Since 1995, I have given so many critical thinking (CT) workshops that I’ve stopped counting. I’ve dialogued with participants from all healthcare disciplines, including occupational therapists (OTs). Being the curious sort, I’ve studied OT course requirements on the Internet. While each discipline has its own unique challenges, I get the sense that OTs require some of the broadest and most complex thinking skills of all. As an OT, you can’t function at a superficial level. You need a knowledgeable, committed mind that’s willing to perservere with many interrelated intricate issues. You have to gain deep insight into the impact of diseases and disabilities on both adults’ and children’s capacity to function in various roles. Once you have that, you begin the challenge of developing and implementing a plan to overcome significant emotional, physical, and social barriers. For your patients, your ability to think critically makes the difference between life-long boredom and dependence —and energized, gainful productivity that continues to grow.

 

Yet, have you noticed thinking isn’t like it always was? Today’s fast-paced healthcare setting is full of surprises. Nothing is simple. People live longer with more chronic and complex problems. There’s greater family involvement, and a variety of care providers involved in a single plan of care. You’re expected to get things done quicker, better, and more cost-effectively. Each day, it seems like you have to learn something new or adapt to a major change. To succeed in the workplace, you must be able to think critically—you need to know how to clearly and quickly focus your thinking in a way that gets the results you want, whether it’s helping a challenging patient, resolving a conflict with a co-worker, or mastering how to use electronic health records (EHR).

 

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

 

 

Because critical thinking is a complex process 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 memorizing definitions.

 

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

 

While all of the above describe what critical thinking entails, in context of today’s standards-driven, evidence–based care, also keep the following description in mind.⁶

 

Critical thinking in healthcare entails outcome-focused thinking that:

 

 

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 the following classic description developed by a Delphi research study:

 

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 are known for describing key intellectual traits.⁸ Some examples are:

 

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 critical thinkers possess: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.

 

 

While the preceding work gives a general picture of what critical thinkers look like, identifying critical thinking indicators — behaviors that promote critical thinking in clinical practice — gives a very specific picture of what CT is in context of various healthcare disciplines. Here’s a summary of what critical thinking indicators (CTIs) entail.¹⁰ They are divided into three categories:

 

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.

 

Knowledge indicators: These are behaviors that indicate the care provider has required knowledge. Examples of OT knowledge indicators are being able to demonstrate, differentiate, and apply the principles of occupational therapy, being able to explain social issues that influence occupational therapy practice, and being able to delineate occupational therapy interventions that address threats to development, rehabilitation, occupational performance, play skills, school function, and full social participation for children and youth.¹¹ Knowledge indicators are contextual to each discipline. For example, some of the knowledge that nurses and OTs have is the same. But nurses and OTs each also have key knowledge that’s unique to their own discipline—thus the importance of interdisciplinary approaches.

 

Intellectual skill indicators/competencies: These are behaviors that indicate the OT 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 about CTIs, the Evidence-Based Critical Thinking Indicators document at www.AlfaroTeachSmart.com/cti.cfm explains how CTIs are determined. 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 an OT, you may need to add or adapt some of the indicators. This document also gives a simple four-circle CT Model that helps you target areas you may want to develop to improve thinking. The four circles address characteristics of critical thinkers, theoretical and experiential knowledge, interpersonal skills, and technical skills.

 

 

To many people, critical thinking means simply good clinical judgment or effective problem-solving.¹² Although these describe critical thinking concepts, to be successful in today’s competitive healthcare arena, you need a broader view: You can’t be satisfied with having just a “problem-solving mentality.” You may 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 are not thinking critically. Critical thinking requires continually asking 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 do is solve problems as best you can, with little time to reflect on your practice? If all you do is solve 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.

 

 

Critical thinking is contextual, changing with circumstances, as you can see in the following phases of thinking:¹³

 

Thinking Ahead: Being proactive, anticipating what might happen, and what you might do to be more prepared. For novices, with limited knowledge and experience, being proactive is difficult and sometimes restricted to reading procedure manuals and textbooks to anticipate what might happen.

 

Thinking in Action: Thinking on your feet — this is rapid, dynamic reasoning that considers several cues and priorities at once, making it difficult to describe. Thinking in action is highly influenced by previous hands-on experience. It’s more intuitive and prone to “knee-jerk” responses and decisions than the other types of thinking listed here.

 

Thinking Back (Reflective Thinking): Analyzing the
reasoning process to identify assumptions, look for flaws and omissions, gain better understanding, and correct and improve thinking. Experienced clinicians double-check and reflect on their thinking in dynamic ways during thinking in action. However, this doesn’t replace reflective thinking that happens after the fact. Deliberate, methodical reflective thinking that happens after the fact, using specific strategies and tools (e.g., journaling, chart reviews, open dialogue with others) brings new insights, more depth, and greater accuracy—you can objectively identify “lessons learned” from experience.

 

 

Another consideration in today’s clinical setting that affects how we view 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.¹⁴ The PPMP model focuses on predicting problems, preventing complications, managing symptoms, and promoting health.

 

What’s the difference between DT and PPMP models? As an OT who is a key member of an interdisciplinary healthcare team, this is an important concept to understand. DT implies that we wait for evidence of problems before beginning treatment. For example, in the past, we monitored people with chronic atrial fibrillation for emboli and strokes, but we didn’t do much about prevention. Today, almost everyone with chronic atrial fibrillation is placed on anticoagulants to manage their risks for emboli and strokes. 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. To think critically, you have to stay abreast of  new technology, latest research, and evidence-based approaches that improve patient outcomes.

 

The concept of a predictive model applies to occupational therapy. As an OT, you use your knowledge to predict future behavior, anticipate the consequences of change, and partner with patients, families, and other care providers to develop comprehensive plans. While certainly some of the time you’re dealing with unknowns, you aren’t “navigating blind,” a terrifying feeling many patients experience. You apply your knowledge and skills to get focused on doing what needs to be done. The time you spend explaining what to expect, identifying what can be done to support patients, and creating a vision of what can be makes a significant impact on emotional well-being. Fear and depression are tremendous brain drains. Offer hope, examples, coaching, and skilled occupational therapy and you free patients’ minds to do the “real work” associated with learning various job- and role-related skills.

 

 

In many cases today critical paths (standard plans that address multidisciplinary care that must be done within certain time frames), protocols, and practice guidelines guide how care is given in specific situations. These types of plans are examples of using the PPMP model because they predict common complications and identify ways to prevent them. However, use of critical paths, protocols, and practice guidelines can either enhance or impede critical thinking. They can enhance thinking when they help thoughtful, knowledgeable care 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. Too often, providers 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 paths can replace “thinking.” As a critical thinker, be sure you use tools such as clinical pathways, protocols and practice guidelines with an open, questioning mind. Focus on your own direct patient assessments. When you use computerized guides, think with the computer (it can’t think for you). Be sure you recognize workers or peers who tend to be task-oriented — they might need a little closer supervision. (See sidebar.)

 

 

As we realize the importance of including patients early in the decision-making process, we now 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

(5) Alternate conclusions, ideas, and solutions were considered.

 

 

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 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 related to your particular discipline and job description. Learn how to put your thinking into words. Only then will others, such as peers 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 the 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 and classroom learning are important, but they 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 may know many OT principles and strategies, but until you’ve been in the trenches, working with many varied patients, dealing with clinical situations isn’t easy. You may know from class that some OT patients are aggressive. But that’s not the same as knowing how to remain calm, cool, and therapeutic when “under fire”. Remember that until you have good technical skills, such as working with technology and assistive devices, most of your brainpower goes toward mastering how to use the technology, leaving little energy for critical thinking. Keeping this in mind helps you set realistic expectations for critical thinking ability. Novices need repeated real-life experiences before they’re likely to be able to think critically about common patient problems.

 

3. Learn strategies that promote critical thinking (see sidebar examples).

 

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

 

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

 

 

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 complexities of measuring CT at http://findarticles.com/p/articles/mi_qa3969/is_200410/ai_n9463172.15 While this article addresses using instruments to evaluate the critical thinking abilities of physical therapy students, much of what is discussed applies to OTs as well.

 

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 describe what behaviors you should be observing when you are trying
to understand someone else’s thinking. Being observant of behavior and being willing to dialogue to understand someone else’s thinking is key to evaluating CT. If you don’t understand behavior or communication, be sure to say something like, “Help me understand what you’re
trying to do.”

 

To evaluate critical thinking ability, consider three things:

 

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?

 

Results: How do the patients look? How patients fare under an occupational therapist’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 an OT 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.

 

Documentation: Does the person always document the same thing as the person before did, or do you see new observations, insights, and comments?

 

In today’s challenging healthcare setting, to survive, even thrive, you must be clearly aware of how you think, how others think, and how to use strategies and tools to maximize your 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 in 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.