PROMOTING CRITICAL THINKING IN CLINICAL

SETTINGS

“The fatal pedagogical error is to throw answers, like stones, at the heads of those who
not yet asked the question”. Paul Tillich

D – DISCOVER
We’ve all heard the comments – “Why don’t these students/ new grads/ employees/ nurse
colleagues/ managers etc. critically think? Nursing Education and Nursing Management
literature has focused heavily on this concern since the early 80’s. Most nursing programs
try hard to infuse critical thinking (CT) content into their curriculum.

This is definitely indicated, since there is little assurance in the California Community
College system, that all entering students come with CT skills. In fact, many do not and it
is up to us to teach thinking and reflection skills along with everything else a novice
nurse has to know. We would contend that the clinical setting is where students really
learn to think. Nursing students learn to think, only if they are encouraged to think and
rewarded for their progress.

Some instructors discourage CT, by “thinking for the students”; putting words in their
mouths; settling for memorized factoids rather than clinical inquiry; focusing on
practicing manual skills (that could probably be better learned in a lab) rather than on
clinical decision making in the clinical arena and role development.

Many new instructors worry that they won’t be able to answer all their students
questions. BUT, more should be concerned about listening well to their students and
asking the kinds of questions that encourage CT.

The EXPLORE section lists many Books and articles that the author has found useful in
her exploration of the voluminous field of study in Critical Thinking,
Metacognition and reflection. The newest nursing literature has been emphasizing
how these skills improve clinical decision making and clinical judgment. This
module attempts to give you a basic understanding of this huge field of inquiry and
help you to help your students become better thinkers.
LEARNING OUTCOMES

• Define and describe desirable CT attributes.

• Practice using Socratic questioning in order to improve CT skills
• Recognize opportunities to encourage CT among students in pre and post
conferences.
• Use comments on care plans and written assignments that encourage CT.
• Apply improved CT skills to your own personal life and clinical practice
• Avoid answering students questions until they have applied CT skills.
R- READ –
So, how do you know a critical thinking nurse when you see one? Here is a
definition of the Thinking Nurse, That I developed in 1994, after reading
countless other definitions.

DEFINTION OF THE THINKING NURSE

A nurse who is a deliberative thinker is fair-minded, reflective

(metacognitive), trustful of reason, sees patterns and contradictions, makes
connections during their thinking that draws on all they know. Sees the big
picture, recognizes many of the implications of possible decisions, and
searches for creative solutions. Such a autonomous thinking nurse applies
these competencies in making sound decisions and taking action in their
personal and professionals lives. (M. Craig, 1994)

Stop and THINK about yourself and the nurses that you work with. Does this
definition describe you or any of your colleagues? Can you see that the clinical
setting is where these skills can be developed and fostered?

A large group of scholars in the “thinking” field came to agreement on the

following description of the ideal critical thinker in the early 90’s.

CRITICAL THINKING DISPOSITION

The ideal critical thinker is habitually inquisitive, well-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 the selection of criteria,
focused in inquiry, and persistent in seeking results which are as precise as
the subject and the circumstances of inquiry permit. (Delphi consensus
definition)

Again, reflect on yourself and your colleagues. Do they exhibit some of these
dispositions? How can this be encouraged? Many people have become
discouraged in their exploration of the Critical Thinking field because of the many
different definitions and complex terminology. I have found that students can
remember the following definition very well, and it helps them focus on CT.
 METACOGNITION
THINKING about your THINKING, while you are

THINKING, in order to improve the quality of your

THINKING.

My husband once described his frustration about a co-worker saying, “she is one of those
people who just doesn’t THINK before she speaks.” Of course, that negative attribute is
the last thing that we can tolerate in a nurse in the complex health care world of today.

If you are “inquisitive” about this topic, I suggest that you go to the Foundation for
Critical Thinking website listed in the EXPLORE section and order at least two of the
Miniature Guides – Critical Thinking Concepts and Tools and The Art of Asking
Essential Questions by Dr. Richard Paul and Dr. Linda Elder. Their Foundation is located
at Sonoma State University and they are well known throughout the world for their clear
tools that help educators teach people to become clear thinkers. At their Foundation
workshops and courses there are always many nurse educators learning and contributing.
NURSE AS THINKER

K. Lynn Wiech’s article “Faculty for the Millennium: Changes needed to attract the
emerging workforce into nursing”, describes nursing as a lifelong educational trajectory
in which nursing is seen as a series of value-added steps.”

Those steps are:

Nurse as doer Skills acquisition

Nurse as thinker Knowledge application

Nurse as practitioner Autonomous knowledge application

Nurse as researcher Knowledge generator

Think about the percentage of your time as a clinical instructor, that is spent on the above
four “steps”. If you are working with beginning students the focus is probably more on
the Nurse as doer. But beginning RN students need to envision themselves as Nurse as
thinker, practitioner and beginning researcher.

Do the clinical evaluation tools that your program is using recognize the nurse as thinker
and practitioner? If not, how might you recommend changing them? (Please note – you
cannot change the tools on your own, but you can recommend changes to the faculty for
future implementation. Most of the tools in use have been approved by the BRN as part
of Program accreditation and must be consistently used throughout the program.

The reason that it is so important for the tools to emphasize the importance of the nurse
as thinker is that students, particularly ineffective thinking students, worry about what
their evaluation form will reflect about them, more than whether you, their instructor
encourages them to become better thinkers.

Our GOAL in the clinical area is to help our students THINK like Nurses. Or better yet,
to be Thinking Nurses. If half of your group comes to you as effective thinkers and the
other half are ineffective in their thinking, your goal is to tip the balance for effective
thinking. It’s certainly not all up to you but it should be the collective goal of the nursing
program.
ASKING ESSENTIAL QUESTIONS

“The quality of our thinking is given in the quality of our questions.”

(Paul & Elder)

In addition to encouraging collective learning with your clinical groups the way you can
help your students become thinking nurses or to think like nurses is through your
questioning. Paul & Elder’s Miniature Guide to the Art of Asking Essential Questions is
based on Critical Thinking Concepts and Socratic Principles.

Most of us have heard about Socratic Questioning and hopefully have been the
beneficiaries of it as students, family members and colleagues. Socrates (469-399 BC)
was one of the primary classical Greek Philosophers. He left no writings himself, but his
famous student Plato described his teaching method, now known as Socratic dialogue or
dialectic. With this method, he drew forth knowledge from his students by pursuing a
series of questions and examining the implications of their answers. Furthermore,
according to the Concise Columbia Encyclopedia, Socrates equated virtue with the
knowledge of one’s true self, holding that no one knowingly does wrong. You may have
seen images of him conducting his Socratic dialogue sitting on one end of a log with his
pupil.

Paul and Elder say that the Socratic questioner deeply probes thinking. They say, that
what the word “Socratic” adds to ordinary questioning “is systematicity, depth and keen
interest in assessing the truth or plausibility of things”.

I have always asked a lot of questions, as an inquisitive child, as a student, practitioner

and instructor. But, I believe that I became a much better questioner after reading the Art
of Asking Essential Questions and other similar books. Since we cannot begin to cover
all that you will find in the 48 page booklet here, we encourage you to purchase an
individual copy of this mini guide for $6.00 each, from www.criticalthinking.org On
page 46, for example, they give examples of questions that use the fundamentals of
Socratic questioning. Those fundamentals are:

• Seek to understand

• Recognize that any thought can exist fully only in a network of

connected thoughts

• Treat all thoughts as in need of development

• Recognize that all questions presuppose prior questions. And all

thinking presupposes prior thinking.”
Can you see why this is such an important skill for all instructors but especially for
clinical nursing instructors?

On their website you can download their list of Universal Intellectual Standards and
Valuable Intellectual Traits. Another tool that they provide, that I have used in evaluating
written assignments, are two rubber stamps. One lets the instructor evaluate Intellectual
Standards quantifiably for assignments; Clarity, precision, accuracy, relevance, depth,
breath, and logic. The other stamp is used to help measure elements of thought – Purpose,
question, data, conclusion, concept, assumptions, implications and point of view.

“Nursing imbues the simplest acts with importance and

instills a desire for the utmost skill and accuracy in their
performance. Beyond all other drives (nursing)
commands devoted service…a broad perspective,…
rigorous analysis, close association with scientific
findings, fine perceptions, and enduring tolerance born
of understanding.”
(Anne Goodrich 1915)
E – EXPLORE

Books
Alfaro-LeFevre, Rosalinda (2003) Critical thinking and clinical judgment – A practical
Approach. (3rd ed) Philadelphia; W.B. Saunders

Brown,M.Neil and Keeley, Stuart. M. (1998) Asking the right questions: A guide to
Critical Thinking (5th Ed.) Upper Saddle River, Prentice Hall

Castillo, S (2003) Strategies, techniques & approaches to thinking. (2nd ed) Philadelphia.
W.B. Saunders

Craig, Margaret, (1996) “Critical thinking, cultural competence and caring” In Hamilton,
Persis, Realities of contemporary nursing, Menlo Park, Addison-Wesley.

De Bono, Edward (1999) Six Thinking Hats. Boston, Back Bay Books- Little Brown &
Co.

Elder, Linda & Paul, Richard (2002) The miniature guide to the art of asking essential
questions , The Foundation of Critical Thinking.

Elder, Linda & Paul, Richard (2001) Critical thinking tools for taking charge of your
learning and your life, Upper Saddle River, Prentice Hall

Elder, Linda & Paul, Richard (1999) , The miniature guide to critical thinking concepts
and tools. The Foundation for Critical Thinking

Fadiman, Anne (1997) The spirit catches you and you fall down, , New York, The
Noonday Press

Halpern, Diane F. (1996) Thought & knowledge – an introduction to critical thinking. (3rd
ed.) Mahwah, NJ Laurence Erlbaum Assoc. Inc.

Halpern, Diane F. (a996) Thinking critically about critical thinking. Mahwah, NJ.
Laurence Erlbaum Assoc. Inc.

Johnson, Betty & Webber, Pamela (2001) An introduction to theory and reasoning in
Nursing, Philadelphia, Lippincott, Williams & Wilkins.

Paul, Richard (1995) Critical Thinking- how to prepare students for a rapidly changing
world, Foundation for Critical Thinking

Rowles, C.J. & Brigham, C.(1998) “Strategies to promote critical thinking and active
learning” (pp.247-274). In Billings, D.M. & Halstead J.A., Teaching in nursing: A Guide
for faculty. Philadelphia: W.B. Saunders
Schuster, Pamela McHugh (2002) Concept Mapping: A critical-thinking approach to
Care Planning, Philadelphia, F.A. Davis

Senge, Peter (1994) The fifth discipline: the art and practice of the learning organization,
New York, Currency Doubleday

Winningham, Maryl & Preusser, Barbara (2001) Critical thinking in Medical-Surgical

Settings: A case study approach (2nd ed) St. Louis, Mosby

JOURNAL ARTICLES
Angel, Bonnie, Duffey, Margery, Belyea, Michael, (2000) “An evidence-based project
for evaluating strategies to improve knowledge acquisition and critical thinking
performance in Nursing students”, Journal of Nursing Education 39:5

Baker Charles (1996) Reflective Leaning: A teaching strategy for critical thinking”,
Journal of Nursing Education, 35:1

Becker, Mary Kay & Neuwirth, Janet M. (2002) “Teaching strategy to maximize clinical
experience with beginning nursing students”, Journal of Nursing Education , 41:2

Bowles, Kathleen, (2000), “The relationship of critical thinking skills and the clinical-
judgment skills of baccalaureate nursing students”, Journal of Nursing Education , 39:8

Callister, Lynn (1996) “Maternal interviews: a teaching strategy fostering critical

thinking”, Journal of Nursing Education 35:1

Duchscher, Judy E. Boychuck, (2003) “Critical thinking: Perceptions of newly graduated

female baccalaureate nurses”, Journal of Nursing Education 41:1

Elliott, Diane, “Promoting critical thinking in the classroom”, Nurse Educator 21:2

Iornside, P.M., (1999) “Thinking in nursing education,” Nursing and Health Care
Perspectives, 20, 238-247.

Maynard, Carleen A. (1996) “Relationship of critical thinking ability to professional

nursing competence”, Journal of Nursing Education 35:1

Perciful, Eileen & Nester, Patricia (1996) “The effect of an innovative clinical teaching
method on nursing student’s knowledge & critical thinking skills”, Journal of Nursing
Education 35:1

Phillips, Debby (2000), “Language as constitutive: critical thinking for multicultural

education and practice in the 21st century”, Journal of Nursing Education, 39:8
Scheffer, Barbara, & Rubenfeld M. Gaie, (2000) “A consensus statement on critical
thinking in nursing”, Journal of Nursing Education, 39:8

Schumacher, Jill & Severson, Annette (1996) “ Building bridges for future practice: an
innovative approach to foster critical thinking”, Journal of Nursing Education 35:1

Smith, Blenda & Johnson, Yvonne (2002) “Using structured clinical preparation to
stimulate reflection and foster critical thinking”, Journal of Nursing Education 41:4

Tanner, Christine, (2000), “Critical thinking: Beyond Nursing Process,” Journal of

Nursing Education, 39:8

Worrell, Pamela, (1996) “Metacognition: implications for instruction in nursing

education”, Journal of Nursing Education 29:4

WEB SITES
www.criticalthinking.org The Foundation for Critical Thinking at Sonoma State

www.sjsu.edu/depts/itv Mission :critical is an interactive tutorial for CT

www.kcnetro.cc.mo.us/longview/ctac/nursing

www.calpress.com Miller & Malcolm article

www.nursingnetwork.com/critthink1.htm

www.chss.montclair.edu/lct/homepage.html Institute for critical thinking

www.philosophy.unimelb.edu.au/reason/critical/ Australian web site

www.cariboo.bc.ca./nursing/faculty/heaslip/ct.htm Article intended for students

www.gc.maricopa.edu/nursing/aux1/269cpguidelines.doc The nursing process is the CT

strategy used to formulate comprehensive plans.
APPLY
IDEAS THAT WORK!

TRAITS OF EFFECTIVE AND INEFFECTIVE THINKERS

I have shared the list below with hundreds of students to help them assess their own
thinking traits.

TRAITS OF AN TRAITS OF INEFFECTIVE

EFFECTIVE THINKER . THINKERS

Welcomes problematic situations Searches for certainty

Uses active inquiry Is cognitively passive, accepting

Is tolerant of ambiguity Is intolerant of ambiguity

Is not self-critical
Is self-critical

Searches for alternatives Tends to be satisfied with first

Attempts and is overconfident
with initial ideas.
Searches for & weighs
Conflicting evidence. Ignores evidence that conflicts

Is reflective Is impulsive

Values rationality Values impulsivity

Perceives thinking as helpful, Perceives thinking as confusing,

Contributory cumbersome

Perceives interdependencies Perceives either/or

When discussing the chart with students it is easy to site examples relevant to nursing.
When discussing it individually with students it is all to easy to point out specific
examples of how they demonstrate effective or ineffective traits. When I first found this
list, and started to modify it, I changed the original column headings from Traits of Good
Thinkers and Traits of Bad Thinkers. You can probably figure out which student nurses
are more willing to consider “ineffective traits” over “bad traits”.

So much of the current literature talks about the incredible need for today’s nurses to be
able to “deal with ambiguity”. When I read this, I think of all the students who become
so exercised when it is necessary to change the date and time of a class or change a
clinical assignment. You have probably seen this also with students and co-workers. IT
certainly is not easy to change personality characteristics that are so grounded in certainty
and inflexible, but that is part of the goal of teaching critical thinking.

E=mc2
Since many of our students have to be convinced that “thinking is helpful and
contributory” or even “vital” to their practice and that nursing rarely presents black &
white or either/or situations, this familiar formula is a good visual learning device. Many
of our students have found success in school by their ability to memorize factoids. When
they start nursing they quickly learn that while helpful, memorizing is not enough to
achieve success as a nurse.

E = m c2

Educational material Critical Thinking

Benefits Content associated with the material,
Facts facts, content, concepts from
all previous experience.

THE BLIND MEN AND THE ELEPHANT

Perhaps you read the story of the Blind Men and The Elephant as a child. John G. Saxe
has adapted the story to a poem and few poems or stories better teach the vital concept of
“point of view” and how it hampers CT.
THE BLIND MEN AND THE ELEPHANT

John G. Saxe

It was six men of Indostan

To learning much inclined
Who went to see the elephant
(Though all of them were blind),
That each by observation
Might satisfy his mind.

The first approached the elephant

And, happening to fall
Against his broad and sturdy side,
At once began to bawl,
“God bless me! But the elephant
IS very like a wall!”

The second, feeling of the tusk

Cried: “Ho! What have we here
So very round and smooth and sharp?
To me ‘tis mighty clear
This wonder of an elephant
Is very like a spear!”

The third approached the animal,

And, happening to take
The squirming trunk within his hands,
Thus boldly up and spake:
“I see, quote he, “the elephant,
Is very like a snake!”

The fourth reached out his eager hand,

And felt about the knee;
“What most this wondrous beast is like
IS mighty plain,” quoth he;
“’Tis clear enough the elephant
Is very like a tree.”

The fifth, who chanced to touch the ear,

Said: “E’en the blindest man
Can tell what this resembles most.
Deny the fact who can,
This marvel of an elephant
 Is very like a fan!”

The sixth no sooner had begun

About the beast to grope,
Than, seizing on the swinging tail
That fell within his scope,
“I see,” quote he, “the elephant
Is very like a rope!”

And so these men of Indostan

Disputed loud and long,
Each in his’ own opinion
Exceeding stiff and strong.
Though each was partly in the right,
And all were in the wrong!

So, oft in theologic wars

The disputants, I ween,
Rail on in utter ignorance
Of what each other mean,
And prate about an elephant
Not one of them has seen!

When discussing this poem with students, it is fun and enlightening to bring up recent
clinical examples where there were differing perceptions of the same case situation.
Since we all tend to look at reality through our own lens of past experience and cultural
awareness, it is amazing that there are not more theologic wars in patient care situations.

A book that best illustrates this situation in health care is titled, When the Spirit Catches
You and you fall down, by Anne Fadiman. The story is about a Hmong child, her
American health care providers and the collision of two cultures. Most of the story takes
place in Merced, California, and in my opinion should be required reading for every
nursing student.

6 Thinking Hats
Edward de Bono’s best selling small book, entitled Six Thinking Hats was originally
directed to business managers to help them improve their thinking. The germ of the idea
came from the notion of a thinking cap. We’ve probably all heard the expression – you’ll
have to put on your thinking cap. His idea is that we can more deliberatively think if we
focus on six different elements of reasoning and thinking. For example, when wearing a
white hat, one is encouraged to focus on facts and figures or to be an analytic thinker. If
a student is asked to think with a real red hat or an imaginary red hat, he or she should be
thinking about that which brings values to bear and also hunches and intuition.
DeBono uses the image of a black hat (which I have adapted to a gold hat) to help
students think about and express the negative consequences or implications. Naturally,
there is another color hat, yellow, for thinking of the positive consequences or
implications. I especially enjoy introducing and revisiting this strategy because of green
hat thinking, which encourages creativity. The blue hat thinker is focusing on
metacognition and attempts to direct or orchestrate the thinking of others. Becoming an
excellent blue hat thinker, is a vital skill for nursing instructors.

I have added a seventh hat to my bag of hats, which I call the multicultural hat, (which
happens to be a lovely multicolored hat from Turkestan), and it encourages thinkers to
examine their biases, prejudices and assumptions.

For many years we have introduced students to these ideas at the beginning of the
program and then we reinforce them in lectures, lab and clinical. For example, in post
conference, an instructor might say, “Wow, I feel like everyone is looking at this
situation with their red hats on, lets break up into groups to examine the situation from a
white hat perspective and a gold hat perspective and a yellow hat perspective etc.

From these experiences, students quickly demonstrate the ability to examine situations
from different perspectives, and points of view, so that they can come to separate emotion
from logic, creativity from information and negative and positive consequences, and so
on. A major skill of an effective thinker is to be able to break down a situation or problem
into pieces that can be examined thoughtfully.

When I was first introduced to DeBono and his ideas, he was lecturing to hundreds of
Critical Thinking Conference attendees at M.I.T. To be certain that we learned how to
apply these ideas he had us divide into many small groups of about ten, and we were all
assigned different color hats (colored paper). The issue that we all discussed was a
proposal to end world hunger involving the UN and surplus foods available in the U.S. I
was amazed at how many different perspectives and ideas were clarified in this process.
In addition to being very impressed with the six hats idea, I gained added respect for
“collective learning”.

COLLECTIVE LEARNING
One of the most common ineffective thinking traits is “Tends to be satisfied with first
attempts and is over confident with initial ideas”. This “rush to judgment” or “fixation”,
as it is referred to in the medical community is notorious for so many of the tragic
mistakes that are made in the so-called health care system.

Peter Senge, another guru in the CT field, points out in the Fifth Dimension and other
writings that Collective Learning is not only possible, but vital to realize the potentials of
human intelligence. His books are also directed to the business community, but are most
relevant to clinical instruction in Nursing. The sacred post-conference, which has played
a critical part in the socialization of nurses for years, is the perfect setting for collective
learning. In this small group environment students need to learn to welcome problematic
situations and use active inquiry etc.

Senge says, “through dialogue people can help each other to become aware of the
incoherence in each other’s thoughts, and in this way the collective thought becomes
more and more coherent.” He encourages is to suspend assumptions – and to become
aware of them and hold them up for evaluation. He encourages us to see each other as
colleagues who don’t need to agree or share the same point of view, but listen and learn,
from colleagues with different views. Part of his vision for such dialog, or collective
learning, is “If I can look out through your view and you through mine, we will each see
something we might not have seen alone.” This is what he calls, “a larger pool of
meaning”, assessable to a group.

The rich diversity of experience and opinion that our students bring to our clinical groups
in an ideal arena for such leaning. Many of us learned the advantages of such collective
learning in our post-conference groups and carry it with is in report, committee work, at
home or in faculty meetings.

COLLABORATION
with others presents new perspectives (points of view), ideas and
options that individuals themselves might not and usually don’t
reach on their own.

ASS umptions
Assumptions based on experience can be the greatest asset when they are
correct, but the greatest hindrance when they are false.

CARTOONS-
One of the many things I observed among the CT gurus is that most of them use cartoons
and illustrations to get their ideas across. Of course they help our visual learners grasp
concepts and tend to be remembered by students.
In the cartoon that follows, picture the small child as a beginning first year student
looking at his or her instructor for support in the frightening “Sea” of the hospital
environment.

Someone said that a nursing student learns as many new words in their first year of
nursing school as they would if they were taking a German class. How many times do we
clarify that our students interpret our words as we intend them?

The “teacher” here could be one of us who is intent on “force feeding factoids” rather
than encouraging CT.

Calvin and Hobbes :

Reflective journals and written assignments are tools that help us evaluate a students
thinking (or lack of it).

Father and Son:

Parents do the most to instill effective or ineffective thinking traits.

Find your own cartoons that you can pass around to your students to encourage
THINKING. Better yet, encourage your students to bring them in to the collective
learning group.

M- MEASURE
1) Which teaching action (behavior) discourages the acquisition of CT for learners?

a. Asking students questions

b. Referring students to the answers in the textbook

c. Requiring through preparation

d. *Answering student questions before or when they are asked.

2) The term for thinking about your thinking, while you are thinking” is:

a. Critical Thinking

b. *Metacognition

c. Metageneration

d. Critical Analysis

3). The Critical Thinking guru who writes the most about “Collective learning” is

a. Richard Paul

b. *Peter Senge

c. Edward de Bono

d. Linda Elder
4). Which of the following aspects of educating nurses relies least on Critical Thinking?

a. *Skills acquisition

b. Knowledge application

c. Autonomous knowledge application

d. Knowledge generation

5) Collective learning techniques fit best in:

a. lecture courses

b. clinical practice

c. *post-conference

d. lab courses

6) Dialectic questioning originated from:

a. Richard Paul

b. *Socrates

c. Plato

d. DeBono

7) Cartoons can help illustrate critical thinking by:

a. *visual learners recognize important concepts

b. keep the students laughing

c. diagramming important ideas

d. poor readers can sometimes understand them

8) De Bono’s Six thinking hats ideas:

a. help students memorize facts

b. help students keep strait thinking concepts

c. *help students focus on different elements of reasoning

d. help students remember to think