

Affiliation.

• 1 Department of Psychiatry, University of Montreal, Montreal, PQ, Canada. [email protected]
• PMID: 22994988
• DOI: 10.1111/j.1365-2753.2012.01897.x

In this paper, we explore the recent emphasis, in various medical contexts, of the term 'critical' or the notion of 'being critical'. We identify various definitions of being critical and note that they differ strikingly. What are these different uses of the term trying to capture that is important in clinical medicine and medical education? We have analysed these qualities as responsibilist, epistemic virtues. We believe that a virtues approach is best able to make sense of the non-cognitive elements of 'being critical', such as the honesty and courage to question claims in the face of persuasion, authority or social pressure. Medical educators and professional bodies seem to agree that being critical is important and desirable. Yet, it is unclear how this quality can be optimally fostered and balanced with the constraints that act upon individual practitioners in the context of institutional medicine including professional standards and the demands of the doctor-patient relationship. Other constraints such as authoritarianism, intimidation and financial pressures may act against the expression of being critical or even the cultivation of critical thinking. The issue of the constraints on critical thinking and the potential hazards it entails will require further consideration by those who encourage being critical in medicine.

© 2012 Blackwell Publishing Ltd.

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Critical Thinking in medical education: When and How?

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Critical thinking in healthcare and education

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Critical thinking is an essential cognitive skill for the individuals involved in various healthcare domains such as doctors, nurses, lab assistants, patients and so on, as is emphasized by the Authors. Recent evidence suggests that critical thinking is being perceived/evaluated as a domain-general construct and it is less distinguishable from that of general cognitive abilities [1].

People cannot think critically about topics for which they have little knowledge. Critical thinking should be viewed as a domain-specific construct that evolves as an individual acquires domain-specific knowledge [1]. For instance, most common people have no basis for prioritizing patients in the emergency department to be shifted to the only bed available in the intensive care unit. Medical professionals who could thinking critically in their own discipline would have difficulty thinking critically about problems in other fields. Therefore, ‘domain-general’ critical thinking training and evaluation could be non-specific and might not benefit the targeted domain i.e. medical profession.

Moreover, the literature does not demonstrate that it is possible to train universally effective critical thinking skills [1]. As medical teachers, we can start building up student’s critical thinking skill by contingent teaching-learning environment wherein one should encourage reasoning and analytics, problem solving abilities and welcome new ideas and opinions [2]. But at the same time, one should continue rather tapering the critical skills as one ascends towards a specialty, thereby targeting ‘domain-specific’ critical thinking.

For the benefit of healthcare, tools for training and evaluating ‘domain-specific’ critical thinking should be developed for each of the professional knowledge domains such as doctors, nurses, lab technicians and so on. As the Authors rightly pointed out, this humongous task can be accomplished only with cross border collaboration among cognitive neuroscientists, psychologists, medical education experts and medical professionals.

References 1. National Research Council. (2011). Assessing 21st Century Skills: Summary of a Workshop. J.A. Koenig, Rapporteur. Committee on the Assessment of 21st Century Skills. Board on Testing and Assessment, Division of Behavioral and Social Sciences and Education. Washington, DC: The National Academies Press. 2. Mafakheri Laleh M, Mohammadimehr M, Zargar Balaye Jame S. Designing a model for critical thinking development in AJA University of Medical Sciences. J Adv Med Educ Prof. 2016 Oct;4(4):179–87.

Competing interests: No competing interests

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The Oxford English Dictionary defines critical thinking as "the objective, systematic, and rational analysis and evaluation of factual evidence in order to form a judgement on a subject, issue, etc."

Put simply, critical thinking is the ability to recognize and examine information to understand the evidence, arguments, and perspectives present in that information. Critical thinking means seeking answers and asking questions.

• TED-Ed Can You Solve This Riddle? (playlist) Try out some of the classic riddles in this playlist from TED Ed. Each video established the riddle with narration and animation. Use your critical thinking skills to solve the riddles!

The following seven steps, developed by Kraus et al., are meant to illustrate the process of critical thinking. While true critical thinking may not follow these steps as written, they can serve as a guide or framework for individuals working on improving their critical thinking skills.

• What am I being asked to believe or accept?
• What evidence is available to support the claim?
• What alternative ways are there to interpret the evidence?
• Rate the evidence/alternatives on 0-10 scale based on validity/strength.
• What assumptions or biases came up when doing the above steps? (e.g., using intuition/emotion, authority, or personal experience rather than science)
• What additional evidence would help us evaluate the alternatives?
• What conclusions are most reasonable or likely?

Kraus, S., Sears, S. R., & Burke, B. L. (2013). Is truthiness enough? Classroom activities for encouraging evidence-based critical thinking. The Journal of Effective Teaching, 13 (2), 83-93.

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The Value of Critical Thinking in Nursing

• How Nurses Use Critical Thinking
• How to Improve Critical Thinking
• Common Mistakes

Some experts describe a person’s ability to question belief systems, test previously held assumptions, and recognize ambiguity as evidence of critical thinking. Others identify specific skills that demonstrate critical thinking, such as the ability to identify problems and biases, infer and draw conclusions, and determine the relevance of information to a situation.

Nicholas McGowan, BSN, RN, CCRN, has been a critical care nurse for 10 years in neurological trauma nursing and cardiovascular and surgical intensive care. He defines critical thinking as “necessary for problem-solving and decision-making by healthcare providers. It is a process where people use a logical process to gather information and take purposeful action based on their evaluation.”

“This cognitive process is vital for excellent patient outcomes because it requires that nurses make clinical decisions utilizing a variety of different lenses, such as fairness, ethics, and evidence-based practice,” he says.

How Do Nurses Use Critical Thinking?

Successful nurses think beyond their assigned tasks to deliver excellent care for their patients. For example, a nurse might be tasked with changing a wound dressing, delivering medications, and monitoring vital signs during a shift. However, it requires critical thinking skills to understand how a difference in the wound may affect blood pressure and temperature and when those changes may require immediate medical intervention.

Nurses care for many patients during their shifts. Strong critical thinking skills are crucial when juggling various tasks so patient safety and care are not compromised.

Jenna Liphart Rhoads, Ph.D., RN, is a nurse educator with a clinical background in surgical-trauma adult critical care, where critical thinking and action were essential to the safety of her patients. She talks about examples of critical thinking in a healthcare environment, saying:

“Nurses must also critically think to determine which patient to see first, which medications to pass first, and the order in which to organize their day caring for patients. Patient conditions and environments are continually in flux, therefore nurses must constantly be evaluating and re-evaluating information they gather (assess) to keep their patients safe.”

The COVID-19 pandemic created hospital care situations where critical thinking was essential. It was expected of the nurses on the general floor and in intensive care units. Crystal Slaughter is an advanced practice nurse in the intensive care unit (ICU) and a nurse educator. She observed critical thinking throughout the pandemic as she watched intensive care nurses test the boundaries of previously held beliefs and master providing excellent care while preserving resources.

“Nurses are at the patient’s bedside and are often the first ones to detect issues. Then, the nurse needs to gather the appropriate subjective and objective data from the patient in order to frame a concise problem statement or question for the physician or advanced practice provider,” she explains.

Top 5 Ways Nurses Can Improve Critical Thinking Skills

We asked our experts for the top five strategies nurses can use to purposefully improve their critical thinking skills.

Case-Based Approach

Slaughter is a fan of the case-based approach to learning critical thinking skills.

In much the same way a detective would approach a mystery, she mentors her students to ask questions about the situation that help determine the information they have and the information they need. “What is going on? What information am I missing? Can I get that information? What does that information mean for the patient? How quickly do I need to act?”

Consider forming a group and working with a mentor who can guide you through case studies. This provides you with a learner-centered environment in which you can analyze data to reach conclusions and develop communication, analytical, and collaborative skills with your colleagues.

Practice Self-Reflection

Rhoads is an advocate for self-reflection. “Nurses should reflect upon what went well or did not go well in their workday and identify areas of improvement or situations in which they should have reached out for help.” Self-reflection is a form of personal analysis to observe and evaluate situations and how you responded.

This gives you the opportunity to discover mistakes you may have made and to establish new behavior patterns that may help you make better decisions. You likely already do this. For example, after a disagreement or contentious meeting, you may go over the conversation in your head and think about ways you could have responded.

It’s important to go through the decisions you made during your day and determine if you should have gotten more information before acting or if you could have asked better questions.

During self-reflection, you may try thinking about the problem in reverse. This may not give you an immediate answer, but can help you see the situation with fresh eyes and a new perspective. How would the outcome of the day be different if you planned the dressing change in reverse with the assumption you would find a wound infection? How does this information change your plan for the next dressing change?

Develop a Questioning Mind

McGowan has learned that “critical thinking is a self-driven process. It isn’t something that can simply be taught. Rather, it is something that you practice and cultivate with experience. To develop critical thinking skills, you have to be curious and inquisitive.”

To gain critical thinking skills, you must undergo a purposeful process of learning strategies and using them consistently so they become a habit. One of those strategies is developing a questioning mind. Meaningful questions lead to useful answers and are at the core of critical thinking .

However, learning to ask insightful questions is a skill you must develop. Faced with staff and nursing shortages , declining patient conditions, and a rising number of tasks to be completed, it may be difficult to do more than finish the task in front of you. Yet, questions drive active learning and train your brain to see the world differently and take nothing for granted.

It is easier to practice questioning in a non-stressful, quiet environment until it becomes a habit. Then, in the moment when your patient’s care depends on your ability to ask the right questions, you can be ready to rise to the occasion.

Practice Self-Awareness in the Moment

Critical thinking in nursing requires self-awareness and being present in the moment. During a hectic shift, it is easy to lose focus as you struggle to finish every task needed for your patients. Passing medication, changing dressings, and hanging intravenous lines all while trying to assess your patient’s mental and emotional status can affect your focus and how you manage stress as a nurse .

Staying present helps you to be proactive in your thinking and anticipate what might happen, such as bringing extra lubricant for a catheterization or extra gloves for a dressing change.

By staying present, you are also better able to practice active listening. This raises your assessment skills and gives you more information as a basis for your interventions and decisions.

Use a Process

As you are developing critical thinking skills, it can be helpful to use a process. For example:

• Ask questions.
• Gather information.
• Implement a strategy.
• Evaluate the results.
• Consider another point of view.

These are the fundamental steps of the nursing process (assess, diagnose, plan, implement, evaluate). The last step will help you overcome one of the common problems of critical thinking in nursing — personal bias.

Common Critical Thinking Pitfalls in Nursing

Your brain uses a set of processes to make inferences about what’s happening around you. In some cases, your unreliable biases can lead you down the wrong path. McGowan places personal biases at the top of his list of common pitfalls to critical thinking in nursing.

“We all form biases based on our own experiences. However, nurses have to learn to separate their own biases from each patient encounter to avoid making false assumptions that may interfere with their care,” he says. Successful critical thinkers accept they have personal biases and learn to look out for them. Awareness of your biases is the first step to understanding if your personal bias is contributing to the wrong decision.

New nurses may be overwhelmed by the transition from academics to clinical practice, leading to a task-oriented mindset and a common new nurse mistake ; this conflicts with critical thinking skills.

“Consider a patient whose blood pressure is low but who also needs to take a blood pressure medication at a scheduled time. A task-oriented nurse may provide the medication without regard for the patient’s blood pressure because medication administration is a task that must be completed,” Slaughter says. “A nurse employing critical thinking skills would address the low blood pressure, review the patient’s blood pressure history and trends, and potentially call the physician to discuss whether medication should be withheld.”

Fear and pride may also stand in the way of developing critical thinking skills. Your belief system and worldview provide comfort and guidance, but this can impede your judgment when you are faced with an individual whose belief system or cultural practices are not the same as yours. Fear or pride may prevent you from pursuing a line of questioning that would benefit the patient. Nurses with strong critical thinking skills exhibit:

• Learn from their mistakes and the mistakes of other nurses
• Look forward to integrating changes that improve patient care
• Treat each patient interaction as a part of a whole
• Evaluate new events based on past knowledge and adjust decision-making as needed
• Solve problems with their colleagues
• Are self-confident
• Acknowledge biases and seek to ensure these do not impact patient care

An Essential Skill for All Nurses

Critical thinking in nursing protects patient health and contributes to professional development and career advancement. Administrative and clinical nursing leaders are required to have strong critical thinking skills to be successful in their positions.

By using the strategies in this guide during your daily life and in your nursing role, you can intentionally improve your critical thinking abilities and be rewarded with better patient outcomes and potential career advancement.

Frequently Asked Questions About Critical Thinking in Nursing

How are critical thinking skills utilized in nursing practice.

Nursing practice utilizes critical thinking skills to provide the best care for patients. Often, the patient’s cause of pain or health issue is not immediately clear. Nursing professionals need to use their knowledge to determine what might be causing distress, collect vital information, and make quick decisions on how best to handle the situation.

How does nursing school develop critical thinking skills?

Nursing school gives students the knowledge professional nurses use to make important healthcare decisions for their patients. Students learn about diseases, anatomy, and physiology, and how to improve the patient’s overall well-being. Learners also participate in supervised clinical experiences, where they practice using their critical thinking skills to make decisions in professional settings.

Do only nurse managers use critical thinking?

Nurse managers certainly use critical thinking skills in their daily duties. But when working in a health setting, anyone giving care to patients uses their critical thinking skills. Everyone — including licensed practical nurses, registered nurses, and advanced nurse practitioners —needs to flex their critical thinking skills to make potentially life-saving decisions.

Meet Our Contributors

Crystal Slaughter, DNP, APRN, ACNS-BC, CNE

Crystal Slaughter is a core faculty member in Walden University’s RN-to-BSN program. She has worked as an advanced practice registered nurse with an intensivist/pulmonary service to provide care to hospitalized ICU patients and in inpatient palliative care. Slaughter’s clinical interests lie in nursing education and evidence-based practice initiatives to promote improving patient care.

Jenna Liphart Rhoads, Ph.D., RN

Jenna Liphart Rhoads is a nurse educator and freelance author and editor. She earned a BSN from Saint Francis Medical Center College of Nursing and an MS in nursing education from Northern Illinois University. Rhoads earned a Ph.D. in education with a concentration in nursing education from Capella University where she researched the moderation effects of emotional intelligence on the relationship of stress and GPA in military veteran nursing students. Her clinical background includes surgical-trauma adult critical care, interventional radiology procedures, and conscious sedation in adult and pediatric populations.

Nicholas McGowan, BSN, RN, CCRN

Nicholas McGowan is a critical care nurse with 10 years of experience in cardiovascular, surgical intensive care, and neurological trauma nursing. McGowan also has a background in education, leadership, and public speaking. He is an online learner who builds on his foundation of critical care nursing, which he uses directly at the bedside where he still practices. In addition, McGowan hosts an online course at Critical Care Academy where he helps nurses achieve critical care (CCRN) certification.

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Glossary of Critical Thinking Terms

accurate : Free from errors, mistakes, or distortion. Correct connotes little more than absence of error; accurate implies a positive exercise of one to obtain conformity with fact or truth; exact stresses perfect conformity to fact, truth, or some standard; precise suggests minute accuracy of detail. Accuracy is an important goal in critical thinking, though it is almost always a matter of degree. It is also important to recognize that making mistakes is an essential part of learning and that it is far better that students make their own mistakes, than that they parrot the thinking of the text or teacher. It should also be recognized that some distortion usually results whenever we think within a point of view or frame of reference. Students should think with this awareness in mind, with some sense of the limitations of their own, the text's, the teacher's, the subject's perspective. See perfections of thought.

ambiguous : A sentence having two or more possible meanings. Sensitivity to ambiguity and vagueness in writing and speech is essential to good thinking. A continual effort to be clear and precise in language usage is fundamental to education. Ambiguity is a problem more of sentences than of individual words. Furthermore, not every sentence that can be construed in more than one way is problematic and deserving of analysis. Many sentences are clearly intended one way; any other construal is obviously absurd and not meant. For example, "Make me a sandwich." is never seriously intended to request metamorphic change. It is a poor example for teaching genuine insight into critical thinking. For an example of a problematic ambiguity, consider the statement, "Welfare is corrupt." Among the possible meanings of this sentence are the following: Those who administer welfare programs take bribes to administer welfare policy unfairly; Welfare policies are written in such a way that much of the money goes to people who don't deserve it rather than to those who do; A government that gives money to people who haven't earned it corrupts both the giver and the recipient. If two people are arguing about whether or not welfare is corrupt, but interpret the claim differently, they can make little or no progress; they aren't arguing about the same point. Evidence and considerations relevant to one interpretation may be irrelevant to others.

analyze : To break up a whole into its parts, to examine in detail so as to determine the nature of, to look more deeply into an issue or situation. All learning presupposes some analysis of what we are learning, if only by categorizing or labeling things in one way rather than another. Students should continually be asked to analyze their ideas, claims, experiences, interpretations, judgments, and theories and those they hear and read. See elements of thought.

argue : There are two meanings of this word that need to be distinguished: 1) to argue in the sense of to fight or to emotionally disagree; and 2) to give reasons for or against a proposal or proposition. In emphasizing critical thinking, we continually try to get our students to move from the first sense of the word to the second; that is, we try to get them to see the importance of giving reasons to support their views without getting their egos involved in what they are saying. This is a fundamental problem in human life. To argue in the critical thinking sense is to use logic and reason, and to bring forth facts to support or refute a point. It is done in a spirit of cooperation and good will.

argument : A reason or reasons offered for or against something, the offering of such reasons. This term refers to a discussion in which there is disagreement and suggests the use of logic and the bringing forth of facts to support or refute a point. See argue.

to assume : To take for granted or to presuppose. Critical thinkers can and do make their assumptions explicit, assess them, and correct them. Assumptions can vary from the mundane to the problematic: I heard a scratch at the door. I got up to let the cat in. I assumed that only the cat makes that noise, and that he makes it only when he wants to be let in. Someone speaks gruffly to me. I feel guilty and hurt. I assume he is angry at me, that he is only angry at me when I do something bad, and that if he's angry at me, he dislikes me. Notice that people often equate making assumptions with making false assumptions. When people say, "Don't assume", this is what they mean. In fact, we cannot avoid making assumptions and some are justifiable. (For instance, we have assumed that people who buy this book can read English.) Rather than saying "Never assume", we say, "Be aware of and careful about the assumptions you make, and be ready to examine and critique them." See assumption, elements of thought.

assumption : A statement accepted or supposed as true without proof or demonstration; an unstated premise or belief. All human thought and experience is based on assumptions. Our thought must begin with something we take to be true in a particular context. We are typically unaware of what we assume and therefore rarely question our assumptions. Much of what is wrong with human thought can be found in the uncritical or unexamined assumptions that underlie it. For example, we often experience the world in such a way as to assume that we are observing things just as they are, as though we were seeing the world without the filter of a point of view. People we disagree with, of course, we recognize as having a point of view. One of the key dispositions of critical thinking is the on-going sense that as humans we always think within a perspective, that we virtually never experience things totally and absolutistically. There is a connection, therefore, between thinking so as to be aware of our assumptions and being intellectually humble.

authority :

1) The power or supposed right to give commands, enforce obedience, take action, or make final decisions.

2) A person with much knowledge and expertise in a field, hence reliable. Critical thinkers recognize that ultimate authority rests with reason and evidence, since it is only on the assumption that purported experts have the backing of reason and evidence that they rightfully gain authority. Much instruction discourages critical thinking by encouraging students to believe that whatever the text or teacher says is true. As a result, students do not learn how to assess authority. See knowledge.

bias : A mental leaning or inclination. We must clearly distinguish two different senses of the word ’’bias’’. One is neutral, the other negative. In the neutral sense we are referring simply to the fact that, because of one's point of view, one notices some things rather than others, emphasizes some points rather than others, and thinks in one direction rather than others. This is not in itself a criticism because thinking within a point of view is unavoidable. In the negative sense, we are implying blindness or irrational resistance to weaknesses within one's own point of view or to the strength or insight within a point of view one opposes. Fairminded critical thinkers try to be aware of their bias (in sense one) and try hard to avoid bias (in sense two). Many people confuse these two senses. Many confuse bias with emotion or with evaluation, perceiving any expression of emotion or any use of evaluative words to be biased (sense two). Evaluative words that can be justified by reason and evidence are not biased in the negative sense. See criteria, evaluation, judgment, opinion......

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Critical Thinking Definition, Skills, and Examples

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Critical thinking refers to the ability to analyze information objectively and make a reasoned judgment. It involves the evaluation of sources, such as data, facts, observable phenomena, and research findings.

Good critical thinkers can draw reasonable conclusions from a set of information, and discriminate between useful and less useful details to solve problems or make decisions. Employers prioritize the ability to think critically—find out why, plus see how you can demonstrate that you have this ability throughout the job application process. 

Why Do Employers Value Critical Thinking Skills?

Employers want job candidates who can evaluate a situation using logical thought and offer the best solution.

 Someone with critical thinking skills can be trusted to make decisions independently, and will not need constant handholding.

Hiring a critical thinker means that micromanaging won't be required. Critical thinking abilities are among the most sought-after skills in almost every industry and workplace. You can demonstrate critical thinking by using related keywords in your resume and cover letter, and during your interview.

Examples of Critical Thinking

The circumstances that demand critical thinking vary from industry to industry. Some examples include:

• A triage nurse analyzes the cases at hand and decides the order by which the patients should be treated.
• A plumber evaluates the materials that would best suit a particular job.
• An attorney reviews evidence and devises a strategy to win a case or to decide whether to settle out of court.
• A manager analyzes customer feedback forms and uses this information to develop a customer service training session for employees.

Promote Your Skills in Your Job Search

If critical thinking is a key phrase in the job listings you are applying for, be sure to emphasize your critical thinking skills throughout your job search.

Add Keywords to Your Resume

You can use critical thinking keywords (analytical, problem solving, creativity, etc.) in your resume. When describing your  work history , include top critical thinking skills that accurately describe you. You can also include them in your  resume summary , if you have one.

For example, your summary might read, “Marketing Associate with five years of experience in project management. Skilled in conducting thorough market research and competitor analysis to assess market trends and client needs, and to develop appropriate acquisition tactics.”

Mention Skills in Your Cover Letter

Include these critical thinking skills in your cover letter. In the body of your letter, mention one or two of these skills, and give specific examples of times when you have demonstrated them at work. Think about times when you had to analyze or evaluate materials to solve a problem.

Show the Interviewer Your Skills

You can use these skill words in an interview. Discuss a time when you were faced with a particular problem or challenge at work and explain how you applied critical thinking to solve it.

Some interviewers will give you a hypothetical scenario or problem, and ask you to use critical thinking skills to solve it. In this case, explain your thought process thoroughly to the interviewer. He or she is typically more focused on how you arrive at your solution rather than the solution itself. The interviewer wants to see you analyze and evaluate (key parts of critical thinking) the given scenario or problem.

Of course, each job will require different skills and experiences, so make sure you read the job description carefully and focus on the skills listed by the employer.

Top Critical Thinking Skills

Keep these in-demand critical thinking skills in mind as you update your resume and write your cover letter. As you've seen, you can also emphasize them at other points throughout the application process, such as your interview. 

Part of critical thinking is the ability to carefully examine something, whether it is a problem, a set of data, or a text. People with  analytical skills  can examine information, understand what it means, and properly explain to others the implications of that information.

• Asking Thoughtful Questions
• Data Analysis
• Interpretation
• Questioning Evidence
• Recognizing Patterns

Communication

Often, you will need to share your conclusions with your employers or with a group of colleagues. You need to be able to  communicate with others  to share your ideas effectively. You might also need to engage in critical thinking in a group. In this case, you will need to work with others and communicate effectively to figure out solutions to complex problems.

• Active Listening
• Collaboration
• Explanation
• Interpersonal
• Presentation
• Verbal Communication
• Written Communication

Critical thinking often involves creativity and innovation. You might need to spot patterns in the information you are looking at or come up with a solution that no one else has thought of before. All of this involves a creative eye that can take a different approach from all other approaches.

• Flexibility
• Conceptualization
• Imagination
• Drawing Connections
• Synthesizing

Open-Mindedness

To think critically, you need to be able to put aside any assumptions or judgments and merely analyze the information you receive. You need to be objective, evaluating ideas without bias.

• Objectivity
• Observation

Problem Solving

Problem-solving is another critical thinking skill that involves analyzing a problem, generating and implementing a solution, and assessing the success of the plan. Employers don’t simply want employees who can think about information critically. They also need to be able to come up with practical solutions.

• Attention to Detail
• Clarification
• Decision Making
• Groundedness
• Identifying Patterns

More Critical Thinking Skills

• Inductive Reasoning
• Deductive Reasoning
• Noticing Outliers
• Adaptability
• Emotional Intelligence
• Brainstorming
• Optimization
• Restructuring
• Integration
• Strategic Planning
• Project Management
• Ongoing Improvement
• Causal Relationships
• Case Analysis
• Diagnostics
• SWOT Analysis
• Business Intelligence
• Quantitative Data Management
• Qualitative Data Management
• Risk Management
• Scientific Method
• Consumer Behavior

Key Takeaways

• Demonstrate that you have critical thinking skills by adding relevant keywords to your resume.
• Mention pertinent critical thinking skills in your cover letter, too, and include an example of a time when you demonstrated them at work.
• Finally, highlight critical thinking skills during your interview. For instance, you might discuss a time when you were faced with a challenge at work and explain how you applied critical thinking skills to solve it.

University of Louisville. " What is Critical Thinking ."

American Management Association. " AMA Critical Skills Survey: Workers Need Higher Level Skills to Succeed in the 21st Century ."

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critical thinking

Definition of critical thinking

Examples of critical thinking in a sentence.

These examples are programmatically compiled from various online sources to illustrate current usage of the word 'critical thinking.' Any opinions expressed in the examples do not represent those of Merriam-Webster or its editors. Send us feedback about these examples.

Word History

1815, in the meaning defined at sense 1

Dictionary Entries Near critical thinking

critical temperature

critical value

Cite this Entry

“Critical thinking.” Merriam-Webster.com Dictionary , Merriam-Webster, https://www.merriam-webster.com/dictionary/critical%20thinking. Accessed 9 May. 2024.

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Constructing critical thinking in health professional education

• Original Article
• Open access
• Published: 04 April 2018
• Volume 7 , pages 156–165, ( 2018 )

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• Renate Kahlke   ORCID: orcid.org/0000-0002-4473-5039 1 &
• Kevin Eva 1  

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Introduction

Calls for enabling ‘critical thinking’ are ubiquitous in health professional education. However, there is little agreement in the literature or in practice as to what this term means and efforts to generate a universal definition have found limited traction. Moreover, the variability observed might suggest that multiplicity has value that the quest for universal definitions has failed to capture. In this study, we sought to map the multiple conceptions of critical thinking in circulation in health professional education to understand the relationships and tensions between them.

We used an inductive, qualitative approach to explore conceptions of critical thinking with educators from four health professions: medicine, nursing, pharmacy, and social work. Four participants from each profession participated in two individual in-depth semi-structured interviews, the latter of which induced reflection on a visual depiction of results generated from the first set of interviews.

Three main conceptions of critical thinking were identified: biomedical, humanist, and social justice-oriented critical thinking. ‘Biomedical critical thinking’ was the dominant conception. While each conception had distinct features, the particular conceptions of critical thinking espoused by individual participants were not stable within or between interviews.

Multiple conceptions of critical thinking likely offer educators the ability to express diverse beliefs about what ‘good thinking’ means in variable contexts. The findings suggest that any single definition of critical thinking in the health professions will be inherently contentious and, we argue, should be. Such debates, when made visible to educators and trainees, can be highly productive.

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What this paper adds

‘Critical thinking’ is a term commonly used across health professional education, though there is little agreement on what this means in the literature or in practice. We depart from previous work, which most often attempts to create a common definition. Instead, we offer a description of the different conceptions of critical thinking held in health professional education, illustrate their dynamic use, and discuss the tensions and affordances that this diversity brings to the field. We argue that diversity in conceptions of critical thinking can allow educators to express unique and often divergent beliefs about what ‘good thinking’ means in their contexts.

Even though the term critical thinking is ubiquitous in educational settings, there is significant disagreement about what it means to ‘think critically’ [ 1 ]. Predominantly, authors have attempted to develop consensus definitions of critical thinking that would finally put these disagreements to rest (e. g. [ 2 , 3 , 4 , 5 ]). They define critical thinking variously, but tend to focus on a rational process involving (for example) ‘interpretation, analysis, evaluation, inference, explanation, and self-regulation’ [ 2 ]. Other authors have challenged this perspective by arguing that critical thinking is a more subjective process, emphasizing the role of emotion and relationships [ 6 , 7 , 8 , 9 ]. In the tradition of critical pedagogy, critical thinking has meant critiquing ideology [ 10 , 11 , 12 ]. Last, still others have argued that critical thinking is discipline or subject-specific, meaning that critical thinking is not universal, but does have a relatively stable meaning within different disciplines [ 13 , 14 , 15 , 16 , 17 , 18 ]. However, none of these attempts to clarify the ambiguity that surrounds critical thinking have led to agreement, suggesting that each of these perspectives offers, at best, a partial explanation for the persistence of disagreements.

This is problematic in health professional education (HPE) because professional programs are mandated to educate practitioners who have a defined knowledge base and skill set. When curriculum designers, educators, researchers, or policy-makers all agree that we should teach future professionals to ‘think critically’, resting on the assumption that they also agree on what that means, they may find themselves working at cross-purposes. Moreover, the focus on a stable meaning for critical thinking, whether within a discipline or across disciplines, cannot account for the potential value of the multiplicity of definitions that exist. That is, the availability of diverse conceptions of critical thinking likely enables educators to express diverse elements of and beliefs about their work, thereby suggesting a need to explore the conceptions of critical thinking held in HPE, and the contexts that inform those conceptions.

With the historical focus on developing broad definitions of critical thinking and delineating its component skills and dispositions, little has been done either to document the diverse conceptions of this term in circulation amongst active HPE practitioners or, perhaps more importantly, to illuminate the beliefs about what constitutes ‘good thinking’ that lie behind them and the relationships between them. Perhaps clarity in our understanding of critical thinking lies in the flexibility with which it is conceptualized. This study moves away from attempting to create universal definitions of critical thinking in order to explore the tensions that surround different, converging, and competing beliefs about what critical thinking means.

In doing so, we map out conceptions of critical thinking across four health professions along with the beliefs about professional practice that underpin those conceptions. Some of these beliefs may be tied to a profession’s socialization processes and many will be tied to beliefs about ‘good thinking’ that are shared across professions, since health professionals work within shared systems [ 19 ] toward the same ultimate task of providing patient care. It is the variety of ways in which critical thinking is considered by practitioners on the whole that we wanted to understand, not the formal pronouncements of what might be listed as competencies or components of critical thinking within any one profession.

Hence, with this study, we sought to ask:

How do educators in the health professions understand critical thinking?

What values or beliefs inform that understanding?

To explore these questions, we adopted a qualitative research approach that focuses on how people interpret and make meaning out of their experiences and actively construct their social worlds [ 20 ].

This study uses an emergent, inductive design in an effort to be responsive to the co-construction of new and unexpected meaning between participants and researchers. While techniques derived from constructivist grounded theory [ 21 ] were employed, methods like extensive theoretical sampling (that are common to that methodology) were not maintained because this study was intended to be broadly exploratory. This ‘borrowing’ of techniques offers the ability to capitalize on the open and broad approach offered by interpretive qualitative methodology [ 20 ] while engaging selectively with the more specific tools and techniques available from constructivist grounded theory [ 22 , 23 ].

The first author has a background in sociocultural and critical theory. Data collection and early analyses were carried out as part of her dissertation in Educational Policy Studies. As a result of her background in critical theory, there was a need for reflexivity focused on limiting predisposition toward participant interpretations of critical thinking that aligned with critical theory. The senior author was trained in cognitive psychology, and contributed to the questioning of results and discussion required to ensure this reflexivity. The first author’s dissertation supervisor also provided support in this way by questioning assumptions made during the initial stages of this work.

Participants were recruited through faculty or departmental listservs for educators. Senior administrators were consulted to ensure that they were aware of and comfortable with this research taking place in their unit. In some cases, administrators identified a few key individuals who were particularly interested in education. These educators were contacted directly by the first author to request participation.

The purposive sample includes four educators from each of four diverse health professional programs ( n  = 16 in total): medicine, nursing, pharmacy, and social work. All participants self-identified as being actively involved in teaching in their professional program and all were formally affiliated with either the University of Alberta (Medicine, Nursing, and Pharmacy) or the University of Calgary (Social Work). These four professions were selected to maximize diversity in approaches to critical thinking given that these professions have diverse perspectives and roles with respect to patient care. However, participants all worked in Alberta, Canada, within the same broad postsecondary education and healthcare contexts.

In addition, sampling priority was given to recruiting participants practising in a diverse range of specialties: primary care, geriatrics, paediatrics, mental health, critical care, and various consulting specialties. Specific specialties within each profession are not provided here in an effort to preserve participant anonymity. The goal was not to make conclusions about the perspective of any one group; rather, diversity in profession, practice context, gender, and years in practice was sought to increase the likelihood of illuminating diverse conceptions of critical thinking.

Data generation

Participants were invited to participate in two in-person semi-structured interviews conducted by the first author. All but one participant completed both interviews. Interviews were audio-recorded and interview guides are included in the online Electronic Supplementary Material. The first was about 1 hour in length and discussed how participants think about critical thinking in their teaching, professional practice, and other contexts. Participants were invited to bring a teaching artefact that represented how they teach critical thinking to the interview. Artefacts were used as a visual elicitation strategy to prompt discussion from a new angle [ 24 ]. Questions focused on what the participant thought about teaching critical thinking using the artefact and how they identified critical thinking (or lack thereof) in their students. Artefacts were not analyzed independently of the discussion they produced [ 25 ].

Interview 1 data were analyzed to produce a visual depiction of the aggregate terms, ideas, and relationships described by participants. The visual depiction took the form of a ‘mind map’ (see Appendix C of the Electronic Supplementary Material) that was generated using MindMup free online software [ 26 ]. In developing the mind map, we sought descriptions of participants’ views that remained as close to the data as possible, limiting interpretations and inferences. The ‘clusters’ that appear in the mind map (e. g., the cluster around ‘characteristics of the critical thinker’) represent relationships or categories commonly described when participants discussed those terms. Terms were not weighted or emphasized based on frequency of use (through font size or bolding) in an effort to allow individual participants to emphasize or deemphasize terms as they thought appropriate during the second interview.

Where there was no clear category or relationship, terms were left at the first level of the mind map, connected directly to ‘critical thinking’ at the centre. Including more connections and inferences would likely have improved the readability of the map for participants; however, we chose to include connections and exact language used by participants (even in cases where terms seemed similar) as often as possible, in an effort to limit researcher interpretation. That said, any attempt to aggregate data or to represent relationships is an act of interpretation and some inferences were made in the process, such as the distinction between descriptions about ‘characteristics’ of the critical thinker (the top left hand corner of the map) and ‘processes’ such as ‘reasoning’ or ‘examining assumptions’ (on the right side of the map). The second interview lasted approximately 45 minutes during which a visual elicitation approach invited participants to respond to the mind map.

Visual elicitation involves employing visual stimuli to generate verbal interview data. Participant-generated mind maps are often used in qualitative data collection [ 27 ], but the literature on using researcher-generated diagrams for visual elicitation is relatively thin [ 25 , 28 ]. In this study, using a researcher-generated mind map for visual elicitation offered several advantages. First, as with other forms of visual elicitation, diagrams of this kind can help participants develop candid responses and avoid rehearsed narratives [ 24 , 29 ]. For example, we used mind maps as one mechanism to reduce the tendency for participants who were familiar with the literature on critical thinking to get stuck on narrating seemingly rehearsed definitions of critical thinking. Second, we chose to use a mind map because it provided a social setting through which participants could react to language generated by others. Doing so does not allow the same degree of social negotiation inherent in focus groups, but it avoids the difficulty involved in attempts to disentangle individual from group views [ 30 ]. Third, the visual elicitation method was chosen because it offered a form of member check [ 31 ] that allowed researchers to understand the evolving nature of participants’ conceptions of critical thinking, rather than assuming that participants offer a single true conception during each and every discussion [ 32 ]. In other words, the mind map was used to prompt participants to elaborate their conception of critical thinking and locate it relative to other participants.

In interview 2, participants were asked to begin by discussing areas or terms on the mind map that resonated most with their own conception of critical thinking; they were then asked to discuss terms or concepts on the map that resonated less or with which they disagreed. They were also asked to comment on how relationships between ideas were represented through the map so that researchers could get a sense of the extent to which the relationships between the concepts depicted reflected the participants’ understanding of those relationships [ 28 ]. Participants were encouraged to disagree with portions of the map and most did actively disagree with some of the terms and relationships depicted, suggesting that the map did not come to dictate more than elicit individual interpretations [ 28 ]. Although participants were encouraged to ‘mark up’ the mind map, and the ‘marked up’ mind maps were treated as data, the primary data sources for this study were the audio-recorded interviews [ 25 ].

Participants were aware that the mind map represented aggregate data from the four health professions in the study, but were not initially told whether any of the responses came predominantly from any one profession; they did not generally seem to be attempting to associate terms with other professions. Nonetheless, interview 2 data are a mix of participants’ reactions to the ideas of others and their elaborations of their own understandings. Naturally, these data build on data generated in interview 1, and represent reactions to both the researcher interpretation of the data and to the conceptions of critical thinking offered by others. Interview 1 data tended to offer an initial, open impression of how participants think about critical thinking in their contexts. Because of these different approaches to data generation, quotes from interview 1 and 2 are labelled as ‘INT1’ or ‘INT2’, respectively.

Data analysis

Data were coded through an iterative cycle of initial and focused coding [ 33 ] with NVivo software. Initial line-by-line coding was used to develop codes that were close to the data, involving minimal abstraction. Initial codes were reviewed by the first author and dissertation supervisor to abstract categories (conceptions of critical thinking), sub-categories (features of those conceptions), and themes related to the relationships between those categories. Focused coding involved taking these categories and testing them against the data using constant comparison techniques derived from constructivist grounded theory [ 21 ]. Category development continued during the framing of this paper, and authors engaged in ongoing conversations to modify categories to better fit the data. In this process, we returned to the data to look for exceptions that did not fit any category, as well as contradictions and overlap between categories.

Interpretive sufficiency [ 34 ], in this study, occurred when no new features illustrating participants’ conceptions of critical thinking were identified. Memos were kept to track the development or elimination of initial insights or impressions. Institutional ethics approval was obtained from the University of Alberta.

Participant identities have been masked to preserve anonymity. The abbreviation ‘MD’ refers to educators in medical education, ‘NURS’ to nursing, ‘PHARM’ to pharmacy, and ‘SW’ to social work. Participants within each group were then assigned a number. For example, the code NURS3 is a unique identifier for a single participant.

Three main conceptions of critical thinking were identified, each of which will be elaborated in greater detail below: biomedical critical thinking, humanist critical thinking, and social justice-oriented critical thinking. It is important to note that these categories focus on the process and purpose of critical thinking, as defined by participants. Participant comments also spoke to the ‘characteristics’ or ‘dispositions’ of critical thinkers, such as ‘open-mindedness’ or ‘creativity’. The focus of this study, however, was on uncovering what critical thinking looks like as opposed to what a ‘critical thinker’ looks like.

The results below interweave responses from different professional groups in order to emphasize the way in which each of the three core conceptions that we have identified crosses professional boundaries. We then provide a brief discussion of the relationships between these three conceptions, emphasizing the limited extent to which these conceptions were profession-specific, and the tensions that we observed between these conceptions. In general, we also interweave results from both interviews because the discussion in interview 2 tended to reinforce the themes arising from interview 1, especially with respect to indications that different conceptions were used fluidly by individuals over time and dependent on the context being discussed. The interview from which data arose is marked after each quote and we have mentioned explicitly whenever a comment was made in specific response to the mind map presented during interview 2.

In this way, our data extend the literature on critical thinking by offering an appreciation of how each of these conceptions provide educators a different way of thinking, talking, and teaching about their work in HPE. We found that even individual participants’ conceptions of critical thinking shifted from time to time. That is, they often articulated more than one understanding of critical thinking over the course of an interview or between interviews 1 and 2. Some of these conceptions were shared by multiple participants but individual constellations of beliefs about what critical thinking means were unique and somewhat idiosyncratic. Thus, while participants’ conceptions of critical thinking were both idiosyncratic and common, they were also flexible and contextual; the meaning of critical thinking was continuously reconstructed and contested. In this way, critical thinking offered a window through which to explore how beliefs about what constitutes ‘good thinking’ in a profession are challenged in educational settings.

Biomedical critical thinking

Participants articulating a biomedical approach saw critical thinking and clinical reasoning as nearly synonymous. They emphasized a process that was rational, logical, and systematic. One participant articulated that critical thinking is ‘ to be able to reason logically’ (NURS4 INT1). Another related:

You have to kind of pull together data that’s relevant to the subject you’re dealing with. You have to interpret it, you have to analyse it, and you have to come up with some type of conclusions at the end as to how you deal with it. (PHARM3 INT1)

Participants discussing this approach agreed that critical thinking involved a systematic process of gathering and analyzing data: ‘I think [critical thinking and clinical reasoning] are the same. I think clinical reasoning is basically taking the data you have on a patient and interpreting it, and offering a treatment plan’ (MD1 INT1).

In keeping with an emphasis on the rational and logical, participants espousing this view often reacted negatively when they saw references to emotion on the mind map in interview 2: ‘as soon as you bring your emotions into the room, you’re no longer applying what I think is critical thinking’ (MD4 INT2). Participants also noted that decision-making was an important component of critical thinking: ‘ you have to make a decision. I think it’s a really important part of it’ (MD2 INT2).

For participants from pharmacy, in particular, critical thinking often meant departing from ‘rules’ that guide clinical practice in order to engage in reasoning and make situationally nuanced decisions. One pharmacist, describing a student not engaging in critical thinking, related that the student asked:

‘Have you ever seen Victoza given at 2.4   milligrams daily?’ … It’s very, you know, it’s very much yes or no. But at a deeper level, it’s actually missing things. … [There are] all these other factors that change the decision, right? … On paper there might be a regular set of values for the dose, … [but] without the rest of the background, that’s a very secondary thing. (PHARM4 INT1)

This perspective was identified as the dominant conception of critical thinking because the terms and concepts falling under this broad approach were most frequently discussed by participants; moreover, when participants discussed other conceptions of critical thinking, they were often explicitly drawing contrast to the biomedical view. While the biomedical perspective was dominant in all four groups (although primarily as a contrasting case for social workers), participants tended to occupy more than one perspective over the course of an interview. They might talk primarily about biomedical critical thinking, but also explicitly modify that perspective by drawing on the other two approaches identified: humanist critical and social justice-oriented critical thinking.

Humanist critical thinking

Participants, when adopting this view, described critical thinking as directed toward social good and oriented around positive human relationships. Humanist conceptions of critical thinking were often positioned as an alternative to the dominant biomedical perspective: ‘having to think of somebody else, at their most vulnerable, makes you know that knowledge alone, science alone, won’t get that patient to the place you want the patient to be. It won’t provide the best care’ (NURS1 INT1). In being so positioned, the humanist conception of critical thinking explicitly departed from the biomedical, which emphasized ‘setting aside’ emotion and de-emphasized the role of relationships in healthcare. In the humanist perspective, participants often discussed the purpose of critical thinking as:

Thinking about something for the betterment of yourself and the betterment of others. We’re social beings as human beings. … I think [critical thinking] has a higher purpose. … But I think that [if] critical thinking … [is] a human trait that we have or hope to have, then it has to have those components of what we are as humans. (NURS1 INT1)

Another participant emphasized that: ‘a great part of critical thinking is that human element and the consideration of ultimately what’s a good thing, a common good’ (NURS2 INT1).

In addressing the relational aspects of humanist critical thinking, participants argued that the focus on ‘hard’ sources of data, such as lab tests or imaging, in biomedical critical thinking was limiting. They were concerned that ‘hard data’ tend to be perceived as more objective and thus more important in biomedical critical thinking, compared with subjective patient narratives. They argued that the patient’s story is essential to critical thinking:

I think it doesn’t matter what kind of expert you are, you have to be able to think about patients in the context that they’re in and consider what the patient has to say, and really hear them. So I think that’s an important—that was a total lack of critical thinking in a totally, ‘I’m just going to get through this next patient to the next one’ . (MD1 INT1)

Taken together, these perspectives suggest that biomedical approaches to critical thinking fail to address the complex relational and psychosocial aspects of professional practice.

Social justice-oriented critical thinking

In social justice-oriented approaches to critical thinking participants articulated a process of examining the assumptions and biases embedded in their world. They often explicitly rejected biomedical conceptions of critical thinking as ‘ reductionistic ’ (SW3 INT1) because, in their view, these approaches fail to address the thinker’s own biases. Educators taking a social justice approach felt that: ‘critical thinking … is around things like … recognizing your own bias and recognizing the bias in the world’ (SW1 INT1). In this perspective, participants saw critical thinking as a process of analyzing and addressing the ways in which individual and societal assumptions limit possible actions and access to resources for individuals and social groups.

Unlike biomedical critical thinking and similar to the humanist view, participants articulating this conception tended to make the values and goals of critical thinking, as they conceived of it, explicit. They often contrasted their articulation of values in critical thinking with the ‘assumed’ and unarticulated values present in the biomedical perspective:

If you are not orientated in a social justice position, [critical thinking is] more about the mechanics, which is valuable as well, but … if we don’t understand the values associated with what we think, it seems to not be meaningless but there’s a piece missing or it’s assumed. The values are assumed. (SW3 INT1)

When taking this perspective, participants argued that it is necessary to understand social systems in order to think critically about individual patient cases. One educator questioned:

Why are there a disproportionate number of aboriginal inpatients than any other group? … When you start critically thinking about seeing the whole patient … there are issues related with all of society and that’s why people have more diabetes. (PHARM1 INT1)

Other participants had measured responses to this approach. One participant added to their primarily biomedical approach in order to accommodate perspectives encountered in the mind map, relating that behind their diagnostic work all physicians:

Certainly see a wide spectrum of social and economic status and cultures and things and recognizing that our system is kind of biased against certain groups as it is and knowing that but really not having a good sense of knowing even where to start deconstructing it. (MD2 INT2)

Relationships between conceptions of critical thinking

Results of this study suggest that critical thinking means a variety of things in different contexts and to different people. It might be tempting to see the three approaches outlined above as playing out along professional boundaries. Certainly, the social justice-oriented conception was more common among social work educators; the humanist approach was most common among participants from nursing; perspectives held by physician educators frequently aligned with dominant biomedical conceptions. In pharmacy, educators seemed to straddle all three perspectives, though they commonly emphasized a biomedical approach. Several participants suggested that their faculty or profession has a common understanding of critical thinking: ‘ critical thinking, for me and maybe for our faculty, is around things like … ’ (SW1 INT1).

However, while the disciplinary tendencies discussed above do appear in the data, these tendencies were not stable; participants often held more than one view on what critical thinking meant simultaneously, or shifted between perspectives. Participants also articulated approaches that were not common in their profession at certain moments, positioning themselves as ‘an outlier’, or positioning their specialty as having a different perspective than the profession as a whole, such that critical thinking might mean ‘thinking like a nurse’, or ‘thinking in geriatrics’. Further, participants’ perspectives shifted depending on the context in which they imagined critical thinking occurring.

This type of positioning and re-positioning occurred in both interviews, although they were particularly pronounced in interview 2, where participants were explicitly asked to react to different viewpoints by responding to the mind map. Examples of shifting perspectives in interview 1 occurred especially when participants from medicine shifted between biomedical and humanist conceptions. These shifts suggested a persistent tension and negotiation between characterizations of critical thinking as a rational process of data collection and analysis, and a more humanist approach that accounts for emotion and the relationship between professional and patient or family. Where participants sought to extend their notion of data beyond ‘hard data’ there is a sense of blending humanism with biomedical approaches to critical thinking. In the quote below, the participant brings together a call for a humanist relationship building with a need to gather and analyze all of the data, including important data about the patient’s experience:

I have colleagues who’ll say [to their patients]: ‘just say yes or no.’ … And it’s not very good and they’re missing stuff. So, critical thinking is—I guess it’s sort of dynamic in that you have to have time and you also have to have an interaction. (MD1 INT1)

While the participants described above negotiated between biomedical and humanist perspectives, participants primarily espousing a social justice-oriented conception of critical thinking responded to the ‘assumed’ values of the biomedical model. In talking about a problem solving-oriented biomedical approach, one participant argued that ‘ it’s important as well to have that, those foundational elements of how we think about what we think, but if we don’t understand the values associated … there’s a piece missing’ (SW3 INT1). Another stated that ‘critical thinking seems to be a neutral kind of process or—no, that can’t be true, can it?’ (SW1 INT2) with the mid-sentence shift indicating that two ways of conceptualizing critical thinking had come into conflict. This participant primarily discussed a social justice-oriented conception of critical thinking, which is not neutral, but at this moment also articulated a neutral, clinical reasoning-oriented or biomedical conception.

These relatively organic moments of negotiation certainly demonstrate a sense of conflicting values, of toggling between one perspective and another. However, they also suggest that there are ways in which these contradictions can be productively sustained. In negotiating between humanist and biomedical perspectives, educators effectively modify the dominant perspective.

In interview 2, when discussing the mind map, participants often encountered views that differed from their own. They responded either by making sense of and accommodating the new perspective, or by rejecting it. As an example of the former approach, one physician reacted to the ‘social justice-oriented’ corner of the mind map (specifically ‘examining assumptions’) by explaining how there are:

Assumptions in the background that come up for me all the time in terms of the different ways people live and want to live and how we run into it all the time … it’s always in the background and actually influencing you and until someone challenges the way you approached something, you don’t know what your assumptions are. (MD1 INT2)

As an example of a participant disagreeing with a perspective encountered in the mind map, one participant rejected social justice as an important component of critical thinking in medicine. They related that critical thinking has ‘got everything to do with reasoning, which makes sense. … Social justice has nothing to do with critical thinking’ (MD4 INT2). Interestingly, this participant also spoke at length about the link between social justice and critical thinking in the first interview, suggesting that a conception might seem ‘wrong’ when an individual is thinking and talking about it in one context, and entirely ‘right’ in another context.

Such results demonstrate that individual conceptions of critical thinking are multiple and flexible, not predetermined or stable. Educators bring certain values or perspectives into the foreground as they relate to the context under discussion, while others recede into the background. Though many participants seemed to have a primary perspective, multiple perspectives on critical thinking can co-exist and are actively negotiated by the individual.

In overview, the three broad conceptions of critical thinking offered here (biomedical, humanist, and social justice-oriented) echo approaches to critical thinking found in the critical thinking literature [ 11 , 35 , 36 , 37 ]. However, this study extends the literature in two key ways. First, our data point to ways in which different conceptions of critical thinking conflict and coalesce, within the field, within each profession, and even within individuals. Second, this tension offers an early empirical account of critical thinking in the health professions that suggests there may be benefits to maintaining flexibility in how one conceives of the concept.

The diverse conceptions of critical thinking identified all appear to have some value in HPE. It might be tempting to view each conception as a unique but stable perspective, reflecting thinking skills that are used within a particular context or value orientation. However, the multiplicity and flexibility of participants’ conceptions in this study offers some explanation as to why previous attempts to develop either generic (e. g. [ 2 , 3 , 5 ]) or discipline-specific [ 13 , 15 , 16 , 17 ] definitions and delineations of critical thinking have failed to stick.

Conceptions of critical thinking are not stable within a context or for a single educator. Educators’ conceptions of critical thinking shift within and between contexts as they navigate overlapping sets of values and beliefs. When educators take up different conceptions of critical thinking, the shifts they make are not just pragmatic; they actively negotiate the values and practices of the different communities in which they participate. Although we certainly saw hints of differences between professions, the strength of this study is that it captured the ways in which conceptions of critical thinking are not stably tied to any given profession. Critical thinking is connected to a broader idea of what ‘good thinking’—and, by extension, the ‘good professional’—looks like for each educator [ 38 ] within a given context or community.

These observations lead one to speculate about what purpose fluidity in conceptions of critical thinking might serve. Educators often have different values and goals for their profession, and, thus, it is not surprising that the meaning of critical thinking would be contested both within and across professions. Through their conceptions of critical thinking, participants contest ideas about what thinking is for in their profession—whether it should be focused on individual patient ‘problems’ or broader social issues, and the extent to which humanism is an important component of healthcare.

It is understandable that so much of the literature on critical thinking has sought to clarify a single ‘right’ definition; there is an argument for making a collective decision about what ‘good thinking’ means. Such a decision might offer clarity to interprofessional teaching and practice, or provide a foundation on which educational policy can be based. However, the critical thinking literature has long sought such a universal agreement and disagreements persist. Results of this study suggest a new approach, one that can account for multiple conceptions of critical thinking within and across health professions and practice contexts. The visual elicitation approach employed, asking participants to respond to the mind map, offered a unique perspective on the data that illuminated contradictions between conceptions held by individual participants, between participants, and between the conceptions themselves.

Such an approach offers a vehicle for thinking and talking about what kind of thinking is valued, both within and between professions. When conceptions of critical thinking are understood as flexible instead of stable, these acts of modification and contestation can be viewed as potential moments for critical self-reflection for individuals and for professional groups on the whole. Moreover, through their discussions of critical thinking, educators actively intervened to consider and assert what they value in their work.

These different conceptions might be complementary as often as they are incompatible. In fact, we would argue that ‘good thinking’ is inherently contentious (and should be) because it is such struggles over what ‘the good’ means in HPE that allow for challenges to the status quo. Advances at the heart of HPE and practice have been hard-won through deliberate reflection, discussion, action, and (often) conflict. For example, the ongoing movement toward relationship-oriented care has arguably occurred as a result of unexpected pushback regarding the limits of considering good healthcare as being entirely patient-centred. Thus, there is a need to bring unarticulated assumptions about important topics into the light so that the goals and values of educators and policy-makers can be openly discussed, even though they are unlikely to ever be fully resolved.

Strengths and limitations

This study offered a broad sample of educators from four different professions, who practised in a range of disciplinary contexts. Given that the sampling approach taken sought breadth rather than depth, the results explore a range of conceptions of critical thinking across HPE, rather than allowing strong claims about any one profession or context. The sample also focussed on conceptions of critical thinking within health professions education at specific institutions in Edmonton, Alberta. A multi-institutional study might build on these results to elaborate the extent to which each health profession has a core shared conception of critical thinking that translates across institutional settings. We expect that there may be significant differences between settings, given that what is meant by critical thinking seems to be highly contextual, even from moment to moment. Mapping aspects of context that impact how individuals and groups think about critical thinking would tell us much more about the values on which these conceptions are based.

Subsequent studies might also explore the extent to which conceptions of critical thinking among those identifying as ‘educators’ are comparable to those identifying as primarily ‘clinicians’. Although the boundary is definitely blurry, these groups engage in different kinds of work and participate in different communities, which we suspect may result in differences in how they conceive of critical thinking.

Conclusions

Rather than attempting to ‘solve’ the debate about what critical thinking should mean, this study maps the various conceptions of this term articulated by health professional educators. Educators took up biomedical, humanist, and social justice-oriented conceptions of critical thinking, and their conceptions often shifted from moment to moment or from context to context. The ‘mapping’ approach adopted to study this issue allowed for an appreciation of the ways in which educators actively modify and contest educational and professional values, even within their own thinking. Because critical thinking appears to be both value and context driven, arriving at a single right definition or taxonomy of critical thinking is unlikely to resolve deep tensions around what ‘good thinking’ in HPE means. Moreover, such an approach is unlikely to be productive. Such tensions produce challenges for shared understanding at the same time that they produce a productive space for discussion about core issues in HPE.

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Acknowledgements

We thank Dr. Paul Newton for his contributions to the analysis of these data, in his role as supervisor of the dissertation work on which this manuscript is based. Thanks also to Dr. Dan Pratt for his help and support in developing this manuscript.

Support for this work was provided by the Government of Alberta (Queen Elizabeth II Graduate Scholarship), by the Social Sciences and Humanities Research Council (Doctoral Fellowship), and by the University of British Columbia (Postdoctoral Fellowship).

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Appendix a: interview guide for initial interview, appendix b: interview guide for second interview, appendix c: mind map, rights and permissions.

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Kahlke, R., Eva, K. Constructing critical thinking in health professional education. Perspect Med Educ 7 , 156–165 (2018). https://doi.org/10.1007/s40037-018-0415-z

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Published : 04 April 2018

Issue Date : June 2018

DOI : https://doi.org/10.1007/s40037-018-0415-z

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