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, and 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. From inpatient settings to outpatient settings to homecare, PTs are expected to take on added responsibilities and make more independent judgments and decisions. Almost every day, it seems 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 need to know how to clearly and quickly focus your thinking in a way that gets the results you want, whether it is helping a challenging patient achieve outcomes in a certain way, resolving a conflict with a coworker, or mastering that new unit computer.

Your ability to think critically can make the difference between whether you succeed or fail. 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 way to define it. 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 processes, and the process is continual³
• Purposeful, informed, outcome-focused thinking that requires careful identification of key problems, issues, and risks involved⁴
• The art of thinking about your thinking, while you’re thinking, to make it better, more clear, accurate, and defensible.⁵

To many healthcare providers, 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 and progress a post-surgical patient. Critical thinking 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.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 are accountable for identifying those at risk and initiating treatment to prevent emboli. For example, use of pulsating antiemboli stockings is standard during and after many surgeries.. Thrombosis detection and prevention is a major initiative in health care settings. To gain an understanding of various measures and technology that assist in thrombosis prevention, click here: http://www.prnewswire.com/news-releases/the-north-american-thrombosis-forum-natf-honors-hospitals-that-excel-in-the-prevention-of-deep-vein-thrombosis-dvt-82049937.html. Another example of the PPMP Model 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 way 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 we have often used passive modalities on patients with chronic disabilities when, in many cases, the latest evidence does not support their use. Staying abreast of the latest research and clinical practice guidelines allows us to promote best practices and achieve better outcomes. 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., as you do routine treatments, take the opportunity to teach about health promotion; for example, 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 and Practice Guidelines

You may recognize critical paths, practice guidelines, and protocols as examples of using the PPMP model. It’s not unusual for patients to be placed on a critical path or protocol that identifies the predicted care required to meet specific outcomes within specific time frames. However, use of critical paths, practice guidelines and protocols can either enhance or impede critical thinking. They can enhance thinking when they help thoughtful, knowledgeable healthcare providers decide what's 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 clinicians 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, practice guidelines, and protocols with an open, questioning mind. Focus on your own direct patient assessments. When using computerized guides, think with the computer (it can’t think for you). Be sure you recognize peers who tend to be task-oriented — they might need a little closer supervision. (See sidebar.)

What Do Critical Thinkers Look Like?

Surprisingly enough, research has shown that most critical thinkers are women between the ages of 30 and 35, fair-skinned, and taller than 5 feet, 4 inches. 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.⁶

Richard Paul and Linda Elder, of the Center for Critical Thinking in California, also describe some key intellectual traits:⁷

• 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.⁸

• 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

The preceding work gives a general picture of what critical thinkers “look like.” Since 2002, I have conducted a study with other experts to identify critical thinking indicators — behaviors that promote critical thinking in clinical practice — helps you know what you have to do to think critically. Here’s a summary of what critical thinking indicators entail:⁹

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

1. General attitudes/characteristics indicators: These are behaviors that indicate general CT characteristics/attitudes (e.g., inquisitive, persistent, reflective, open-minded, proactive, resilient, self-aware). These indicators are the same for all disciplines.
2. Knowledge indicators: These are behaviors that indicate that the caregiver (or provider) 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, and to give key details of anatomy, pathophysiology, and pharmacology). Remember that knowledge indicators are contextual to each discipline. For example, some of the knowledge that nurses and PTs have is the same. But nurses and PTs each also have key knowledge that’s unique to their own discipline — thus the importance of interdisciplinary approaches.
3. Intellectual skill indicators/competencies: These are behaviors that indicate that the PT 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, available at www.AlfaroTeachSmart.com/cti.html, 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 you must do to think critically in today’s practice setting. While this document is specific to nurses, many of the indicators apply to all healthcare disciplines. As a PT, you may need to add or adapt some of the indicators. 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. If you have suggestions for adapting the Evidence-Based Critical Thinking Indicator document to include more PT-related behaviors, contact the author at www.AlfaroTeachSmart.com.

Including Patients — Reflecting on Care

As we realize the importance of including patients and families in the decision-making process and reflecting on the care we give, we now are able to determine approaches that are in line with patient values and priorities. We can improve outcomes by streamlining approaches to include what really matters to each individual patient, including such things as cultural, language, and other special needs.

Thinking critically means reflecting on how you make care decisions and deciding whether: (1) patient participation in the process was at an optimum level; (2) information is accurate and complete; (3) assumptions were identified, and thinking tailored to individual patients and circumstances; (4) conclusions were based on facts (evidence), rather than guesswork; and (5) alternate conclusions, ideas, and solutions were considered.

Being an independent, reflective thinker who doesn’t make assumptions is key to critical thinking. In today’s fast-paced clinical setting, we need “everyone’s eyes and brains.” For example, I remember a PT who did an evaluation on a stroke patient who physicians had determined was in a persistent vegetative state. Rather than assuming that the physicians were correct, the PT did a thorough assessment. He immediately realized that the patient was responding in ways that someone in a vegetative state would be unable to do. He alerted the physicians and caregivers that additional assessment was needed. This patient eventually made significant recovery, was able to go shopping with her son, and do many things independently.

How to Think Critically

Unlike today’s youth, who are 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 the seat of their pants or by reading books. Gaining critical thinking skills requires experiential learning with guidance by supportive mentors, teachers, and peers. 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.

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 working with monitors, 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. Novice PTs will need repeated real-life experiences before they’re likely to be able to think critically about patient 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. Continually reflect on the quality of your thinking. Seek out the perspectives of trusted colleagues and supervisors about whether you’re demonstrating critical thinking. 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. CT instruments are difficult to develop and don’t always predict critical thinking ability in real situations. You can find a good, comprehensive article that addresses some of the difficulties of measuring CT in PT students at http://findarticles.com/p/articles/mi_qa3969/iss_200410/ai_n9463172.¹⁰

Many factors affect how someone thinks in a given 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 three things:

1. Patterns of behavior: How people behave — what they say and do over time — gives you a good idea of 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 PT’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 PT who seems haphazard and scattered. To determine if this is simply a style difference, check on the patients’ progress via outcome measures. If the patients are progressing as expected, you’re probably dealing with a style difference, not a critical thinking problem.
3. Recorded communication: Is charting clear and relevant? Do progress notes offer new insights, or are they repetitive? Are other written communications, such as e-mails and papers, sensible and understandable?

In today’s challenging healthcare setting, the PTs 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 reading the latest peer-reviewed evidence-based literature. Seek out opportunities to gain the theoretical and experiential knowledge you need to think critically in your particular practice.

EDITOR’S NOTE: To read another CE article by Rosalinda Alfaro-LeFevre that addresses the impact of personality, birth order, learning styles, and culture on thinking, read PT236 Don’t Worry, Be Happy: Harmonize Diversity Through Personality Sensitivity at http://localadmin.nurse.com/PTce/www.todayinpt.com/CE/PT236