Have you noticed that the one thing you can count on when working in today’s fast-paced healthcare setting is that it’s full of surprises, that nothing is simple anymore? People live longer with more chronic and complex problems, providing new challenges. There’s greater family involvement, and more workers involved in a single plan of care. In hospitals, homes, and communities, nurses are expected to take on added responsibilities and make more independent judgments and decisions. Almost every day, it seems like you have to learn something new or adapt to a major change. To survive and thrive in today’s (and tomorrow’s) workplace, you need highly developed abilities, especially critical thinking skills. You have to know how to clearly and quickly focus your thinking in a way that gets the results you want, whether it be helping a challenging patient achieve an outcome in a timely manner, resolving a conflict with a coworker, or mastering that new unit computer.

Let’s look at what critical thinking is and how you can develop the characteristics and skills required to think critically.

What is critical thinking?

Because critical thinking is a complex activity that can be described in more than one way, there’s no one right definition of critical thinking. Many authors, including myself, develop their own descriptions that complement and clarify someone else’s, which is, by the way, a good example of using this way of thinking. Critical thinking requires you to “personalize” information, to analyze it and draw conclusions about what it means to you, rather than simply memorizing words.

Before going on to examine the relevance of critical thinking to your practice, consider the following frequently cited critical thinking descriptions:

• Knowing how to learn, reason, think creatively, generate and evaluate ideas, see things in the mind’s eye, make decisions, and solve problems¹
• Reasonable, reflective thinking that focuses on what to believe or do²
• The ability to solve problems by making sense of information using creative, intuitive, logical, and analytical mental process, and the process is continual³
• Purposeful, informed, outcome-focused thinking that requires careful identification of key problems, issues, and risks involved^4,5
• The art of thinking about your thinking, while you’re thinking, to make it better, more clear, accurate, and defensible.⁶

To many nurses, critical thinking means simply good clinical judgment or effective problem-solving. Although these describe the concepts of critical thinking, to be successful in today’s competitive healthcare arena, caregivers need a broader view: You can’t be satisfied with just having a “problem-solving mentality.” You could be demonstrating good problem-solving and clinical judgment, but if you don’t have a sincere desire to improve — to find ways to broaden your skills and knowledge and to find ways to make current practices more efficient and effective — you aren’t thinking critically. And clients and peers who know the value of constant improvement and professional growth may leave you behind.

A more progressive, holistic way to define critical thinking is a commitment to look for the best way, based on the most current research and practice findings; for example, the best strategy to manage pain in a specific person or situation. Critical thinking in nursing means constantly striving to find a better way by focusing on questions such as: What are the outcomes? How can we do this better? How satisfied are our patients with their care (see Figure 1)? Think about your daily practice. Are you focusing on outcomes? Do you know the strength of the evidence that supports your decisions and interventions? Do you pay attention to patient and consumer satisfaction? Are you actively involved in finding ways to improve, or are there many days when all you’re doing is solving problems as best you can, with little time to reflect on your practice? If all you’re doing is solving problems, you’re unlikely to be thinking critically: If you’re thinking critically — making time to reflect on your practice and make improvements and corrections — you may not have some of those problems in the first place. You would have identified how to prevent many of the problems that you’re trying to solve before they happened.

Shifting to a predictive model

Another consideration in today’s clinical setting that affects how we describe critical thinking is that there’s a shift in thinking about how to manage health problems. We are now more proactive, moving from a diagnose and treat (DT) model to a predict, prevent, manage, and promote (PPMP) model.^4,5 The PPMP model focuses on predicting problems, preventing complications, managing symptoms, and promoting health.

What’s the difference between a DT model and a PPMP model? DT implies that we wait for evidence of problems before beginning treatment. For example, in the past, we monitored people with fractured hips for emboli, but we didn’t do much about preventing them. We monitored people closely until sure enough they threw an embolus. Today, providers routinely identify those at risk and begin treatment to prevent emboli immediately after surgery by administering anticoagulants and applying pulsating antiemboli stockings. Another example is how we manage exposure to human immunodeficiency virus (HIV). In the past, we simply monitored HIV-exposed individuals until symptoms appeared. Today, using the PPMP model, when someone has significant exposure to HIV, we begin treatment immediately, before the virus even appears in the blood. DT has a narrow approach that’s strong on treating problems, but weak on preventing them and their complications. PPMP is based on evidence. We now know the typical course of many health problems and how to alter their progression and achieve outcomes in a more timely fashion by identifying risk factors and intervening early. You may be thinking, this approach isn’t new…we’ve always focused on prevention and early intervention. But, realize that today — thanks to computers, new technology, and hard work on the part of many expert clinicians and researchers — we have a higher degree of reliable evidence addressing how to predict, prevent, and manage problems in various situations and populations. As a critical thinker, it’s your job to pay attention to new technology and evidence-based approaches that improve patient outcomes. Think about how many years we did X-rays after central venous line insertions to confirm placements — now with new evidence and technology, we are much more proactive, using live ultrasound to monitor how lines are inserted, thereby reducing risks of serious complications, such as a collapsed lung. Remember the importance of the “fourth P” (promote). To think critically, you should be predicting, preventing, and managing problems, and also promoting function (e.g., pointing out to patients the beneficial effects of walking on a daily basis and of using stress management techniques to promote optimum physical and mental function).

Using critical paths

You may recognize critical paths as an example of using the PPMP model. It’s not unusual for patients to be placed on a critical path that identifies the predicted care required to meet outcomes in a timely fashion. However, critical paths can either enhance or impede critical thinking. They can enhance thinking when they help thoughtful, knowledgeable staff decide what is most important in the management of specific health problems. But they can impede thinking in those who are task-oriented, not thought-oriented, and who simply get the job done, without constantly assessing, questioning, reflecting, evaluating, and changing approaches. All too often, we see staff who are so influenced by knowing the predicted care, that they rush through assessments and make assumptions that impede progress and may be dangerous, as if the path can replace “thinking.” As a critical thinker, be sure you use tools such as clinical pathways with an open, questioning mind, focusing on your own direct patient assessments. Be sure you recognize helpers who tend to be task-oriented — they might need a little closer supervision. (See side bar.)

What do critical thinkers look like?

Surprisingly enough, research has shown that most critical thinkers are women between the ages of 30 and 35 years, fair-skinned, and over 5’4”. However, if you aren’t questioning this statement, you’re definitely not thinking critically about what you’re reading. When we ask, “What does a critical thinker look like?” we mean, “What characteristics do we see in someone who thinks critically?” Consider this description:

The ideal critical thinker is habitually inquisitive, self-informed, trustful of reason, open-minded, flexible, fair-minded in evaluation, honest in facing personal biases, prudent in making judgments, willing to reconsider, clear about issues, orderly in complex matters, diligent in seeking relevant information, reasonable in selection of criteria, focused on inquiry, and persistent in seeking results that are as precise as the subject and the circumstances of inquiry permit.⁷

Richard Paul and Linda Elder, of the Center for Critical Thinking in California, also describe some key intellectual traits:⁸

• Intellectual humility: Willingness to admit what you don’t know
• Intellectual integrity: Continual evaluation of your own thinking and willingness to admit when it may be flawed
• Intellectual courage: Awareness of the need to face and fairly address ideas, beliefs, or viewpoints about which you have negative feelings and haven’t given serious hearing
• Intellectual empathy: A conscious effort to understand others by putting your own feelings aside and imagining yourself in their place

Authors Noreen and Peter Facione have identified seven habits of the mind, seven critical thinking dispositions, that those who think critically demonstrate.⁹

• Truthseeking: A courageous desire for the best knowledge, even if such knowledge fails to support or undermines one’s preconceptions, beliefs, or self-interests
• Open-Mindedness: Tolerance to divergent views and self-monitoring for possible bias
• Analyticity: Demanding the application of reason and evidence, alert to problematic situations, inclined to anticipate consequences
• Systematicity: Valuing organization, focus, and diligence to approach problems of all levels of complexity
• Self-Confidence: Trusting one’s own reasoning skills and seeing oneself as a good thinker
• Inquisitiveness: Curiosity and eagerness to acquire knowledge and learn explanations even when the applications of the knowledge are not immediately apparent
• Maturity: Prudence in making, suspending, or revising judgment; an awareness that multiple solutions can be acceptable; an appreciation of the need to reach closure even in the absence of complete knowledge.

Critical thinking indicators

While the preceding work gives a general picture of what critical thinkers “look like,” a study that identifies critical thinking indicators — behaviors that promote critical thinking in clinical nursing practice — helps you know what you have to do to think critically.  Here’s a summary of what critical thinking indicators entail:¹⁰

Critical Thinking Indicators (CTIs) are divided into three categories:

1. General attitudes/characteristics indicators: These are behaviors that indicate CT characteristics/attitudes (e.g., inquisitive, persistent, reflective, open-minded, proactive, resilient, self-aware)
2. Knowledge indicators: These are behaviors that indicate that the nurse has required knowledge (e.g., ability to discuss ethics codes and professional standards, to describe signs and symptoms of common health problems and related complications, to explain the difference between nursing and medical models, and to give key details of pharmacology, anatomy, and physiology)
3. Intellectual skill indicators/competencies: These are behaviors that indicate that the nurse has required intellectual skills/competencies (e.g., ability to assess systematically and comprehensively, distinguish relevant from irrelevant, identify missing information, recognize inconsistencies, identify assumptions, and draw valid conclusions).

If you want to know more, The Evidence-Based Critical Thinking Indicators document at www.AlfaroTeachSmart.com/ cti.cfm explains how the CTIs were determined and gives a comprehensive list of behaviors promoting CT. Concrete examples for each CTI are listed, giving “a language” to talk about what nurses must be able to do to think critically in today’s practice setting. This document also gives a simple four-circle CT Model that can help you target areas you want to develop to improve thinking. The four circles address characteristics of critical thinkers, theoretical and experiential knowledge, interpersonal skills, and technical skills.

Nursing process and critical thinking

As new care models emerge, some nurses believe newer models will replace the use of the nursing process (Assessment, Diagnosis, Outcome Identification, Planning, and Evaluation). However, it’s important to remember that American Nurses Association Standards state that the nursing process:

1. Serves as a critical thinking model that promotes a competent level of nursing care
2. Forms the foundation for decision-making and encompasses all significant actions nurses take
3. Underpins virtually all care models.¹¹

To apply evidence-based care models (e.g., case management, critical pathways) and to do the critical thinking you need to do to pass standard tests (e.g., National Council Licensure Examinations [NCLEX] and other certification tests), you need a strong foundation in principles of nursing process. For example, you must know that the first step to thinking critically in any situation is to assess to identify assumptions and determine whether you have all the necessary facts. The importance of understanding nursing process principles is reenforced by the fact that when multiple choice items on NCLEX ask the question, “What would you do first?” the correct response is almost always something that addresses what you would need to assess.5 For example, suppose a test question has a situation in which a patient complains of unrelieved pain and you’re asked, “What would you do first?” If you have the choice of the answers: Give pain medication, Teach pain management, Activate the Chain of Command, or Assess the pain, the correct answer is Assess the pain.

Including patients — Reflecting on care

As we realize the importance of including patients in the decision-making process and reflecting on the care we give, we are more specific about what it takes to use the nursing process as a tool for critical thinking. For example, the Nursing Process Summary posted at www.alfaroteachsmart.com/handouts.htm stresses the need to reflect on thinking to determine whether: (1) Patient participation in the process has been at an optimum level, (2) Information is accurate and complete, (3) Assumptions have been identified, and thinking tailored to individual patient and circumstances, (4) Conclusions are based on facts (evidence), rather than guesswork, and (5) Alternate conclusions, ideas, and solutions have been considered.

How to think critically

Unlike today’s youth, who are being taught very specific strategies to improve their thinking, most of us have learned how to think rather haphazardly, partially from observation and experience, and partially from school. Experts agree that we simply can’t continue to conduct “business as usual,” expecting people to develop the thinking skills needed to thrive in a rapidly changing world the way they always have — by just figuring it out for themselves. We now know that thinking is a skill, just like tennis, skiing, or golf — a skill that must be learned, adapted, and practiced to succeed in the fast-paced game of life and work.

Just as with any skill, developing critical thinking skills requires insight, knowledge, experience, practice, and feedback. More specifically, you need to:

1. Gain insight. The first step to improving thinking is gaining an understanding of what critical thinking is and an awareness of how you and others think. Become familiar with CTIs. Learn how to put your thinking into words. Only then will others, such as colleagues and supervisors, be able to evaluate your thinking and decide for themselves whether you’re thinking critically. Today, there’s often more than one solution to a given problem. Be sure you can explain and support the thinking behind the solutions you choose.

2. Acquire specific theoretical and experiential knowledge related to diagnosis and management of patients and problems commonly seen in your particular practice setting. You can’t expect yourself to think critically if you don’t have a broad theoretical and experiential knowledge base. Textbook or classroom learning is important, but it can’t take the place of experiential learning. Thinking critically in the clinical setting requires that you have experience in the clinical setting. For example, you won’t be able to recognize abnormal breath sounds until you’ve had practice actually hearing them. Until you have good technical skills, such as managing IVs and other equipment, most of your brainpower goes toward mastering these types of skills, leaving little energy for critical thinking. Keeping this in mind should help you set realistic expectations for critical-thinking ability. New nurses will need repeated experiences before they are likely to be able to think critically about nursing problems.

3. Learn strategies that promote critical thinking, as listed in the sidebar.

4. Practice. Unless you seek opportunities to repeat the critical-thinking skills required in your practice setting, for example, assessing systematically and comprehensively, you’re unlikely to gain or maintain competency performing the skill.

5. Ask for feedback. You probably do some self-evaluation, but it’s important to seek out the perspectives of trusted colleagues and supervisors about whether you’re demonstrating critical thinking skills and characteristics. Often, it’s the feedback you get from others that can really help you improve.

Evaluating CT

Many researchers continue to work to develop valid instruments to evaluate thinking. But evaluating what goes on in someone else’s head isn’t easy, as many factors affect how someone thinks in any situation and no one can read someone else’s mind. In the clinical setting, using the CTIs as a guide is helpful for evaluating thinking, because they give observable behaviors that promote critical thinking. Being observant of behavior and being willing to dialogue to understand someone else’s thinking is key to evaluating CT.

To get an idea of critical thinking ability, consider two things:

1. Patterns of behavior: How nurses behave — what they say and do over time — tells you how they think. Can you think of several colleagues who are, or are not, critical thinkers, just by reflecting on their behavior over time?

2. Results: How do the patients look? How patients fare under a nurse’s care is usually a result of critical thinking. Considering patient results to evaluate thinking is helpful when working with diverse thinkers. For example, you may have a very methodical approach to patient care, and be supervising a nurse who seems haphazard and scattered. To determine if this is simply a style difference, check on the patients. If the patients are well cared for, you’re probably dealing with a style difference, not a critical thinking problem.

In today’s challenging healthcare setting, the nurses who will survive, even thrive, are those who are clearly aware of how they think, how others think, and how to use strategies and tools to maximize their potential. Learn to work smarter, not harder. Make a commitment to improve your thinking by engaging in open and honest dialogue, by identifying and examining assumptions behind usual practices, by looking for new approaches, and by seeking out opportunities to gain the theoretical and experiential knowledge you need to think critically in your particular practice.