Medical Student Guide For Critical Thinking

critical thinking exercises medical

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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What is Critical Thinking in Nursing? (With Examples, Importance, & How to Improve)

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Successful nursing requires learning several skills used to communicate with patients, families, and healthcare teams. One of the most essential skills nurses must develop is the ability to demonstrate critical thinking. If you are a nurse, perhaps you have asked if there is a way to know how to improve critical thinking in nursing? As you read this article, you will learn what critical thinking in nursing is and why it is important. You will also find 18 simple tips to improve critical thinking in nursing and sample scenarios about how to apply critical thinking in your nursing career.

What Is Critical Thinking In Nursing?

4 reasons why critical thinking is so important in nursing, 1. critical thinking skills will help you anticipate and understand changes in your patient’s condition., 2. with strong critical thinking skills, you can make decisions about patient care that is most favorable for the patient and intended outcomes., 3. strong critical thinking skills in nursing can contribute to innovative improvements and professional development., 4. critical thinking skills in nursing contribute to rational decision-making, which improves patient outcomes., what are the 8 important attributes of excellent critical thinking in nursing, 1. the ability to interpret information:, 2. independent thought:, 3. impartiality:, 4. intuition:, 5. problem solving:, 6. flexibility:, 7. perseverance:, 8. integrity:, examples of poor critical thinking vs excellent critical thinking in nursing, 1. scenario: patient/caregiver interactions, poor critical thinking:, excellent critical thinking:, 2. scenario: improving patient care quality, 3. scenario: interdisciplinary collaboration, 4. scenario: precepting nursing students and other nurses, how to improve critical thinking in nursing, 1. demonstrate open-mindedness., 2. practice self-awareness., 3. avoid judgment., 4. eliminate personal biases., 5. do not be afraid to ask questions., 6. find an experienced mentor., 7. join professional nursing organizations., 8. establish a routine of self-reflection., 9. utilize the chain of command., 10. determine the significance of data and decide if it is sufficient for decision-making., 11. volunteer for leadership positions or opportunities., 12. use previous facts and experiences to help develop stronger critical thinking skills in nursing., 13. establish priorities., 14. trust your knowledge and be confident in your abilities., 15. be curious about everything., 16. practice fair-mindedness., 17. learn the value of intellectual humility., 18. never stop learning., 4 consequences of poor critical thinking in nursing, 1. the most significant risk associated with poor critical thinking in nursing is inadequate patient care., 2. failure to recognize changes in patient status:, 3. lack of effective critical thinking in nursing can impact the cost of healthcare., 4. lack of critical thinking skills in nursing can cause a breakdown in communication within the interdisciplinary team., useful resources to improve critical thinking in nursing, youtube videos, my final thoughts, frequently asked questions answered by our expert, 1. will lack of critical thinking impact my nursing career, 2. usually, how long does it take for a nurse to improve their critical thinking skills, 3. do all types of nurses require excellent critical thinking skills, 4. how can i assess my critical thinking skills in nursing.

• Ask relevant questions • Justify opinions • Address and evaluate multiple points of view • Explain assumptions and reasons related to your choice of patient care options

5. Can I Be a Nurse If I Cannot Think Critically?

critical thinking exercises medical

The Value of Critical Thinking in Nursing

Gayle Morris, BSN, MSN

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

Male nurse checking on a patient

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

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

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.

Portrait of Jenna Liphart Rhoads, Ph.D., RN

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.

Portrait of Nicholas McGowan, BSN, RN, CCRN

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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Cultivating Critical Thinking in Healthcare

Published: 06 January 2019

critical thinking exercises medical

Critical thinking skills have been linked to improved patient outcomes, better quality patient care and improved safety outcomes in healthcare (Jacob et al. 2017).

Given this, it's necessary for educators in healthcare to stimulate and lead further dialogue about how these skills are taught , assessed and integrated into the design and development of staff and nurse education and training programs (Papp et al. 2014).

So, what exactly is critical thinking and how can healthcare educators cultivate it amongst their staff?

What is Critical Thinking?

In general terms, ‘ critical thinking ’ is often used, and perhaps confused, with problem-solving and clinical decision-making skills .

In practice, however, problem-solving tends to focus on the identification and resolution of a problem, whilst critical thinking goes beyond this to incorporate asking skilled questions and critiquing solutions .

Several formal definitions of critical thinking can be found in literature, but in the view of Kahlke and Eva (2018), most of these definitions have limitations. That said, Papp et al. (2014) offer a useful starting point, suggesting that critical thinking is:

‘The ability to apply higher order cognitive skills and the disposition to be deliberate about thinking that leads to action that is logical and appropriate.’

The Foundation for Critical Thinking (2017) expands on this and suggests that:

‘Critical thinking is that mode of thinking, about any subject, content, or problem, in which the thinker improves the quality of his or her thinking by skillfully analysing, assessing, and reconstructing it.’

They go on to suggest that critical thinking is:

  • Self-directed
  • Self-disciplined
  • Self-monitored
  • Self-corrective.

Critical Thinking in Healthcare nurses having discussion

Key Qualities and Characteristics of a Critical Thinker

Given that critical thinking is a process that encompasses conceptualisation , application , analysis , synthesis , evaluation and reflection , what qualities should be expected from a critical thinker?

In answering this question, Fortepiani (2018) suggests that critical thinkers should be able to:

  • Formulate clear and precise questions
  • Gather, assess and interpret relevant information
  • Reach relevant well-reasoned conclusions and solutions
  • Think open-mindedly, recognising their own assumptions
  • Communicate effectively with others on solutions to complex problems.

All of these qualities are important, however, good communication skills are generally considered to be the bedrock of critical thinking. Why? Because they help to create a dialogue that invites questions, reflections and an open-minded approach, as well as generating a positive learning environment needed to support all forms of communication.

Lippincott Solutions (2018) outlines a broad spectrum of characteristics attributed to strong critical thinkers. They include:

  • Inquisitiveness with regard to a wide range of issues
  • A concern to become and remain well-informed
  • Alertness to opportunities to use critical thinking
  • Self-confidence in one’s own abilities to reason
  • Open mindedness regarding divergent world views
  • Flexibility in considering alternatives and opinions
  • Understanding the opinions of other people
  • Fair-mindedness in appraising reasoning
  • Honesty in facing one’s own biases, prejudices, stereotypes or egocentric tendencies
  • A willingness to reconsider and revise views where honest reflection suggests that change is warranted.

Papp et al. (2014) also helpfully suggest that the following five milestones can be used as a guide to help develop competency in critical thinking:

Stage 1: Unreflective Thinker

At this stage, the unreflective thinker can’t examine their own actions and cognitive processes and is unaware of different approaches to thinking.

Stage 2: Beginning Critical Thinker

Here, the learner begins to think critically and starts to recognise cognitive differences in other people. However, external motivation  is needed to sustain reflection on the learners’ own thought processes.

Stage 3: Practicing Critical Thinker

By now, the learner is familiar with their own thinking processes and makes a conscious effort to practice critical thinking.

Stage 4: Advanced Critical Thinker

As an advanced critical thinker, the learner is able to identify different cognitive processes and consciously uses critical thinking skills.

Stage 5: Accomplished Critical Thinker

At this stage, the skilled critical thinker can take charge of their thinking and habitually monitors, revises and rethinks approaches for continual improvement of their cognitive strategies.

Facilitating Critical Thinking in Healthcare

A common challenge for many educators and facilitators in healthcare is encouraging students to move away from passive learning towards active learning situations that require critical thinking skills.

Just as there are similarities among the definitions of critical thinking across subject areas and levels, there are also several generally recognised hallmarks of teaching for critical thinking . These include:

  • Promoting interaction among students as they learn
  • Asking open ended questions that do not assume one right answer
  • Allowing sufficient time to reflect on the questions asked or problems posed
  • Teaching for transfer - helping learners to see how a newly acquired skill can apply to other situations and experiences.

(Lippincott Solutions 2018)

Snyder and Snyder (2008) also make the point that it’s helpful for educators and facilitators to be aware of any initial resistance that learners may have and try to guide them through the process. They should aim to create a learning environment where learners can feel comfortable thinking through an answer rather than simply having an answer given to them.

Examples include using peer coaching techniques , mentoring or preceptorship to engage students in active learning and critical thinking skills, or integrating project-based learning activities that require students to apply their knowledge in a realistic healthcare environment.

Carvalhoa et al. (2017) also advocate problem-based learning as a widely used and successful way of stimulating critical thinking skills in the learner. This view is echoed by Tsui-Mei (2015), who notes that critical thinking, systematic analysis and curiosity significantly improve after practice-based learning .

Integrating Critical Thinking Skills Into Curriculum Design

Most educators agree that critical thinking can’t easily be developed if the program curriculum is not designed to support it. This means that a deep understanding of the nature and value of critical thinking skills needs to be present from the outset of the curriculum design process , and not just bolted on as an afterthought.

In the view of Fortepiani (2018), critical thinking skills can be summarised by the statement that 'thinking is driven by questions', which means that teaching materials need to be designed in such a way as to encourage students to expand their learning by asking questions that generate further questions and stimulate the thinking process. Ideal questions are those that:

  • Embrace complexity
  • Challenge assumptions and points of view
  • Question the source of information
  • Explore variable interpretations and potential implications of information.

To put it another way, asking questions with limiting, thought-stopping answers inhibits the development of critical thinking. This means that educators must ideally be critical thinkers themselves .

Drawing these threads together, The Foundation for Critical Thinking (2017) offers us a simple reminder that even though it’s human nature to be ‘thinking’ most of the time, most thoughts, if not guided and structured, tend to be biased, distorted, partial, uninformed or even prejudiced.

They also note that the quality of work depends precisely on the quality of the practitioners’ thought processes. Given that practitioners are being asked to meet the challenge of ever more complex care, the importance of cultivating critical thinking skills, alongside advanced problem-solving skills , seems to be taking on new importance.

Additional Resources

  • The Emotionally Intelligent Nurse | Ausmed Article
  • Refining Competency-Based Assessment | Ausmed Article
  • Socratic Questioning in Healthcare | Ausmed Article
  • Carvalhoa, D P S R P et al. 2017, 'Strategies Used for the Promotion of Critical Thinking in Nursing Undergraduate Education: A Systematic Review', Nurse Education Today , vol. 57, pp. 103-10, viewed 7 December 2018, https://www.sciencedirect.com/science/article/abs/pii/S0260691717301715
  • Fortepiani, L A 2017, 'Critical Thinking or Traditional Teaching For Health Professionals', PECOP Blog , 16 January, viewed 7 December 2018, https://blog.lifescitrc.org/pecop/2017/01/16/critical-thinking-or-traditional-teaching-for-health-professions/
  • Jacob, E, Duffield, C & Jacob, D 2017, 'A Protocol For the Development of a Critical Thinking Assessment Tool for Nurses Using a Delphi Technique', Journal of Advanced Nursing, vol. 73, no. 8, pp. 1982-1988, viewed 7 December 2018, https://onlinelibrary.wiley.com/doi/10.1111/jan.13306
  • Kahlke, R & Eva, K 2018, 'Constructing Critical Thinking in Health Professional Education', Perspectives on Medical Education , vol. 7, no. 3, pp. 156-165, viewed 7 December 2018, https://link.springer.com/article/10.1007/s40037-018-0415-z
  • Lippincott Solutions 2018, 'Turning New Nurses Into Critical Thinkers', Lippincott Solutions , viewed 10 December 2018, https://www.wolterskluwer.com/en/expert-insights/turning-new-nurses-into-critical-thinkers
  • Papp, K K 2014, 'Milestones of Critical Thinking: A Developmental Model for Medicine and Nursing', Academic Medicine , vol. 89, no. 5, pp. 715-720, https://journals.lww.com/academicmedicine/Fulltext/2014/05000/Milestones_of_Critical_Thinking___A_Developmental.14.aspx
  • Snyder, L G & Snyder, M J 2008, 'Teaching Critical Thinking and Problem Solving Skills', The Delta Pi Epsilon Journal , vol. L, no. 2, pp. 90-99, viewed 7 December 2018, https://dme.childrenshospital.org/wp-content/uploads/2019/02/Optional-_Teaching-Critical-Thinking-and-Problem-Solving-Skills.pdf
  • The Foundation for Critical Thinking 2017, Defining Critical Thinking , The Foundation for Critical Thinking, viewed 7 December 2018, https://www.criticalthinking.org/pages/our-conception-of-critical-thinking/411
  • Tsui-Mei, H, Lee-Chun, H & Chen-Ju MSN, K 2015, 'How Mental Health Nurses Improve Their Critical Thinking Through Problem-Based Learning', Journal for Nurses in Professional Development , vol. 31, no. 3, pp. 170-175, viewed 7 December 2018, https://journals.lww.com/jnsdonline/Abstract/2015/05000/How_Mental_Health_Nurses_Improve_Their_Critical.8.aspx

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What is Critical Thinking?

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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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NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

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

Cover of Patient Safety and Quality

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 .

Affiliations

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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Fun Critical Thinking Activities for Nursing Students

critical thinking exercises medical

Medical courses are popular for their complexity and demanding nature. For your everyday student fighting to pay tuition, rent, food, and loans, pursuing a career in the field can be a nightmare. Those who’ve made the journey understand the importance of critical thinking for nursing students. Every facet of the course requires thorough analysis and logical engagement. Nonetheless, educators can intervene to make the journey fun and memorable by introducing exciting activities into the classroom. Below are 10 projects to consider in your classroom.

The Importance of Critical Thinking for Nursing Students

There’s no denying that critical thinking is of utmost importance for nursing students. Well, no professional field would survive without analytical skills. But nursing is about people’s well-being, which makes the practice even more sacred. Below are a few reasons why critical thinking is essential to the practice:

Patient safety

The primary role of a RN is to care for their patients. But this isn’t always the case. Some nurses, e.g., Charles Cullen, have committed atrocities against their patients. Many others have harmed their patients unintentionally or due to negligence. In the medical field, the consequences of a wrong decision can be severe. As such, we need our nurses to be on top of their game. They must possess necessary critical thinking skills to identify potential risks and avert or remedy them.

Clinical judgment

Unlike popular opinion, the role of nurses isn’t limited to administering drugs and caring for them. There are many scenarios that demand clinical judgments, e.g., evaluating symptoms and making a diagnosis, deciding on appropriate medication dosage, recognizing signs of an allergic reaction, etc. These are delicate and life-defining matters that demand critical thinking skills.

Ethical decision-making

Nothing is as demanding as making an ethical decision. The dilemma involved can make or break even the best nurses. In training, they’re often advised to make the decisions they can live with, and in the best interest of their patients. We hope you can see the catch. Whatever the situation, such cases require weighing different ethical principles, values, and perspectives, making them almost impossible to deal with. Handling critical thinking questions during training can make it a bit easier.  

Completing course assignments

All medical courses have a heavy workload of assignments, practicals, and clinical placements. If you add personal life requirements, it becomes almost impossible to handle. In some courses, students handle voluminous works that require days and weeks of reading. The vastness aside, you must be smart to understand the terminology and concepts in nursing. This is where most students fail. However, there’s no cause for alarm. You can always seek help when stranded with your essays and dissertations. There are reputable companies that specialize in nursing writing that can come through on short notice. WriteMyPaperHub , for instance, has very creative and highly trained PhD writers in nursing and medicine who can deliver complex papers within the deadline you need.

Stimulating the Mind: 10 Fun Critical Thinking Activities for Nursing Students

There are several fun critical thinking activities for nursing students to consider. However, many can be costly, time-consuming, or too demanding. For an ordinary classroom, group activities should be simple and interesting. Here, we’ve assembled 10 activities and critical thinking games for nursing students.

1. Case studies

Nursing is a very practical course. As such, any opportunity to explore real-life patient scenarios is highly welcome. This exercise provides just that. Students can organize themselves into small groups and tackle a problem, for example, examine a wound, identify its probable causes, and propose how to treat it.

There’s no better way of sharpening your critical thinking skills than through open discourses. Let your students disagree to agree, for they will gain so much more from being corrected by their peers than rote memorization. Therefore, occasionally pick a controversial or ethical topic and let them debate on it. Just ensure that the engagement is structured for maximum impact.    

3. Reflection journals

Journals can be a student’s best companion. Medical courses can be demanding, putting undue pressure on college students. However, with proper planning and focus, dedicated persons are likely to make it through. A diary can help you organize yourself, appreciate the difficulties you’ve overcome, reflect on your clinical experiences, and motivate you to keep pushing. But keeping it isn’t enough. You must read and reflect on your journey if you’re to stay on track.

4. Simulation exercises

Advances in technology have significantly impacted medical training. For instance, Virtual Reality (VR) is helping instructors to deliver realistic scenarios to their learners remotely. Imagine creating and sharing realistic images of viruses, pathogens, or sick people with your learners and asking them to explore them under pressure and deliver a verdict. It’s like being in the lab!

5. Critical thinking worksheets

Also commonly referred to as critical thinking flow sheets, this activity can be instrumental in testing students’ abilities. It’s a step-by-step process involving clinical scenarios that require extensive research. Here, learners are supposed to gather data on a specific issue, analyze it carefully, and arrive at a diagnosis. It’s a thorough process that employs logic and problem-solving skills.

6. Role-playing

Nursing schools don’t train nurses to be just subordinates. Their curriculum entails everything about patient care and simple diagnosis. In fact, in remote areas with no clinicians, they’re the doctors of the day. Their instructors can organize scenarios that expose them to such situations and let them act as the physicians in charge. They can also act as other people in the healthcare team, e.g., clerks, therapists, and pharmacists. Organizing such critical thinking activities can enhance their preparation and training.

7. Flipped classroom

Even though nursing is quite hands-on, its trainers can deliver their courses and instructions remotely. A flipped classroom is a dynamic approach to learning that allows students to explore their materials at home. Technological advances have made it possible for remote collaboration, making this one of the most enjoyable and fun activities.

8. Group discussions

Unlike debates that pit groups and individuals against each other, group discussions are less confrontational, making them ideal for younger learners. These setups are also suitable for discussing ethical dilemmas. While it’s often hard to find common ground for such issues, challenging assumptions are critical for nursing practice.

9. Decision-making games

The life of a nurse involves making numerous critical decisions. Some of these big resolutions require an instant response. This requires rigorous training. Trainers can use board games, for instance, to pressure students into making healthcare-related decisions fast. This can help them in making informed choices under pressure.

10. Mind mapping

You can introduce this activity as a visual instrument for arranging, generating, and investigating ideas and the links between different nursing concepts.

Critical Thinking for Critical Patient Support!

Nurses are the pillars that hold the healthcare system together. However, their services are only as good as their training and abilities. If we want the best out of our nurses, we must sharpen their critical thinking skills and make them ready for service. In this short article, we’ve explored a few activities that can help nursing trainees develop critical thinking skills essential for their future roles as healthcare professionals.

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The Current State of Critical Thinking in EMS

Critical thinking is not something that one can just begin to do, writes Radu Venter It is a skill that must first be taught, developed over time and regularly maintained.

The Current State of Critical Thinking in EMS

Emergency medical services (EMS) journals regularly discuss a lack of critical thinking evident in paramedics and how this deficiency is a significant flaw in the profession. Some provide tips and tricks to paramedics looking to develop their critical thinking. Others outline examples of mindsets to follow and biases to avoid. These articles stand by the need for further critical thinking training in EMS, but there are some significant absences that limit their ability to assist practitioners seeking to develop their skills.

Before continuing, we must ask whether critical thinking is a valuable skill for paramedics. Is there a benefit to having paramedics make decisions on their own? Should we instead have them strictly follow flowcharts in patient assessment, initial treatment and prompt transport to a hospital where a doctor can oversee definitive care? Alternately, do we want more basic practitioners to follow the flowcharts and those of higher levels to think critically?

  • Critical Thinking, Part One
  • Critical Thinking, Part Two
  • EMS Providers Use Detective Skills to Solve Case

The current system is largely based on the third option. Paramedics working at advanced levels are expected to be able to critically think. Certain treatments available to these practitioners may be detrimental to the patient, so it falls on the practitioner to assess, reason and treat appropriately. Paramedics working at a more basic level do not have such expectations. Their training encompasses a more limited scope, prioritizing treatment of only more severe conditions. While critical thinking skills may be a goal of advanced care education, at the basic level, the goal is to create technicians. Technicians prioritize practical skills, with less focus on the theoretical. Thus, it is possible to educate a technician rapidly — basic life support programs are thus much shorter. As explained by Daniel Limmer in his EMS World article, “A technician is not expected to use high levels of reasoning skills. Technicians are strictly protocol driven and respond in a specific way when a certain group of signs and symptoms appear.” 1

Why, then, is there all this frustration with a lack of critical thinking in our profession, even with practitioners working at the basic level? The simplest answer is that when the practitioner aspires to the next level of training, critical thinking becomes more important. Unfortunately, to become an advanced level practitioner, the technician must then re-learn a fair amount of their practice. The second reason critical thinking is necessary for all paramedics has to do with the fluidity of patient assessment and treatment. Every skill performed requires an element of critical thinking. The practitioner must be able to select an appropriate diagnostic to perform or therapy to administer. They must then be able to verify the information received or confirm the therapy was effective. Kelly Grayson supports this point, noting that our current focus is more on what skills paramedics can perform, rather than the underlying knowledge necessary to determine when the skill is required and the ability to perform it proficiently. 2 A further avenue of exploration is whether the skill was even necessary in the first place.

Further, paramedics must be able to determine which algorithm for patient treatment will provide the greatest benefit. They must also be able to identify treatment priorities, and which hospital is most appropriate for transport. Finally, there is no effective flowchart for the patient who is suffering from a serious medical condition and wishes to stay at home. Paramedics of any ability level forced to operate in these novel situations without clear directions must then be able to think through the situation and work through the problem.

Two Elements of Critical Thinking

Current EMS articles on how to develop critical thinking fall into the trap of providing guidelines without going into enough depth. Scott Cormier’s two-part article on critical thinking provides a few examples of approaches to critical thinking as well as biases to avoid. 3,4 Unfortunately, they do not touch on the foundation of critical thinking, such as the traits of a good critical thinker, or provide examples to the reader to be able to apply these approaches in their own practice.

Others are more mechanical in nature than cognitive. In Daniel Limmer’s article, he states that practitioners should aspire to be clinicians instead of merely technicians. Where a technician identifies a symptom and works to treat it, a clinician strives to obtain a complete picture of the patient through a thorough assessment and the use of a differential diagnosis, prior to initiating a treatment. Performing thorough assessments of the patient, prioritizing focus on immediate threats to airway, breathing and circulation, and creating a differential diagnosis do not require as much critical thinking as might be expected.

I would suggest that a clinician’s approach has less to do with their ability to critically think, but more to do with thoroughness. In the example Limmer provides, the only difference between a technician and a clinician is the completion of a more thorough assessment that leads to a different diagnosis and, therefore, a different treatment plan. Though creating a differential diagnosis involves elements of critical thinking, it can also be a largely mechanical process — paramedics can easily memorize medical conditions to rule out in the case of a patient presenting with a specific complaint. Of the six steps suggested, only the last two involve critical thinking. Unfortunately, these are the shortest steps in the article. The best example I was able to discover is Rom Duckworth’s article, urging practitioners to assess sources of information for accuracy, validity, and a lack of bias, while also questioning currently-held beliefs. 5 This article focuses on the cognitive skills inherent in critical thinking, avoiding the mechanical pitfalls other articles fall into. However, like the other articles, it is very brief and does not provide examples for practitioners to either follow or practice.

The second major flaw underlying these articles is the assumption that the readers have enough background knowledge of the topic in order to be able to make critical decisions. For example, students in an advanced care paramedic class are asked to create a treatment plan for a cardiac complaint. The patient has sudden onset chest pain, radiating to the left arm, as well as significant pitting edema to upper and lower extremities. The patient also has a significant cardiac history. At the chest, wheezes are auscultated. Several students in the class treat the patient with salbutamol and ipratropium bromide, working to improve air entry and decrease wheezing through bronchodilation. A subsequent discussion introduced the existence of cardiac wheezes, caused not by bronchospasm, but by the presence of fluid in the lungs due to diminished cardiac output. The therapy selected by the students would be minimally effective at best, potentially detrimental to the patient at worst.

Reflecting on this experience, are the students at fault for not determining the patient’s wheezing to be cardiac in origin? Prior learning at the primary care paramedic level focused on treating wheezing as a symptom. Little focus was given to other potential causes of wheezing and treatment plans had a linear approach. Wheezing at that level is an automatic indication for nebulizer therapy.

The flaw lies not in a lack of critical thinking, because there was no room for the students to critically think. The assessment revealed wheezing, the students presumed that it was caused by bronchospasm, and then followed the appropriate protocol. The issue is that the students lacked enough background knowledge to understand the anatomy and physiology of the lungs and the pathophysiology of cardiac wheezing. A critical thinker with this background knowledge would have been able to determine the cause of the wheezing, weigh the benefits of available treatments and choose to initiate or withhold treatments based on the information given to them.

The Next Step

Critical thinking is not something that one can just begin to do. It is a skill that must first be taught, developed over time and regularly maintained. It is a combination of traits that one must possess and processes that must be developed and followed. A critical thinker must be sufficiently open-minded to other ideas and be willing to challenge current knowledge and experience.

This skill should be introduced at the earliest level possible, to benefit practitioners from the beginning of their career. Alongside critical thinking, a foundation of strong clinical knowledge must be present to allow for effective decisions to be made.

1. EMSWorld. Beyond the Basics: The Art of Critical Thinking Part 1 [Internet]. Emsworld.com; April 2008 [cited 2020 Jul 21]. Available from: https://www.emsworld.com/article/10321160/beyond-basics-art-critical-thinking-part-1 .

2. EMS1. EMS 2.0: Critical Thinking in Prehospital Training [Internet] EMS1.com; Oct 2009 [cited 2020 Jul 21]. Available from: https://www.ems1.com/ems-products/education/articles/ems-20-critical-thinking-in-prehospital-training-eCjskymt7gQYBFLe/ .  

3. JEMS. Critical Thinking: Part 1 [Internet]. JEMS.com; May 2017 [cited 2020 Jul 21]. Available from: https://www.jems.com/2017/05/15/critical-thinking-part-one/ .

4. JEMS. Critical Thinking: Part 2 [Internet]. JEMS.com; May 2017 [cited 2020 Jul 21]. Available from: https://www.jems.com/2017/05/15/critical-thinking-part-two/ .

5. EMS1. 5 Critical Thinking Skills Crucial to EMS Professional Development [Internet]. EMS1.com; August 2017 [cited 2020 Jul 21]. Available from: https://www.ems1.com/ems-management/articles/5-critical-thinking-skills-crucial-to-ems-professional-development-fQIz2bctBpYHktUP/ . 

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  • Published: 20 March 2023

Thinking more wisely: using the Socratic method to develop critical thinking skills amongst healthcare students

  • Yueh-Ren Ho 1 , 2 ,
  • Bao-Yu Chen 3 &
  • Chien-Ming Li 2 , 4  

BMC Medical Education volume  23 , Article number:  173 ( 2023 ) Cite this article

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In medicine, critical thinking is required for managing and tolerating medical uncertainty, as well as solving professional problems and treating diseases. However, the core of Confucianism, teacher-centered and exam-oriented settings in middle and high school education may pose challenges to developing critical thinking in Han Chinese or Taiwanese students. Students may be adversely affected by these pedagogies since student-centered settings were more effective in stimulating their critical and reflective thinking, as well as a sense of responsibility, in the ever-changing world. Therefore, guiding students with less stable foundations of critical thinking might require a different approach. A review article highlighted the potential utility of the Socratic method as a tool for teaching critical thinking in the healthcare field. The method involves posing a series of questions to students. More importantly, medical students and residents in clinical teaching are familiar with the method. Almost all healthcare students must complete a biochemistry laboratory course as part of their basic science training. Thus, we aimed to train students to develop critical thinking in the biochemistry laboratory course by using learning sheets and teacher guidance based on the Socratic method and questioning.

We recruited second-year students from a medical school, of whom 32 had medical science and biotechnology majors (MSB), 27 had pharmaceutical science majors (PS), and 85 were medical undergraduate (MU) students. An exercise in critical thinking was conducted during a biochemistry laboratory course, which consisted of five different biochemical experiments, along with learning sheets that contained three or four critical thinking questions. Then, the teacher evaluated the students’ ability to think critically based on nine intellectual dimensions (clarity, accuracy, precision, relevance, depth, breadth, logic, fairness, and significance) based on the universal intellectual standards developed by Prof. Linda Elder and Richard Paul. In the following analysis, regression models and multivariate analysis were used to determine how students improved over time, and trajectory analysis were carried out in order to observe the trends in students’ critical thinking skills construction.

Clarity and logic dimensions were identified as the key elements to facilitate the development of critical thinking skills through learning sheets and teacher guidance in students across all three different healthcare majors. The results showed that metacognitive monitoring via Socratic questioning learning sheets have demonstrated potential encourage students to develop critical thinking skills in all dimensions. Another unique contribution of current study was present the heterogeneous learning patterns and progress trajectories of clarity and logic dimensions within classes.

Using the Socratic learning model could effectively develop students’ critical thinking skills so they can more effectively care for their patients.

Peer Review reports

Introduction

Emerging trends in information technology requires that the new generation of medical students become critical thinkers [ 1 ]. The General Medical Council (GMC) of the United Kingdom encourages teachers to facilitate the acquisition of critical thinking skills by students in the medical and health professions [ 2 ]. Decades of research have proven that critical thinkers can present dispositions like flexibility, persistence, and willingness when faced with a range of tasks; they display meta-cognitive monitoring and a willingness to self-correct to seek long-term consensus[ 3 ]. Although, critical thinking is constructed from childhood in most Western countries and are valued by higher education as a necessary skill for coping with society [ 4 ]. However, critical thinking constructing and teaching has attracted little attention in Eastern education systems until recently [ 5 , 6 ].

Aside from the development of critical thinking skills is a key component of educational systems, recent educational philosophy also emphasizes both thinking processes as well as metacognitive integration skills [ 7 ]. Metacognitive monitoring includes making ease-of-learning judgments (i.e., processing fluency and beliefs), judgments of learning, feeling-of-knowing judgments (i.e., assessing the familiarity of the cue and the question itself or the domain of the question), and having confidence in the retrieved answers [ 8 , 9 ]. It is an adaptive skill of personal insight that health-profession students need to succeed in the rapidly changing and challenging healthcare industry [ 2 , 10 ]. Despite this, higher education curriculum does not emphasize on teaching these skills [ 7 ]. Additionally, any attempts to change the standards in higher education are generally met with resistance and challenges since they are require to encourage teachers to create new curriculum and change the current teaching content by researchers in current study who have more than 40 years’ teaching experience observaions. Healthcare curriculum, in general, remains conservative; Taiwan is not an exception.

Critical thinking is a fundamental component of innovative thinking and has thus become the fundamental skill for cultivating innovative talents in Western education [ 11 ]. Western scholars have asserted that teaching critical thinking should start at an early age and that its foundations should be laid in elementary and secondary schools. There are many ways to define critical thinking. A leading educational expert, Prof. Dewey, defined critical thinking as inclusive of reflective thinking and argued that the thinking process should also be taken as one of the objectives of education [ 12 ]. There are a few general dispositions that an ideal critical thinker would present according to Prof. Ennis’ observation of the constitutive abilities, such as (1) provide a clear statement of the conclusion or question; (2) provide clear reasons and be specific about their relationships with each other; (3) try to be well informed; (4) always seek and use credible sources, observations and mention them frequently; (5) consider the entire situation; (6) be mindful of the context’s primary concern; (7) be aware of alternative options; (8) be open-minded toward other points of view and refrain from making a judgment when there are insufficient evidence and reasons; (9) be willing to change your position when sufficient evidence and reasons support it; (10) seek as much precision as the nature of the subject admits; (11) whenever possible, seek the truth, and more broadly, strive to “get it right”; and (12) utilize their critical thinking abilities and dispositions [ 13 , 14 , 15 , 16 ]. In the eyes of Profs. Dewey and Ennis, critical thinking is a process of careful thought and reflection before a decision is made [ 17 ].

Nevertheless, the measurement or evaluation of critical thinking skills and abilities does not seem easy. Based on another perspective on critical thinking, intellectual standards are evolving [ 18 ]. According to Profs. Elder and Paul, critical thinking is the ability to use the most appropriate reasoning in any situation [ 18 ]. To evaluate these abilities, they established nine dimensions of critical thinking to represent different aspects of critical thinking: clarity, accuracy, precision, relevance, depth, breadth, logic, significance, and fairness [ 18 ]. As Profs. Elder and Paul concluded, those who possess discipline and critical thinking skills would make use of intellectual standards every day; thus, people should target these standards when they ask questions during the thinking process [ 18 , 19 ]. As a result of teachers’ regular introduction of the tools of critical thinking in their classrooms, the Socratic questioning and discussions become more productive and disciplined, thereby enabling students to realize the significance of questioning during the learning process [ 20 , 21 , 22 ].

According to a review article, teaching critical thinking to healthcare students (primarily medical and pharmacy students) through Socratic methods is more effective in developing critical thinking for a number of reasons [ 23 ]. In particular, Socratic questioning provides students with the opportunity to justify their own preconceived beliefs and thoughts after a series of specific, targeted inquiries [ 24 ]. Using Socratic questioning can also assist healthcare students, interns, or residents in thinking critically by understanding the “deep structure” of the question, i.e., deconstructing the question and understanding its true meaning [ 23 ]. The effectiveness of Socratic questioning lies in ascertaining the current knowledge of the students [ 25 ] and establishing a foundation for teaching at their level [ 26 ]. The teacher can accomplish this probing by asking progressively more challenging questions until the limits of the students’ knowledge are discovered [ 25 , 27 , 28 ], as well as by allowing students to express their existing knowledge, which in turn will allow them to synthesize new knowledge [ 26 ], and the dialogue represents the Socratic method [ 29 ]. Alternatively, a critical thinker is more likely to engage in certain established metacognitive strategies under the Socratic paradigm and/or channel the intellectual dimensions of critical thinking [ 17 ].

Unfortunately, Han Chinese students have struggled with learning critical thinking, which is thought to be part of their characterological profile [ 30 ]. This struggle has been faced by students studying abroad [ 11 ] and in students enrolled in the Han Chinese education system, which mainly cultivates Confucianism [ 31 ]. There are at least two types of problems with developing critical thinking in Han Chinese or Taiwanese education. The first involves the core of Confucianism, where foreign teachers have tried to promote critical thinking in elementary and high schools but sensed ethical concerns from the students who refused to participate. This is likely because if they chose to participate, they would have felt obligated to express disagreement and negative feelings to the instructor. The Han Chinese culture values harmony and “not losing face,” emphasizing a holistic perspective and collective good. Thus, students would feel uncomfortable because disagreeing with someone’s opinion in public is consciously or often avoided [ 30 ]. Therefore, encouraging the student to participate in healthy discussions and respectfully challenge their teachers is the starting point for promoting critical thinking in students enrolled in the Han Chinese educational system.

Second, in the Western education approach, learners take an active role in and are responsible for their learning process. On the contrary, the Han Chinese and Taiwan education systems are teacher-centered and exam-oriented; students are expected to follow their teachers’ instructions and perform well in class. More importantly, the textbook or teacher-centered framework lacks half of Ennis’s twelve constitutive abilities for critical thinking [ 13 , 14 , 15 ], such as judging the credibility of a source, observing and judging observation reports, drawing explanatory conclusions (including hypotheses), making and judging value judgments, and attributing unstated assumptions. As a result, Han Chinese students may find it difficult to develop critical thinking skills and present key traits and dispositions that are indicative of an ideal critical thinker. Hence, guiding and evaluating critical thinking in students might not be implemented through the same approach in Eastern educational circumstances as in the West. By understanding the difficulties that Han Chinese students face in developing critical thinking, the current study aims to design a set of critical thinking models that are suitable for Han Chinese students as a starting point for reform teaching.

Research questions, hypotheses and objectives

Research has shown that the laboratory class is not just limited to a step-wise approach to experimentation. It also allows students to develop their critical thinking skills by repeatedly engaging a simple learning framework [ 32 ]. To explore this further, the current study’s primary purpose is to use Socratic questioning in a biochemistry laboratory course with specifically designed learning sheets and feedback from teacher to guide students to improve their critical thinking skills. The learning sheets were evaluated following the universal intellectual standards for critical thinking developed by Prof. Elder and Paul [ 19 , 33 ]. For this study, we hypothesized that students with different healthcare majors might present different improvement trajectories in their intellectual dimensions according to the years of teaching observations in the three healthcare majors. Based on the research and rationale described above, the intervention effect of Socratic questioning in a biochemistry laboratory course was hypothesized as follows (see Fig.  1 ):

Pre-intervention critical thinking abilities are different amongst students of different healthcare majors, especially in each intellectual dimension (H1a). Post-intervention critical thinking abilities would develop in students from each healthcare major after using the Socratic method (H1b).

Critical thinking abilities differs significantly between pre- and post-assessments of the intellectual dimensions of students with the three different healthcare majors (H2).

After clarifying the relation of Socratic method interventions in the class, we aim to scrutinize the trajectories of students between majors further to understand the learning style in class (Aim 1). Furthermore, we also aim to identify the key intellectual dimensions that could lead to an overall improvement in the critical thinking of students in each major (Aim 2). Additionally, we observed improvement trajectories of specific intellectual dimensions within major (Aim 3).

figure 1

Socratic method framework and structure of the research hypotheses behind the biochemistry laboratory course

Literature review

Critical thinking engagement in the eastern and western medical education.

Over the last decade, medical education has been undergoing a variety of approaches for effectiveness teaching and transformation [ 34 ]. Many paradigms of active teaching/learning methodologies have been adopted in both Eastern and Western medical education systems, some of which are used partially (actual or conceptual similar) Socratic questioning to challenge students’ critical thinking. In this regard, the primary philosophy of case-based learning (CBL) established in the 1920s by Harvard Medical School is to guide students to apply their acquired knowledge base via critical thinking to make clinical decisions to solve the problems that they may encounter in the healthcare environment [ 35 ]. A meta-analysis study of China’s dental education reported that the CBL was a practical pedagogical method across the Chinese dental education system [ 36 ]. The results showed that the CBL method significantly increased knowledge scores, skill scores, comprehensive ability scores, and teaching satisfaction compared with the traditional lecture-based learning (LBL) mode in 2,356 dental students. Hence, there is an urgent need to change the traditional didactic lecture or teacher-centered classroom setting in which students are passive listeners instead of active participants.

Healthcare professionals are also required to solve complex problems and efficiently integrate didactic preclinical knowledge into actual clinical application in patient care [ 35 ]. On the other hand, the design thinking process may enhance both creativity and innovation so that healthcare professionals can respond to clinical problems effectively [ 37 , 38 ]. Problem-based learning (PBL) is a pedagogical approach widely accepted in medical education. It promotes active learning and results in better outcomes [ 39 , 40 , 41 ]. PBL focuses on active lifelong learning by triggering problems, directing student focus, and facilitating tutor involvement [ 39 , 42 , 43 , 44 ]. However, it is noteworthy that some hybrid PBL models have become less effective over time, as well as less aligned with the intended philosophy of student-centered learning [ 45 ]. Another alternative blended learning approach of PBL is team-based learning (TBL), which allows medical educators to provide students with pre-class work, in-class initial tests with immediate feedback, and real clinical problem-solving activities [ 46 ]. In the year-one studies of the Sydney Medical Program, a greater level of engagement in learning, a deeper understanding of concepts, and a sense of responsibility were shown among the medical students working in a TBL setting than among those in a PBL setting [ 47 , 48 ].

Medical educators face another significant challenge with the millennial generation, which has ubiquitous information technology access throughout its education. Thus, it is extremely important to improve students’ motivation to learn through hands-on instruction or teacher–student interaction and then stimulate students’ thinking and learning. In recent years, gamification has been successfully integrated into medical and scientific endeavors, enhancing motivation, participation, and time commitment across a variety of settings [ 49 , 50 , 51 ]. Another healthcare curriculum reform to stimulate active learning is flipped classroom (FC), which assigns learners didactic material, creating opportunities of longitudinal and interprofessional learning experiences for students during class participation [ 52 ] to encourage extracurricular learning, such as critical thinking. As part of the FC model, medical educators also develop formative and diagnostic assessments to identify learning gaps. According to these teaching modules, encouraging students to participate, emphasizing their learning, and observing their development trajectory are the core ideas in recent educational designs [ 53 ].

Although most of above-mentioned studies have been performed in the Eastern and Western education systems, however, without mentioning the differences between cultures and learning styles. Most importantly, the cultivation and foundations of critical thinking neglect the fact that Eastern and Western education systems emerged from very different learning and thinking patterns. Moreover, clinical reasoning and decision achievements depend on established critical thinking skills, therefore, it becomes more important to construct critical thinking early and comprehensively [ 54 ]. While Han Chinese students are not familiar with the core of critical thinking, the most effective approach to teaching critical thinking is still a highly debated topic in medical schools. Taken Taiwan medical education as an example, most clinical courses focuses on professional skills, problem solving, and disease treatment rather than construct critical mindset and metacognitive skills. Education strategies often emphasize the outcome while neglecting the process. Nevertheless, medical educators should also emphasize the process of forming students’ critical thinking when instructing and guiding them in this regard. Consequently, using metacognitive monitoring to enhance critical thinking in healthcare education would be appropriate, especially for Han Chinese systems with a Confucianist outlook. Thus, critical thinking via metacognitive monitoring is important in healthcare education, especially in Han Chinese systems with a Confucianist background.

Proficiency in the art of socratic questioning to enhance students’ critical thinking

Socratic questioning is a disciplined method of engaging in content-driven discourse that can be applied for various purposes: analyzing concepts, finding out the truth, examining assumptions, uncovering assumptions, understanding concepts, distinguishing knowledge from ignorance, and following the logical implications of thought. The scholars who established the intellectual standards of critical thinking have consistently indicated that “The key to distinguishing it from other types of questioning is that the Socratic questioning is systemic, disciplined, and deep and usually focus on foundational concepts, principles, theories, issues, or problems [ 20 , 21 , 22 ].” In short, the Socratic method is a questioning method that stimulates personal understanding. More importantly, the core principle of learning from the unknown fits best within healthcare environments.

Numerous studies have consistently urged teachers to develop Socratic dialogue in their classrooms, regardless of their learning stages and situations [ 55 , 56 , 57 ]. Using enhancement exercises in an elementary school, a study introduced a Socratic questioning strategy to provide guidance and hints to students so that they could think more deeply about an issue or problem before sharing their thoughts [ 55 ]. The lecturer of a speech course in higher education demonstrated how Socratic questioning could help students learn when confronted with a series of questions [ 56 ]. The process improves students’ ability to ask and answer questions and helps them overcome some obstacles related to their lack of self-confidence. In the book Socratic circles: Fostering critical and creative thinking in middle and high school , Dr. Matt Copeland stated that, in middle and high schools, teachers must facilitate discussions by asking questions [ 58 ]. Furthermore, this method could be applied not only to elementary school, middle school, high school but also to higher education classes [ 59 ]. During the Covid-19 pandemic, synchronous discussions in online learning demonstrated that the Socratic questioning strategy successfully improves students’ critical thinking skills [ 57 ].

The incorporation of Socratic questioning in healthcare education curriculum is under development, including for general medical education [ 60 ], medical [ 61 ], pharmacy [ 54 , 62 ], and nursing students [ 63 ]. A review article of revisiting the Socratic method as a tool for teaching critical thinking in healthcare professions revels few advantages of Socratic questioning [ 23 ]. Three type of Socratic questions were mention and could commonly used in different clinical situations [ 23 ], such as procedure question would use in those with correct answers (e.g., Which of the following medications has antithrombotic function? ); preference question can apply in those with no correct answers (e.g., What type of consultation is most suitable for this patient? ); judgment question would be the most challenge critical thinking within a Socratic paradigm by integrating different domain knowledge and skills (e.g., Does this patient require antibiotic treatment? ). It is necessary to apply and analyze information in a logical manner as well as self-regulate and use critical thinking in order to achieve the best outcome for patients. For medical doctors, pharmacists or clinical laboratory technicians to provide high quality health care across all disciplines, critical thinking is inherently required.

In medical school, the emphasis is laid on training learners in meta-capabilities, such as self-driven pattern recognition, ideally as part of an apprenticeship under the supervision of an expert diagnostician [ 61 ]. An in-depth study of the current trends in developing critical thinking amongst medical students demonstrated the use of dialogue for proper questioning and how it directs the learner’s thinking [ 64 ]. Moreover, another study confirmed that critical thinking occurs only when students are motivated and challenged to engage in higher-level thought processes [ 65 ]. In the pharmacy classroom, educators can play a significant role in influencing their students’ mindsets.  Growth mindsets can be cultivated through the creation of an environment that encourages it. [ 62 ]. The Socratic questioning method can facilitate critical thinking in nursing education. One study showed that problem solving using critical thinking skills can be facilitated in both educational and practice settings by using Socratic inquiry [ 63 ].

The Socratic method has been adapted in different ways to different domains, but it has become closely associated with many areas, such as basic scientific thinking training, legal dialectical guidance, and clinical teaching. Some adaptations are helpful, some are not. The adaptations can be looked at through reasoning-focused lenses with varying degrees of magnification —a high-magnification adaptation rigorously and precisely tracks or guides the path of reasoning. Thus, how to use the Socratic method to direct students onto the path of critical thinking with appropriate guidance, but not revealing answers becomes an art that tests instructors’ teaching experience and proficiency in questioning.

Critical thinking and reflection exercises in the laboratory course

Medical schools have increasingly encouraged students to become life-long, self-directed learners because of the continual changes in the evidence-based healthcare environment. Science is often applied in everyday life, including translating knowledge from scholarly fields [ 66 ]. However, there is a vast gap between what is taught in medical schools and what is actually required in practice has increasingly widened in this information era. The majority of healthcare professionals are not considered to be real scientists. [ 2 ]. Nevertheless, they need to know how to apply scientific knowledge to their practice. Therefore, a science curriculum in medical school, such as a biochemistry laboratory course, should provide an opportunity to learn scientific methods and conceptual frameworks. It should also promote critical reasoning, providing healthcare students with problem-solving skills.

Medical educators need to accept that critical thinking is important for healthcare students and know how to teach it effectively [ 67 ]. Medical educators are now faced with a dilemma: should they develop a new course or adapt old course to develop critical thinking skills?  An effective learning model should promote and stimulate students’ development of such skills [ 67 ]. One of the most common compulsory courses for healthcare students is the biochemistry laboratory course [ 68 , 69 ]. These courses are specifically designed to introduce students to prescribed experiments, requiring them to complete stepwise protocols by themselves [ 68 , 70 ]. The students are expected to understand the concepts behind the methods, procedures, and assays. However, this type of curriculum construction often fails to provide students with adequate opportunities to monitor their critical thinking and thus reduces the chances of developing problem-solving skills [ 70 ]. In order to provide students with more opportunities to think critically, previous studies have also adapted laboratory, basic science, and science fusion courses to help students develop critical thinking skills [ 67 , 68 , 71 , 72 , 73 ].

Several studies have demonstrated that students need critical thinking skills to interpret data and formulate arguments. Thus, science education, particularly in the laboratory setting, is designed to teach quantitative critical thinking (i.e. interpretation and critical evaluation of statistical reports), but the evidence has suggested that this is seldom, if ever, achieved [ 74 , 75 , 76 , 77 , 78 , 79 ]. By providing multiple opportunities for students to participate in critical thinking in the physics laboratory classes at Stanford University, scholars engaged the students to improve the experiment and modify the model repeatedly [ 32 ]. Additionally, a simple learning framework using decision-making cycles and demonstrating experts’ critical thinking significantly improved students’ critical thinking. We thus argue that students should engage in critical thinking exercises with repeated comparisons, decisions, and teacher guidance that are meant to construct their critical thinking in each of their disciplines.

Participants

This research was conducted during the 2017–2018 academic year. The participants were second-year students in the College of Medicine at the National Cheng Kung University (NCKU) of Taiwan. A total of 144 students participated in this study, of whom 32 had medical science and biotechnology majors (hereafter, MSB), 27 had pharmaceutical science majors (hereafter, PS), and 85 were medical undergraduate (hereafter, MU) students. The biochemistry laboratory course was compulsory for these three majors.

For each biochemistry laboratory class, the teacher assembled five to six groups of four to five students each. The course contained five different biochemical experiments: (1) Plasmid DNA (deoxyribonucleic acid) extraction and purification; (2) restriction enzyme digestion and electrophoresis of plasmid DNA; (3) polymerase chain reaction (PCR) amplification of plasmid DNA; (4) recombinant protein expression in Escherichia coli ; and (5) quantification of recombinant protein. The experimental learning sheets included three or four critical thinking questions (Table S1 ), encouraging students to explore experimental principles and alternative explanations further. To facilitate discussion, students were organized into small groups of four to five students seated around a single table, discussing and answering the questions. At this time, the students would pen down their first answers to the critical thinking questions, and the teacher would grade them based on the universal intellectual standards (learning sheets, first evaluation).

Furthermore, according to the students’ answers, the teacher offered a response by asking more questions according to the Socratic method to encourage students to think deeper rather than provide the correct answers. At the following week’s class, the teacher returned the learning sheet and supervised the ongoing activity, clarifying any questions raised by students and encouraging them to re-discuss and re-answer the critical thinking questions according to the teacher’s suggestions. The objective was to create a highly interactive environment to engage students in learning the relevant principles of each laboratory, including troubleshooting experiments and formulating critical concepts and skills. After the discussion, the teacher reexamined the students’ responses and assessed them based on the universal intellectual standards for subsequent grading (learning sheets, second evaluation).

The biochemistry laboratory courses and the Socratic method in current study are performed and taught by a senior biochemistry teacher (PhD in Institute of Basic Medical Science, NCKU) who has 40 years teaching experience. The teacher has long focused on teaching critical thinking skills to students, and also offers four senior clinical case related courses by practicing the Socratic method, such as clinical concept, critical thinking in medicine, clinical reasoning and special topics in clinical reasoning with more than 20 years of experience. Therefore, in the course, teacher will often ask a series of questions for students to think about the relevance of biochemical science and clinical practice.

Assessment development

The research team designed the learning sheets to guide discussion on the key issues concerning five biochemical experiments. The learning sheets were assessed according to the universal intellectual standards for critical thinking [ 33 ]. However, the assessment was adapted to include nine intellectual dimensions to assess student reasoning [ 19 , 33 ]: clarity, accuracy, precision, relevance, depth, breadth, logic, fairness, and significance (Table S2 ). Each dimension was evaluated using a binary score (0 = does not present the skill; 1 = presents the skill) for each question in the learning sheets for both the first and second evaluations. The students received the teacher’s guidance following the first evaluation, providing them with the opportunity to reconsider their reasoning and revise their answers. Our goal was to improve our students’ learning by stimulating the teaching process; at the same time, we were committed to allowing students to speak freely so that we could more effectively facilitate prospective discussions. Thus, the critical thinking scoring system based on nine intellectual dimensions was only for the purpose of the research, without consequences on students’ study progress. In this regard, students were not able to know their intellectual scores. As a result, their course grades were not determined by the learning sheets; rather, they were determined by the general operation, experiment report, and the learning attitude demonstrated during the experiments.

Statistical analysis

Descriptive statistics and variable tests.

We calculated the differences between the performance means for the first and second evaluations using paired t -tests. The mean differences between the students from the three majors were analyzed using a one-way analysis of variance (ANOVA). For the improvement slope for each universal intellectual dimension, we used the second evaluation scores of each experiment as the point with which to construct a quadratic equation curve in one variable (dimension) and then access the slope to represent the students’ improvement. The higher the slope score, the greater the students’ progress on that dimension.

Multivariate analysis

We used traditional analytical methods to observe and analyze the students’ improvement in the five experiments. Data from the second evaluation scores of each experiment served as the multi-time point measurement data. The Cox regression model for multivariate analysis was used to investigate the effect of several variables upon the time during which a specified outcome happened [ 80 ]. For each dimension, the model’s outcome determined that a student’s improvement slope was defined as minor progress if it was lower than the improvement slopes of their peers in the same major overall. However, if the student’s improvement slope was higher than the overall progress intercept of their peers, then it was defined as greater progress. The Cox regression models’ outcomes for each dimension were divided into two groups: minor and more progress. For this model’s outcome, (1) we calculated all dimensions’ slopes mean from each major (MSB: 0.369; PS: 0.405; MU: 0.401); (2) then compared the mean slope of the individual students with the mean slope of major; (3) if the student’s individual improvement slope was lower than mean slope of major, then defined as minor progress; if the student’s individual improvement slope was higher than mean slope of major, then defined as greater progress. From the analysis at this point, we understood that teacher could help students from different majors develop the different dimensions of critical thinking with the use of Socratic methods and simple repeated thinking framework practice. Additionally, we wanted to represent the improvement of intellectual dimensions between the students of different majors and their heterogeneity in critical thinking.

Dimension identification and comparison

To understand which intellectual dimensions were most representative of student improvement across majors, the analysis was divided into three sections: (1) to identify the progress percentage of all nine intellectual dimensions; (2) to identify the progress percentage of statistically significant intellectual dimensions; (3) to compare the differences among all nine dimensions, the significant dimensions, and the reciprocal dimensions. This analysis offered a better understanding of what dimensions represented the overall improvement of students’ critical thinking. Our first step was to calculate the percentage of improvement for each experiment by determining the results of the first and second evaluations for each intellectual dimension. Second, we took average percentage of improvements for each dimension. Finally, we used Student’s t -test to compare the differences among the average of all nine dimensions, the significant dimensions, and the reciprocal dimensions.

Trajectory analysis

In this study, we also hypothesized that each student’s learning and progress trajectories were heterogeneous across different majors. Depending on the major, there may also be differences between students in the same class. To focus our observations on the students’ use of the clarity and logic dimensions, we used a trajectory-tracking analysis [ 81 , 82 ] and categorized the students into two groups based on the participants’ improvement levels within the same major.

Descriptive data

We recruited 144 second-year students from three majors in the College of Medicine, among which 32 were MSB, 27 were PS, and 85 were MU students. All participants’ first and second evaluations were compared in all five biochemistry experiments. The statistically significant between-group differences in the mean initial evaluation results for each dimension are presented in Table  1 .

Overall improvement from the initial to second evaluations throughout the five experiments (H1, H2, and Aim 1)

Table  1 presents the mean results of the first and second evaluations; the five experiments exhibited statistically significant differences ( p  < 0.05) across all study groups and dimensions. More detailed analyses revealed significant differences in performance in the second evaluation between the groups after all five biochemistry experiments in the clarity ( p  = 0.0019), depth ( p  = 0.0097), breadth ( p  < 0.0001), logic ( p  = 0.0371), and significance ( p  = 0.0037) dimensions. However, for some of the dimensions (clarity, accuracy, precision, logic, and fairness), the initial evaluation results differ significantly between the MU and the MSB students, but this was not the case for the secondary evaluation results. The MSB students exhibited the best progress (2nd mean score minus 1st mean score) in the clarity dimension across all experiments. The PS students exhibited the best performance in the logic dimension ( p  < 0.05) in the second evaluation after the five experiments.

The results of the MSB students improved steeply in most dimensions in the five experiments, especially depth (slope: 0.472), logic (0.455), and clarity (0.410) (Table  2 ). Time had a stronger effect on several of the dimensions in the multivariate analysis, specifically clarity ( p  = 0.0012), relevance ( p  = 0.0007), and logic ( p  < 0.0001). By contrast, the PS students showed a significant overall improvement in the clarity (slope: 0.212, p  < 0.0001), accuracy (0.539, p  = 0.0063), precision (0.381, p  = 0.0085), relevance (0.216, p  < 0.0001), breadth (0.426, p  = 0.0045), and logic (0.515, p  = 0.0027) dimensions over the observation period (Table  3 ). Finally, the MU students showed a significant overall improvement in six dimensions: clarity (slope: 0.277, p  < 0.0001), accuracy (0.520, p  = 0.0003), depth (0.459, p  = 0.0092), breadth (0.356, p  = 0.0100), logic (0.544, p  = 0.0190), and significance (0.327, p  = 0.0225) (Table  4 ).

Trajectory tracking of the overall, significant, and reciprocal dimensions (Aim 2 and Aim 3)

Figure  2 a illustrates the overall improvement of students across the three majors in all nine dimensions, as assessed via trajectory analysis. The trajectory-tracking algorithm revealed that the significant dimensions for each group were as follows: MSB students—clarity, relevance, and logic; PS students—clarity, accuracy, precision, relevance, breadth, and logic; and MU students—clarity, accuracy, depth, breadth, logic, and significance (Tables  2 , 3 and 4 ; Fig.  2 b). The comparison of each group’s average percentage of improvement between the nine dimensions, the significant dimensions, and the reciprocal dimensions (clarity and logic) is summarized in Fig.  2 c. Figure  2 d–i depicts the students’ improvement in clarity and logic within the different majors using group-based trajectory modeling.

figure 2

Overall improvement comparison between the students of three majors using a trajectory-tracking analysis approach . ( a ) The mean evaluation scores from the second evaluation minus those from the first evaluation for the nine dimensions were considered an improvement. They were converted to percentages to compare them to the performance in the first evaluation. ( b ) The mean evaluation scores from the second evaluation minus those from the first evaluation for the significant dimensions (within the students of each major, Tables  2 – 4 ) were considered to represent improvement and were converted to percentages to compare them to the performance in the first evaluation. ( c ) Comparison of the average percentage improvement among all nine dimensions, the significant dimensions, and the reciprocal dimensions (i.e., clarity and logic). ( d ) Trajectory analysis to assess the progress of the two subgroups of medical laboratory science and biotechnology students in the clarity dimension. ( e ) Trajectory analysis to assess the progress of the two subgroups of pharmaceutical students in the clarity dimension. ( f ) Trajectory analysis to assess the progress of the two subgroups of undergraduate medical students in the clarity dimension. ( g ) Trajectory analysis to identify the progress of the two subgroups of medical laboratory science and biotechnology students in the logic dimension. ( h ) Trajectory analysis to assess the progress of the two subgroups of pharmaceutical students in the logic dimension. ( i ) Trajectory analysis to assess the progress of the two subgroups of undergraduate medical students in the logic dimension

Empirical contributions

The Han Chinese educational system relies on the passive transmission of knowledge, as evidenced by the years of preparation by students’ through paper-based exams. By adopting this approach during teaching and learning, students do not develop a critical thinking mindset. Our experience has shown that when we encounter first-year students who have just graduated from high school, their previous education failed to develop critical thinking skills. Many foreign and Western teachers have the same experience when they encounter Asian students studying abroad for the first time. Thus, this research aims to provide clinical teachers with guidance on reducing the blind spots that students face when introduced to critical thinking. Moreover, this research aims to provide teachers with a simple teaching model and structure to guide students with less stable foundations in critical thinking. For the teaching structure and process, please refer to the procedure paragraph in the methods section and the teaching flow chart in Fig.  1 . Furthermore, the scoring system shown in the assessment development paragraph in the methods, as well as the scoring rubric is presented in Table S1 .

To our knowledge, this is the first study that uses the Socratic method and the universal intellectual standards to assess and improve critical thinking skills in biochemistry laboratory courses across different healthcare majors. We also used a novel design for teaching critical thinking, with multi-timepoint assessments and trajectory-tracking analysis to observe the students’ process and the improvement intheir critical thinking. This Socratic method, combined with critical thinking-based learning sheets, significantly improved the students’ critical thinking in all nine dimensions of the universal intellectual standards, according to the first and second evaluations conducted in each of the five sessions. Another unique contribution of this study is that it analyzed the progression results at multiple time points in the critical thinking performance of students across different majors. According to the results of comparing the average percentage improvement between all nine dimensions, the significant and reciprocal dimensions (i.e., clarity and logic) do not significantly differ from each other statistically speaking. By reducing the nine intellectual dimensions scoring system, medical educators can focus more on establishing clarity and logic skills in students. In sum, our most important finding was the identification of the clarity and logic dimensions as key elements that facilitate the development of critical thinking skills via the Socratic method in students across three different healthcare majors.

The trajectories of outcomes for students of medical science and biotechnology majors

Understanding what we learn has been identified as the starting point in the professional-development journey [ 2 ]. In principle, if thinking and decision making can be taught, educational intervention is possible. Nevertheless, for a science class like biochemistry, abductive reasoning requires a deep understanding of knowledge, and thinking must be inspired through stimulation.

In this study, the evaluation scores for MSB students did not improve significantly in almost any dimension at the beginning of the course. At first, most students felt uncomfortable with criticizing others, disagreeing with others, or challenging teacher’s knowledge and authority when they spoke their minds. Other MSB students believed that their ability to find answers and make decisions was inadequate and expected the teacher to provide the correct answers. However, preclinical medical technologists must gradually develop their critical thinking skills. Thus, the teacher provided critical thinking cues during the class and monitored the group discussions.

On the other hand, teachers must encourage these types of students, enabling them to accomplish simpler learning goals by providing them with easier-to-attempt clues. The joy of discovering answers on their own rather than the frustration of not achieving high goals should be encouraged. This coaching process improved the MSB students’ willingness to think and explore, leading to greater relevance and breadth of coverage.

The teacher used generation, conceptualization, optimization, and implementation [ 33 ] with the Socratic method to stimulate critical thinking in a four-step cycle in the five experiments. When the spontaneous discussion started in the generation phase, they tried to clarify their knowledge of the theme and identify the problem from the learning sheet. The following step was to conceptualize the problem, and the students drafted all of the possibilities and problems. Teacher frequently asked the students, ‘ What are other possible reasons? ’ Finally, the teacher provided feedback to help the MSB students reach a proper solution and implement it. The teacher would also ask the students leading questions like ‘ What relevant theories can be confirmed more precisely? ’ These guiding processes sharpened their logic and helped them better understand what they had learned. In sum, the benefits of this process included an enhanced ability to think logically, clarification of questions and knowledge gaps, and improvements in the thought process about the theme discussed.

The steady improvement of critical thinking in the students of pharmaceutical science

Currently, pharmacists are seeing their roles and responsibilities shift to becoming patient counselors and educators on the rational use of medicine. Pharmacists are trained to focus on patient-centered care and resolve current and potential drug-related problems [ 83 , 84 ]. Critical thinking, clinical reasoning, and decision-making skills are needed to solve these problems. Nowadays, pharmacists are not just responsible for carrying out doctor’s orders, while there are always alternative treatment options available for them to recommend. Teacher therefore repeatedly emphasized the link between critical thinking and pharmacist practice and encouraged students to ask questions and find out the best alternative through Socratic method in the classroom.

During class, the PS students were required to exert considerable mental effort to conduct an inquiry to solve the learning sheet questions. Instead of providing students with clues or information to help them solve the problems, the teacher guided the PS students on how to seek the information they needed for themselves. The question for the PS students was be ‘ What are the possibly executable strategies? ’ The teacher also joined the students in discussion, using the Socratic method to stimulate critical thinking and draw out ideas and underlying suppositions. In high-quality cooperative argumentative dialogue, teacher should not direct or refer learning, nor should they ask students for the correct answers as in a traditional classroom. The hints that teacher would provide were more like ‘ The narrative explanation can be more precise. ’ Thus, asking high-quality questions and providing feedback also challenges the instructors’ teaching experience.

The PS students were guided not only toward the development of critical thinking skills but also toward solving problems using evidence-based knowledge and decision-making skills. The Socratic method process meets the student where they are on the educational spectrum and encourages and helps them advance. Using this method, the PS students engaged in student-to-student interaction to build knowledge as a group and individually. The course of five experiments conducted via the learning sheets improved many aspects of the students’ critical thinking, including their clarity, relevance, breadth, and logic. In sum, the abilities that they developed in the course should help them focus more on the possible outcomes of pharmacotherapy, medication surveillance, and proper communication and therefore improve the quality of their professional future.

The advanced construction of critical thinking skills in undergraduate medical students

In medical education, “ better thinking and learning skills grounded in understanding ” are recommended for future doctors [ 2 ]. Practicing medicine requires an ability to address current and future diseases using new diagnostic and therapeutic methods [ 10 ]. Therefore, problem solving is not the only core medical skill; the ability to deal with complex, insoluble health issues is also required [ 83 ]. In this domain, critical thinking skills have proven essential in tackling difficult, complex, interdisciplinary health problems [ 10 ].

In our study, the MU students began with high-performance scores in almost all dimensions. As a result, teachers needed to create a more challenging and thought-provoking learning environment to encourage them to think more broadly and deeply. Thus, the teacher would give students advice like ‘ Searching for more relevant information can increase the breadth of knowledge ’ and ‘ If the result is true, what is the relevant theory? ’ Most MU students were faster than other majors at defining and constructing critical thinking. However, another phenomenon often observed in the classroom was that the MU students were more reluctant to express their reasoning than the students of other majors. In other words, MU students were afraid to speak openly about their reasoning and thinking, probably due to the excessive pursuit of the correct answer. In sum, the course of five experiments conducted via the learning sheets enhanced abilities of clarity, accuracy, depth, breadth, logic, and significance in MU students.

Apart from providing structure for their critical thinking, as was done with the other preclinical students, the teacher guided the MU students to use advanced critical thinking skills by regularly analyze their thinking processes, reflecting on the decision-making and thinking process [ 84 ]. Researchers have suggested that reflective practice is key to successful medical professionalism [ 85 ] and humanism [ 86 , 87 ]; but more importantly, it may help medical professionals develop better physician–patient relationships [ 88 ]. Therefore, to advance the critical thinking experience of the MU students, teacher should encourage them to gather ideas, analyze, evaluate, and synthesize information. The teacher guided them to reflect on their plan and solve the questions on the learning sheets using their thoughts and words. These reflective practices could involve various biases in the thinking process and outcome, such as the base-rate fallacy, bias blind spot, or choice-supportive bias. The Socratic debate is a common way to model a complex thinking situation and may help teachers inspire students to become critical thinkers. MU students improved their abilities in the clarity, accuracy, depth, breadth, logic, and significance dimensions in the five experiments. This kind of training in thinking should help preclinical students constantly challenge and critically appraise evidence within their context, as well as their patients’ and their own belief and value systems.

Limitations

This study provides a model for developing a specific learning environment like a biochemistry laboratory class into one that will help students develop their critical thinking skills through inquiry. Our results have shown this method to be feasible and effective. However, there were a few limitations to this study. First, although it included students from three different majors, there was no interdisciplinary collaboration that would have simulated collaborations and communication among other healthcare professionals from different fields, as occurs in clinical practice. Introducing such collaboration may have produced more exciting and comprehensive ideas for solving the problems. Training in these professions is specialized to a considerable extent, so inter-professional collaboration should improve therapeutic outcomes and optimize patient care. Second, the original scoring system was time-consuming. However, one of our study objectives was to modify and reduce the nine intellectual dimensions scoring system into the clarity and logic dimensions. Based on the analysis in the current study, the clarity and logic dimensions were sufficient for monitoring the growth of students’ critical thinking.

The present curriculum innovation aimed to teach critical thinking skills to preclinical students in various medical majors using a Socratic questioning learning model instead of a cookbook approach to learning in laboratory courses. The development of problem-solving and critical thinking skills, in addition to process-related skills, in biochemistry laboratory courses supplements traditional curriculum in a helpful way. The curriculum innovation that we described and proposed may represent an incremental step forward for the discipline; it is a novel educational approach for promoting critical thinking skills, fostering an appreciation of the affective domain, and enabling reflective practice by using small-group processing skill instruction and one-on-one Socratic questioning. The current study results are based on training critical thinking skills that should enable students to engage in the “reflection-on-action” process, which might provide an additional bridge between basic medical knowledge and clinical practice. More importantly, reconstructive mental reviews may indirectly shape preclinical students’ future actions in the challenging healthcare industry characterized by uncertainty and novel circumstances.

Data Availability

Due to conditions on participant consent and other ethical restrictions, the datasets used and analysed in the current study are not publicly available. If you have any database data requirements, please contact the corresponding author of this study.

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Acknowledgements

The authors wish to thank Chi-Her Lin, MD for their encouragement and support in the writing of this manuscript, and Prof. Woei-Jer Chuang, Hung-Chi Cheng, Chang-Shi Chen, Po-Hsin J. Huang, Chien-hung Yu, and Wen-Tsan Chang for their help with the experimental design. Special thanks to Tanvi Gupta for her help with the improving reading fluency.

This work was supported by the Teaching Practice Research Program, Ministry of Education, Taiwan (Grant No: PMN1110350, PMN1100853, PMN1090364, PMN108075, PMN107018).

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Department of Biochemistry and Molecular Biology, College of Medicine, National Cheng Kung University, University Road No.1, East District 701, Tainan City, Taiwan (R.O.C.)

Yueh-Ren Ho

School of Medicine, College of Medicine, National Cheng Kung University, University Road No.1, East District 701, Tainan City, Taiwan (R.O.C.)

Yueh-Ren Ho & Chien-Ming Li

Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, University Road No.1, East District 701, Tainan City, Taiwan (R.O.C.)

Bao-Yu Chen

Division of Infectious Diseases, Department of Internal Medicine, Chi Mei Medical Center, Zhonghua Raod No.901, Yongkang District 710, Tainan City, Taiwan (R.O.C.)

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Contributions

Yueh-Ren Ho: substantially contributed to the conception, data curation, interpretation, drafting and critical revision of the paper. She has given final approval to the manuscript and agrees to be accountable for the work. Bao-Yu Chen: substantially contributed to the conception, formal analysis, methodology, visualization, and writing and editing the manuscript. Chien-Ming Li: substantially contributed to the conception, data curation, review and editing the manuscript.

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A Deep Dive into 10 Thought-Provoking Critical Thinking Exercises

A Deep Dive into 10 Thought-Provoking Critical Thinking Exercises | Future Education Magazine

Today, information bombards us from all directions, and the ability to think critically has become a paramount skill. Beyond the rote memorization of facts, critical thinking exercises involve the analysis, evaluation, and synthesis of information to make informed decisions. In this comprehensive guide, we’ll explore ten engaging and effective critical thinking exercises designed to enhance cognitive abilities, foster intellectual agility, and contribute to overall cognitive excellence.

List of Critical Thinking Exercises: 

1. socratic questioning: unlocking wisdom through dialogue.

A Deep Dive into 10 Thought-Provoking Critical Thinking Exercises | Future Education Magazine

The Socratic method, with its roots in ancient philosophy, serves as a foundational exercise for critical thinking. It involves posing open-ended questions stimulating thoughtful dialogue and exploring complex topics. The exercise encourages individuals to engage in structured discussions, challenging assumptions, and dissecting various perspectives on a chosen subject matter.

Exercise: Organize or participate in Socratic discussion groups where participants tackle topics ranging from ethical dilemmas to societal issues. The goal is to foster an environment where thoughtful questioning leads to a deeper understanding of the subject matter.

2. Brain Teasers and Puzzles: Nurturing Analytical Thinking

Solving puzzles, riddles, and brain teasers is a classic exercise for enhancing problem-solving skills and developing cognitive flexibility. Engaging in these activities challenges the mind, fostering creativity and adaptability.

Exercise: Dedicate regular time to solving Sudoku, crosswords, or logic puzzles. These exercises provide mental stimulation and improve memory, concentration, and logical reasoning.

3. Debate Club Participation: Sharpening Persuasive and Analytical Skills

Joining a debate club provides a platform to practice constructing persuasive arguments, critically evaluating opposing viewpoints, and refining communication skills. The exercise encourages individuals to think on their feet, respond to counterarguments, and strengthen their ability to convey ideas convincingly.

Exercise: Actively participate in structured debates on topics ranging from current affairs to philosophical dilemmas. This fosters the development of not only critical thinking but also effective communication.

4. Case Study Analysis: Applying Critical Thinking to Real-World Scenarios

A Deep Dive into 10 Thought-Provoking Critical Thinking Exercises | Future Education Magazine

Analyzing real or hypothetical case studies allows individuals to apply critical thinking exercises to assess situations and propose effective solutions. This exercise mimics the problem-solving demands of various professions and prepares individuals to think critically in real-world contexts.

Exercise: Review business case studies, legal scenarios, or medical cases, identifying key issues and recommending strategic approaches. This hands-on approach enhances decision-making skills.

5. Concept Mapping: Visualizing Complex Ideas for Better Understanding

Creating visual representations of ideas, relationships, and hierarchies through concept mapping enhances understanding and promotes analytical thinking. This exercise encourages individuals to see the interconnectedness of concepts and improves visual-spatial thinking.

Exercise: Utilize mind maps or concept maps to illustrate complex concepts or plan projects. This visual approach aids in organizing thoughts, identifying relationships between ideas, and enhancing overall comprehension.

6. Decision-Making Simulations: Learning Through Virtual Scenarios

Participation in decision-making simulations replicates real-world scenarios, encouraging thoughtful analysis and strategic thinking. This exercise allows individuals to make decisions within a controlled environment, experiencing the consequences of their choices.

Exercise: Explore online simulations or business strategy games that require strategic decision-making. These simulations provide a risk-free environment for learning and testing different decision-making approaches.

7. Read Diverse Perspectives: Broadening Horizons through Literature

Exposure to a variety of perspectives, cultures, and ideologies through literature and diverse media broadens understanding and encourages critical thinking. This exercise prompts individuals to consider alternative viewpoints and challenges preconceived notions.

Exercise: Read books, and articles, or watch documentaries from authors with differing viewpoints. This exposure to diverse perspectives fosters empathy, cultural awareness, and a more nuanced understanding of the world.

8. Critical Writing Exercises: Articulating Coherent Arguments

A Deep Dive into 10 Thought-Provoking Critical Thinking Exercises | Future Education Magazine

Developing analytical writing skills involves articulating coherent arguments and supporting them with evidence, fostering clarity and logical reasoning. This exercise enhances the ability to express complex thoughts in a structured and persuasive manner.

Exercise: Engage in writing essays or analyses on thought-provoking topics. Focus on constructing compelling arguments with evidence-based reasoning. This exercise not only hones critical thinking exercises but also improves written communication.

9. Ethical Dilemma Deliberation: Exploring Morality and Decision-Making

Delving into ethical dilemmas requires individuals to examine the moral implications of decisions, considering multiple ethical frameworks. This exercise encourages individuals to think critically about the consequences of their actions on both a personal and societal level.

Exercise: Engage in discussions and analyze ethical scenarios, exploring the ethical dimensions of various decisions. This exercise prompts individuals to consider the broader implications of their choices.

10. Data Analysis Challenges: Making Informed Decisions Based on Data

Enhancing quantitative critical thinking involves interpreting and drawing conclusions from data, promoting data literacy. This exercise empowers individuals to make informed decisions based on quantitative information.

Exercise: Work with datasets, analyze trends, and draw meaningful insights. Developing proficiency in data analysis enhances the ability to make evidence-based decisions in various contexts.

Conclusion:

Cultivating cognitive excellence through critical thinking exercises is a journey that requires active engagement in diverse exercises. The ten exercises presented in this guide offer a comprehensive range of activities to foster cognitive agility. From engaging in Socratic questioning to tackling ethical dilemmas and analyzing data, these exercises empower individuals to approach challenges with a discerning and analytical mindset. Embrace the journey of continuous intellectual development through these practical and stimulating critical thinking exercises, and witness the transformative power of a sharpened mind.

Also Read: 10 Team-Building Games That Promote Critical Thinking

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7 Puzzles to Challenge Your Critical Thinking

Can you spot the connections and sort these items.

Posted March 5, 2015 | Reviewed by Ekua Hagan

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The theme of this post is critical thinking—and the kinds of puzzles that can be constructed around it. This term is used frequently in psychology and education . There are various definitions, but the one that best suits our purpose and which is, in the end, perhaps the best, is the ability to comprehend the logical connections among ideas, words, phrases, and concepts . In the relevant scientific literature, of course, the term is used much more broadly as a framework for understanding human cognition . But in my opinion, the best way to understand things is to construct puzzles to illustrate their basic essence.

Critical thinking involves skill at recognizing a pattern in given information and especially recognizing how the information is connected to the real world. Here are a couple of very simple examples. First, consider the five words below:

  • Cruise ship
  • Walking on foot
  • Automobile (not a race car)

Now, put them in order from the slowest to the fastest, when they are going at maximum speed. The solution, of course, is: 4-2-5-1-3.

As with all such puzzles, there might be slightly different solutions—one could claim that some automobiles go faster than cruise ships. This “indeterminacy” characterizes this kind of thinking. However, some puzzles are straightforward. For instance, what do the following five things have in common?

The answer? These are all words referring to shades of blue.

The seven puzzles below are to the ones above, though hopefully more challenging. Some involve knowledge of facts, but critical thinking is still involved in such cases because the organization of the facts according to some principle is always involved—for example, a puzzle may ask you to put five items in order of their dates of invention.

The following tongue-in-cheek definition of critical thinking by Richard W. Paul, a leading expert on critical thinking theory, says it all: “Critical thinking is thinking about your thinking while you’re thinking in order to make your thinking better.”

I. What do the following 5 things have in common?

  • Orange juice

II. Put the following buildings or structures in order of height, from the shortest to the tallest.

  • Typical camping tent

III. What do the following animals have in common?

IV. Put the following inventions in order from earliest to most recent.

V. What feature do the following words have in common?

  • Imagination

VI. Put these bodies of water in order in terms of volume, from smallest to largest .

VII. What do the following landmasses have in common?

I. They are all drinkable liquids. II. 5-1-4-3-2 III. They all have a tail. They are also all quadrupeds. IV. To the best of my knowledge: 5-4-3-1-2 V. They start with a vowel: a, e, i, o, u VI. 4-2-1-5-3 VII. They are all peninsulas.

Marcel Danesi Ph.D.

Marcel Danesi, Ph.D. , is a professor of semiotics and anthropology at Victoria College, University of Toronto. His books include The Puzzle Instinct and The Total Brain Workout .

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Become a better critical thinker with these 7 critical thinking exercises

Become a better critical thinker with these 7 critical thinking exercises

Critical thinking is a skill you can use in any situation. Whether you're a student, entrepreneur, or business executive, critical thinking can help you make better decisions and solve problems.

But learning critical thinking skills isn't always an easy task. Many tools, techniques, and strategies are available, and choosing the right one can be challenging. Vague suggestions on the internet like "read more" aren't very helpful, and elaborate business examples don’t apply to many of us.

As average problem-solvers, we need actionable thinking exercises to improve our critical thinking skills and enhance our thinking processes. Regularly performing exercises that specifically stretch our decision-making and reasoning skills is the most effective method of improving our thinking abilities.

This article will explore several exercises that will help you develop critical thinking skills. Whether you are preparing for an exam, making an influential decision for your business, or going about your daily life, these fun activities can build your reasoning skills and creative problem-solving abilities.

Boost your logical thinking skills and start practicing a critical mindset with these 10 critical thinking exercises.

A Quick Look at Critical Thinking

As a thoughtful learner, you likely already understand the basics of critical thinking, but here's a quick refresher.

Critical thinking involves analyzing problems or issues objectively and rationally. Critical thinkers are able to understand their own biases and assumptions, as well as those of others. They’re also able to see the world from a different point of view and understand how their experiences impact their thinking.

Developing critical thinking skills is essential because it allows us to see things from multiple perspectives, identify biases and errors in reasoning, and be open to possible solutions. Making informed decisions is easier when we have a better understanding of the world around us.

Why We Need to Practice Critical Thinking

Critical thinking exercises: brain and four puzzle pieces

We aren't born with critical thinking skills, and they don’t naturally develop beyond survival-level thinking. To master critical thinking, we must practice it and develop it over time.

However, learning to think critically isn't as easy as learning to ride a bicycle. There aren't any step-by-step procedures to follow or supportive guides to fall back on, and it is not taught in public schools consistently or reliably. To ensure students' success, teachers must know higher-order thinking skills (HOTS) and how to teach them, research says.

Unfortunately, although teachers understand the importance of HOTS and attempt to teach it, studies show that their capacity to measure students' HOTS is low. Educator and author Dr. Kulvarn Atwal says, "It seems that we are becoming successful at producing students who are able to jump through hoops and pass tests."

As critical thinking skills become more important in higher grades, some students find it challenging to understand the concept of critical thinking. To develop necessary thinking skills, we must set aside our assumptions and beliefs. This allows us to explore and question topics from a "blank page" point of view and distinguish fact from opinion.

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7 Critical Thinking Exercises To Improve Your Critical Thinking Skills

Critical thinking exercises: steel model of the brain lifting dumbbells

The good news is that by assessing, analyzing, and evaluating our thought processes, we can improve our skills. Critical thinking exercises are key to this improvement. Our critical thinking builds and improves with regular practice, just like a muscle that gets stronger with use.

If you want to become a better critical thinker , here are some critical thinking exercises to try:

Exercise #1: The Ladder of Inference

You can exercise your critical thinking skills by using the Ladder of Inference model . This thinking model was developed by renowned organizational psychologist Chris Argyris. Each rung on the ladder of inference represents a step you take to arrive at your conclusions.

The decision-making process starts when we are faced with a problem or situation. As soon as we observe something problematic or important, we presume what is causing it, and then we use that assumption to draw conclusions. Based on those conclusions, we take action.

For example, say you're at a party and see a friend across the room. You catch their eye and wave, but they turn and walk away. Using the ladder, you might climb the rungs as follows:

  • Observe that your friend walked away.
  • Select a few details of the situation, including your wave and your assumption that they saw you.
  • Meaning is attached based on the environment, making you think your friend must have other people to talk to at the party.
  • Assumptions are made based on that meaning, assuming that means your friend doesn’t like you as much as them.
  • Conclusions are drawn from the assumption, and you determine that your friend must be mad at you or doesn't want you to be at the party.
  • Beliefs are formed, making you think you're not welcome.
  • Action is taken, and you leave the party.

In this example, you started with a situation (someone walking away at a crowded party) and made a series of inferences to arrive at a conclusion (that the person is mad at you and doesn't want you there).

The Ladder of Inference can be a helpful tool to frame your thinking because it encourages you to examine each step of your thought process and avoid jumping to conclusions. It's easy to make assumptions without realizing it, as in this scene. Perhaps your friend never even saw you wave from across the crowded room.

Exercise #2: The Five Whys

The "Five Whys" technique is an analytical skill that can help you uncover the source of a problem. The activity was created by Sakichi Toyoda, the founder of Toyota, and consists of repeatedly asking “why?” when a problem is encountered to determine its root cause.

This exercise can be difficult because knowing if you've discovered the source of your problem is challenging. The "five" in "Five Whys" is just a guideline — you may need to ask more. When you can't ask anything else, and your response is related to the original issue, you've probably arrived at the end.

Even if you need several rounds of questioning, just keep going. The important part that helps you practice critical thinking is the process of asking "why?" and uncovering the deeper issues affecting the situation.

For instance, say you're trying to figure out why your computer keeps crashing.

  • You ask " why ," and the answer is that there's a software problem.
  • Why? Because the computer keeps running out of memory.
  • Why? Because too many programs are running at the same time.
  • Why? Because too many browser tabs are open .
  • Why? Because multitasking is fragmenting your focus, you're doing too many things at once.

In this example, working through the "why's" revealed the underlying cause. As a result, you can find the best solution, which is concentrating on just one thing at a time.

Exercise #3: Inversion

Wooden blocks with seven black arrows and one red arrow

Inversion is another critical thinking exercise that you can use in any situation. Inversion is sort of like taking on the role of the devil's advocate. In this exercise, adopt the opposite view of whatever issue you're exploring and consider the potential arguments for that side. This will help broaden your critical thinking skills and enable you to see other perspectives on a situation or topic more clearly.

For example, let's say you're thinking about starting your own business. Using inversion, you would explore all of the potential arguments for why starting your own business is bad. This might include concerns like:

  • You could end up in debt.
  • The business might fail.
  • It's a lot of work.
  • You might not have time for anything else.

By exploring these potentially adverse outcomes, you can identify the potential risks involved in starting your own business and make a more sound decision. You might realize that now is not the right time for you to become an entrepreneur. And if you do start the company, you'll be better prepared to deal with the issues you identified when they occur.

Exercise #4: Argument Mapping

Argument mapping can be a beneficial exercise for enhancing critical thinking skills. Like mind mapping, argument mapping is a method of visually representing an argument's structure. It helps analyze and evaluate ideas as well as develop new ones.

In critical thinking textbooks, argument diagramming is often presented to introduce students to argument constructions. It can be an effective way to build mental templates or schema for argument structures, which researchers think may make critical evaluation easier .

Argument maps typically include the following:

  • Conclusion: What is being argued for or against
  • Premises: The reasons given to support the conclusion
  • Inferences: The connections made between the premises and conclusion

The argument map should be as clear and concise as possible, with a single word or phrase representing each element. This will help you make connections more easily. After the map is completed, you can use it to identify any weak points in the argument. If any areas aren't well-supported, additional premises can be added.

Argument mapping can be applied to any situation that requires critical thinking skills. The more time you take to map out an argument, the better you'll understand how the pieces fit together. Ultimately, this will help you think more creatively and critically, and make more informed decisions.

Exercise #5: Opinion vs. Fact

Critical thinking activities that focus on opinions and facts are particularly valuable and relevant new learning opportunities. Our constantly-connected world makes it easy to confuse opinions and facts , especially with sensationalist news articles and click-bait headlines.

How can you tell a fact from an opinion? Facts are generally objective and established, whereas opinions are subjective and unproven. For example, "the cloud is in the air" is a fact. "That dress looks good on you" is an opinion.

Practice your critical thinking skills by reading or listening to the news. See if you can identify when someone is stating an opinion rather than a fact. Ask yourself the following questions:

  • Who is saying what? What reasons might be behind their statements?
  • Does the claim make sense? Who would disagree with it and why?
  • How can you tell if the data is reliable? Can it be fact-checked? Has it been shared by other credible publishers?
  • How do you know whether or not the presenter is biased? What kind of language is being used?

This powerful exercise can train your mind to start asking questions whenever presented with a new claim. This will help you think critically about the information you're taking in and question what you're hearing before accepting it as truth.

Exercise #6: Autonomy of an Object

In her book " The Critical Thinking Tool Kit ," Dr. Marlene Caroselli describes a critical thinking exercise called "Living Problems, Lively Solutions." This exercise uses the autonomy of an object as a problem-solving tool to find a possible solution.

To do this, you'll personify your problem and place it in another context — a different time or place. This allows you to uncover unique solutions to the problem that might be tied to your mental associations with that setting.

For example, if your problem is poor time management , you might personify the issue as a thief of your time. The idea of a thief could make you think of jail, which might prompt thoughts of locking up specific distractions in your life. The idea of jail could also make you think of guards and lead you to the possible solution of checking in with an accountability buddy who can make sure you're sticking to your schedule.

The autonomy-of-object technique works because it stimulates thoughts you wouldn’t have considered without the particular context in which you place the problem.

Exercise #7: The Six Thinking Hats

Wooden blocks with different colored hats drawn on it

Designed by Edward de Bono, the Six Thinking Hats is a critical thinking exercise that was created as a tool for groups to use when exploring different perspectives on an issue. When people use other thinking processes, meetings can become challenging rather than beneficial.

To help teams work more productively and mindfully, de Bono suggests dividing up different styles of thinking into six categories, represented as hats:

  • The white hat is objective and focuses on facts and logic
  • The red hat is intuitive, focusing on emotion and instinct
  • The black hat is cautious and predicts negative outcomes
  • The yellow hat is optimistic and encourages positive outcomes
  • The green hat is creative, with numerous ideas and little criticism
  • The blue hat is the control hat used for management and organization

With each team member wearing a different hat, a group can examine an issue or problem from many different angles, preventing one viewpoint (or individual) from dominating the meeting or discussion. This means that decisions and solutions reached using the Six Thinking Hats approach will likely be more robust and effective, and everyone’s creative thinking skills will benefit.

Train Your Brain With Critical Thinking Exercises

Using critical thinking regularly in various situations can improve our ability to evaluate and analyze information. These seven critical thinking exercises train your brain for better critical thinking skills . With daily practice, they can become habits that will help you think more critically each day.

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Critical Thinking Exercises

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Critical thinking is a skill that students develop gradually as they progress in school. While the skill becomes more important in higher grades, some students find it difficult to understand the concept of critical thinking .

The reason critical thinking can be difficult to grasp is because it requires students to set aside assumptions and beliefs to learn to think without bias or judgment.

Critical thinking involves suspending your beliefs to explore and question topics from a "blank page" point of view. It also involves the ability to distinguish fact from opinion when exploring a topic.

These exercises are designed to help develop critical thinking skills.

Critical Thinking Exercise 1: Tour Guide for an Alien

This exercise provides an opportunity to think outside your normal way of thinking.

Pretend that you have been assigned the task of conducting a tour for aliens who are visiting the earth and observing human life. You're riding along in a blimp, viewing the landscape below, and you float over a professional baseball stadium. One of the aliens looks down and is very confused by what he sees. You explain that there is a game going on and he asks several important questions.

  • What is a game? 
  • Why are there no female players?
  • Why do people get so excited about watching other people play games?
  • What is a team?
  • Why can't the people in the seats go down on the field and join in?

If you try to answer these questions fully, it will quickly become apparent that we carry around certain assumptions and values. We support a certain team, for instance, because it makes us feel like we're a part of a community. This sense of community is a value that matters to some people more than others.

Furthermore, when trying to explain team sports to an alien, you have to explain the value we place on winning and losing.

When you think like an alien tour guide, you are forced to take a deeper look at the things we do and things we value. Sometimes they don't sound logical from the outside looking in.

Critical Thinking Exercise 2: Fact or Opinion

Do you think you know the difference between fact and opinion? It's not always easy to discern. When you visit websites, do you believe everything you read? The abundance of available information makes it more important than ever for students to develop critical thinking skills. Additionally, it's an important reminder that you must use trustworthy sources in your school work.

If you don't learn the difference between fact and opinion, you may end up reading and watching things that continue to reinforce beliefs and assumptions you already own.

For this exercise, read each statement and try to determine whether it sounds like a fact or an opinion. This can be completed alone or with a study partner .

  • My mom is the best mom on earth.
  • My dad is taller than your dad.
  • My telephone number is difficult to memorize.
  • The deepest part of the ocean is 35,813 feet deep.
  • Dogs make better pets than turtles.
  • Smoking is bad for your health.
  • Eighty-five percent of all cases of lung cancer in the U.S. are caused by smoking.
  • If you flatten and stretch out a Slinky toy it will be 87 feet long.
  • Slinky toys are fun.
  • One out of every one hundred American citizens is color blind.
  • Two out of ten American citizens are boring.

You will probably find some of the statements easy to judge but other statements difficult. If you can effectively debate the truthfulness of a statement with your partner, then it's most likely an opinion.

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Critical thinking definition

critical thinking exercises medical

Critical thinking, as described by Oxford Languages, is the objective analysis and evaluation of an issue in order to form a judgement.

Active and skillful approach, evaluation, assessment, synthesis, and/or evaluation of information obtained from, or made by, observation, knowledge, reflection, acumen or conversation, as a guide to belief and action, requires the critical thinking process, which is why it's often used in education and academics.

Some even may view it as a backbone of modern thought.

However, it's a skill, and skills must be trained and encouraged to be used at its full potential.

People turn up to various approaches in improving their critical thinking, like:

  • Developing technical and problem-solving skills
  • Engaging in more active listening
  • Actively questioning their assumptions and beliefs
  • Seeking out more diversity of thought
  • Opening up their curiosity in an intellectual way etc.

Is critical thinking useful in writing?

Critical thinking can help in planning your paper and making it more concise, but it's not obvious at first. We carefully pinpointed some the questions you should ask yourself when boosting critical thinking in writing:

  • What information should be included?
  • Which information resources should the author look to?
  • What degree of technical knowledge should the report assume its audience has?
  • What is the most effective way to show information?
  • How should the report be organized?
  • How should it be designed?
  • What tone and level of language difficulty should the document have?

Usage of critical thinking comes down not only to the outline of your paper, it also begs the question: How can we use critical thinking solving problems in our writing's topic?

Let's say, you have a Powerpoint on how critical thinking can reduce poverty in the United States. You'll primarily have to define critical thinking for the viewers, as well as use a lot of critical thinking questions and synonyms to get them to be familiar with your methods and start the thinking process behind it.

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IMAGES

  1. Critical Thinking as a Nurse

    critical thinking exercises medical

  2. Printable Critical Thinking Worksheets

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  3. CRITICAL THINKING EXERCISES.docx

    critical thinking exercises medical

  4. Human Physiology

    critical thinking exercises medical

  5. 6 Main Types of Critical Thinking Skills (With Examples)

    critical thinking exercises medical

  6. CRITICAL THINKING

    critical thinking exercises medical

VIDEO

  1. Critical Thinking Exercises, chapter 12

  2. Let's Do A Critical Thinking Exercise!!!

  3. Creative and Critical Thinking Exercises

  4. Things I Learned In Nursing: Objective Critical Thinking

  5. Memorable Moments on Soft Skills Training & Development

  6. Mastering Science Knowledge Tests: Grade 5 : Video 01

COMMENTS

  1. Medical Student Guide For Critical Thinking

    Medistudents team. August 18, 2021. 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.

  2. Critical Thinking in Nursing: Developing Effective Skills

    Critical thinking in nursing is invaluable for safe, effective, patient-centered care. You can successfully navigate challenges in the ever-changing health care environment by continually developing and applying these skills. Images sourced from Getty Images. Critical thinking in nursing is essential to providing high-quality patient care.

  3. What is Critical Thinking in Nursing? (With Examples, Importance, & How

    The following are examples of attributes of excellent critical thinking skills in nursing. 1. The ability to interpret information: In nursing, the interpretation of patient data is an essential part of critical thinking. Nurses must determine the significance of vital signs, lab values, and data associated with physical assessment.

  4. The Value of Critical Thinking in Nursing

    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.

  5. Cultivating Critical Thinking in Healthcare

    Critical thinking skills have been linked to improved patient outcomes, better quality patient care and improved safety outcomes in healthcare (Jacob et al. 2017).. Given this, it's necessary for educators in healthcare to stimulate and lead further dialogue about how these skills are taught, assessed and integrated into the design and development of staff and nurse education and training ...

  6. Critical Thinking Skills

    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 ...

  7. Clinical Reasoning, Decisionmaking, and Action: Thinking Critically and

    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.

  8. PDF Understanding Critical Thinking to Create Better Doctors

    promoting critical thinking among medical students. For assessing the critical thinking abilities of medical students it is important to establish clear criteria for assessment. The outcomes of the activities suggested in this article for fostering critical thinking can be used as a criterion for assessing critical thinking. There are various ...

  9. PDF Fostering Critical Thinking in Nurses

    Nurse Education Today, 33(9), 1062-1067. Fostering Critical Thinking in Nurses. If you have any questions about the program you have just watched, you may call us at: (800) 424-4888 or fax (806) 743-2233. Direct your inquiries to Customer Service.

  10. Fun Critical Thinking Activities for Nursing Students

    Medical courses are popular for their complexity and demanding nature. For your everyday student fighting to pay tuition, rent, food, and loans, pursuing a career in the field can be a nightmare. Those who've made the journey understand the importance of critical thinking for nursing students. Every facet of the course requires thorough analysis and […]

  11. Cengage Learning

    The Human Touch: Critical Thinking Exercise; Chapter 2. The Human Body in Health and Disease. Anatomical Reference Systems. Anatomy and Physiology Defined; The Body Planes; ... The Human Touch: Critical Thinking Exercise; Comprehensive Medical Terminology Review. Overview of Comprehensive Medical Terminology Review; Study Tips. Use Your ...

  12. The Current State of Critical Thinking in EMS

    Emergency medical services (EMS) journals regularly discuss a lack of critical thinking evident in paramedics and how this deficiency is a significant flaw in the profession.

  13. (PDF) Teaching and Assessing Critical Thinking and ...

    Teaching and Assessing Critical Thinking and Clinical Reasoning Skills in Medical Education. of teaching which dates back to 470-399 BC dur ing Socrates era (Paul, Elder, & Bartell, 1997). This ...

  14. Thinking more wisely: using the Socratic method to develop critical

    Background In medicine, critical thinking is required for managing and tolerating medical uncertainty, as well as solving professional problems and treating diseases. However, the core of Confucianism, teacher-centered and exam-oriented settings in middle and high school education may pose challenges to developing critical thinking in Han Chinese or Taiwanese students. Students may be ...

  15. Medical Terminology for Health Professions

    The proven combination of learning exercises that follows each chapter's text is designed to make teaching medical terminology easy by thoroughly engaging learners with a variety of formats, real-life medical scenarios, and critical thinking exercises.

  16. What Are Critical Thinking Skills and Why Are They Important?

    It makes you a well-rounded individual, one who has looked at all of their options and possible solutions before making a choice. According to the University of the People in California, having critical thinking skills is important because they are [ 1 ]: Universal. Crucial for the economy. Essential for improving language and presentation skills.

  17. A Deep Dive into 10 Thought-Provoking Critical Thinking Exercises

    2. Brain Teasers and Puzzles: Nurturing Analytical Thinking. Solving puzzles, riddles, and brain teasers is a classic exercise for enhancing problem-solving skills and developing cognitive flexibility. Engaging in these activities challenges the mind, fostering creativity and adaptability. Exercise: Dedicate regular time to solving Sudoku ...

  18. 7 Puzzles to Challenge Your Critical Thinking

    First, consider the five words below: Cruise ship. Bicycle. Airplane. Walking on foot. Automobile (not a race car) Now, put them in order from the slowest to the fastest, when they are going at ...

  19. Be a Better Thinker With These 7 Critical Thinking Exercises

    Exercise #1: The Ladder of Inference. You can exercise your critical thinking skills by using the Ladder of Inference model. This thinking model was developed by renowned organizational psychologist Chris Argyris. Each rung on the ladder of inference represents a step you take to arrive at your conclusions.

  20. 10 Great Critical Thinking Activities That Engage Your Learners

    Other Critical Thinking Activities. Jigsaw—Developing Community and Disseminating Knowledge: Learners take on the role of "experts" or "specialists" of a particular topic. Then a panel of experts is assembled to get the larger picture. K-W-L Charts—Assessing What We Know/What We Still Want to Learn: Charts to document "What I Know ...

  21. Critical Thinking Exercises for Students

    Critical Thinking Exercise 1: Tour Guide for an Alien. This exercise provides an opportunity to think outside your normal way of thinking. Pretend that you have been assigned the task of conducting a tour for aliens who are visiting the earth and observing human life. You're riding along in a blimp, viewing the landscape below, and you float ...

  22. Quiz & Worksheet

    1. In relation to critical thinking, which one of the following best defines an objective? The speaker's aim or goal. The critical thinker's aim or goal. What both the listener and speaker hope to ...

  23. Using Critical Thinking in Essays and other Assignments

    Critical thinking, as described by Oxford Languages, is the objective analysis and evaluation of an issue in order to form a judgement. Active and skillful approach, evaluation, assessment, synthesis, and/or evaluation of information obtained from, or made by, observation, knowledge, reflection, acumen or conversation, as a guide to belief and action, requires the critical thinking process ...