Critical Thinking

The role of critical thinking in healthcare disciplines cannot be overemphasized. The ability to synthesize complex information and triage action based on critical analysis is a core skill to providing high-quality patient care. Papp et al. (2014) defined critical thinking as the ability to apply higher-order cognitive skills (such as conceptualization, analysis, and evaluation) and the disposition to be deliberate in that process, leading to an appropriate and logical action.

Greg K. is a 45-year-old male who presented with a constellation of symptoms, including fatigue, joint pain, skin rashes, and occasional fevers. Initially, the primary care physician suspected a viral infection, but when the symptoms persisted and worsened over several weeks, Greg was referred to a specialist for further evaluation.

Critical thinking is the cognitive search for one answer to a problem through logical thinking. It is a fundamental principle that underlies healthcare disciplines. Creative thinking begins with one problem but instead entertains multiple solutions.Healthcare professionals must be agile and innovative in recognizing and addressing clinical issues. A healthcare professional’s ability to practice critical thinking will significantly enhance or hinder their ability to make decisions in the healthcare setting. Critical thinking in healthcare is essential to professional accountability in providing quality patient care.

Repeated exposure to realistic and risk-free scenarios amplifies objective analysis skills, proficiency, critical thinking, and self-confidence (Al Gharibi et al., 2020). Healthcare educational programs integrate simulation exercises into the curriculum to develop critical thinking using real-world scenarios (Guerrero et al., 2022). Simple and complex scenarios are utilized to create situations where the students must make rapid decisions that directly impact patient outcomes. Self-reflection as part of the simulation exercise allows the student to understand better the ‘why’ behind the decision and consider alternatives that might improve outcomes in the future.

Cultural differences can affect how critical thinking is understood and applied. For example, in the United States, decision-making is considered an active component of critical thinking, whereas, in Thailand, there was a strong association between happiness and critical thinking.

Personal factors can also influence the way critical thinking is perceived and practiced. For example, decreased medical knowledge and lack of perceived time can negatively impact the ability to exercise critical thinking. Poor metacognitive skills, a fixed mindset, heuristics, and biases all affect the ability to think critically (Persky et al., 2019).

Attributes of a concept are defining factors that must be present for critical thinking to be present and effective. According to The Foundation for Critical Thinking (2023), attributes defining critical thinking include knowledge acquisition, knowledge application, information analysis, decision-making, and reflection.

Open-mindedness, autonomy, and knowledge are prerequisites for critical thinking that affect the student’s or professional’s capacity to engage in critical thinking. A vital requirement for critical thinking is the learner’s willingness to remain open-minded. Open-mindedness prepares the learner to consider alternative solutions or courses of action for improved outcomes. In the case study above, the nurse remained open-minded to the possibility that Greg’s symptoms may not all be attributed to Lyme disease. Being open-minded in this situation allowed the identification of an underlying factor beyond the immediate illness.

Autonomy has also been identified positively as a prerequisite for critical thinking. Independent thinking is paramount for clinicians who want to become critical thinkers. The process needs to become internalized and automated within the individual. In the case study presented, the nurse practitioner consulted with colleagues on the case, but ultimately, the decision on how to proceed with treatment remained with the nurse practitioner.

Critical thinking increases competence in clinical practice, which in turn improves patient outcomes. Clinical competence among graduates from healthcare educational programs is not homogenous and highly depends on the curriculum's focus on developing critical thinking skills. Employers are keen to recruit professionals with a solid educational foundation and have refined their critical thinking skills to a competent or expert level.

Knowledge is not enough to ensure a healthcare professional's competence. The ability to apply the acquired knowledge to positively affect the patient’s health outcomes is the fundamental skill that critical thinking exercises can assess for and improve. Remaining open-minded, retaining autonomy while exploring other options with colleagues, and having a solid knowledge base are all foundational to implementing critical thinking.

The final part of concept analysis in critical thinking is identifying empirical referents. An empirical referent in critical thinking within healthcare professions is the clinical competence of the professional. The professional is duty-bound to maintain clinical competence in their area of practice. One method of evaluating the empirical referent of clinical competence is to measure patient quality care outcomes.

Healthcare professionals must adjust to swiftly evolving clinical circumstances and utilize minimal resources to care for patients with complex medical conditions. These clinical practitioners must navigate medical situations that are often ambiguous, multifaceted, and stressful, where each decision can trigger a series of events that may ultimately determine the fate of the patients under their care.

In cases where traditional interventions are not effective, clinicians must use creative thinking combined with critical thinking to come up with patient-specific solutions that are quickly implemented and flexible so that they may be adaptable to other patients.

In most healthcare professions, the process is an essential method of systemic and rational planning in providing specialized care in a patient-centric manner. The process has five parts: assessment, diagnosis, planning, implementation, and evaluation (ADPIE).

“Intuition is the perception and understanding of concepts without the use of conscious reasoning”(Papathanasiou et al., 2014). It is typically not considered an appropriate technique for clinical decision-making. Some clinicians view it as a type of educated guessing, whereas others regard it as an integral component of clinical knowledge and skill acquisition. Some maintain that clinical instincts can be cultivated and refined through experience, rendering experienced clinicians invaluable. Note, however, that intuition is highly dependent upon clinical experience. The reliance on intuition should be discouraged with new graduates.

You are a nurse working in a post-surgical unit. Anna K is a 70-year-old Asian female who recently underwent abdominal surgery for a benign tumor. She was admitted to your unit within the last 24 hours. Her past medical history includes hypertension, type 2 diabetes, and depression. The surgery was uneventful, and Anna was stable during her post-operative recovery.

On the morning of postoperative day two, Anna’s vital signs were within normal range, but she had become restless and agitated by lunchtime. She rated her abdominal pain at a level 6 on a scale of 0 to 10 and described a “sharp stabbing” pain around the incision. Her dressing initially appeared dry and intact but has not been rechecked since the beginning of the shift. Her urine output is lower than expected, and she has not had a bowel movement since the surgery.

The nurse must have a fundamental knowledge base about surgical procedures to fully understand Anna's risks. Although her vital signs were initially stable, her status has changed with the increase in pain and clinical presentation. This situation requires the nurse to complete a new assessment, including vital signs. During the assessment, the nurse must use critical thinking skills, pulling from her knowledge about surgery and infection, to problem-solve the underlying issues that may be contributing to her increasing pain, restlessness, and agitation.

The nurse’s priority is to assess Anna’s pain further. It is critical to determine the nature, location, and intensity of the pain and inquire about any other associated symptoms that might be present, including nausea or vomiting, which could indicate paralytic ileus.

The surgical site should also be inspected again, along with auscultation of her bowel sounds to assess for borborygmus, signs of infection, hematoma, or dehiscence, which could cause increased pain and might require immediate intervention. Given Anna’s low urine output, the nurse should also consider dehydration as inadequate fluid intake could contribute to restlessness, abdominal discomfort, and constipation. Fluid replacement should be considered in collaboration with the medical provider to avoid fluid overload in patients with hypertension.

A medication review, including any analgesic or opioids administered for pain, should also be completed. If Anna did not receive any pain medication as scheduled, this could be contributing to her increasing pain at this time. Pain medication can also contribute to constipation.

If not already addressed, patient education regarding the importance of deep breathing exercises, coughing, and early ambulation to prevent post-surgical complications should also be considered and done. Helping Anna understand the expected course of recovery and what symptoms to report to staff allows her to have some control over her recovery process. It helps with early intervention if problems develop, especially after discharge.

As the nurse, you completed a full nursing assessment with vital signs and medication review. You found that the patient had a low-grade fever with redness and drainage around the incision site. A call was made to the surgeon, reporting the new findings. The surgeon came to the unit and completed a wound culture before ordering a new antibiotic with dressing changes every four hours. Anna’s pain was managed with her new treatment plan, and the crisis was averted with early intervention. Knowledge base is vital to critical thinking and is foundational for positive patient outcomes.

You are an outpatient Doctor of Physical Therapy who receives a referral for Mark, a 36-year-old man with a diagnosis of low back pain with sciatica. He has a history of episodic low back pain, for which physical therapy and NSAIDs have helped in the past. He is presently on Naproxen sodium 500mg, twice daily, as an anti-inflammatory and pain reliever, as well as Flexeril for muscle spasms at night. He was initially seen by his primary care physician, who performed an X-ray, which was unremarkable. Based on Mark's request and reports of past success with physical therapy, the primary care physician proceeds to refer him to physical therapy with a recommendation of joint mobilization, lumbar traction, and core stabilization exercises.

The patient is a well-developed, pleasant, healthy male of average weight and height. His gait is antalgic and guarded, and he demonstrates a severe unwillingness to move during his transitional movements from sitting to standing and while walking to the examination room and the plinth.  Upon patient interview, you are informed that he was lifting an iron support beam as part of his home construction project and immediately had severe pain in his lower back and down his right lower leg to his toes. He does not volunteer information about bowel or bladder control, but once asked; he does admit that he lost bladder control yesterday. He simply could not feel that he had to go. He attributed this to being distracted by his severe pain. He noted that “something weird” was happening when he used the restroom, and both legs went numb whenever he tried to urinate or have a bowel movement. He reports that he has not been sexually active since his injury. Upon examination, he demonstrates immediate pain reproduction with slight forward flexion and extension.  Special testing revealed a positive straight leg raise test at 15 degrees on the right lower extremity and 20 degrees on the left lower extremity. He has decreased bilateral reflexes in the L4, L5, and S1 reflexes and a non-dermatomal decreased sensation to light touch in his bilateral feet and lower legs right>left. He has bilateral weakness with manual muscle testing in his quadriceps, anterior tibialis, fibularis, and ankle plantar flexors. When tested in sitting, he had more than three beats of clonus in his plantar flexors on the right foot.

In Mark’s case, you must use your critical thinking skills to determine if Mark is appropriate for outpatient physical therapy. Once you have completed your evaluation, you need to decide if you will treat Mark, and if so, is Mark appropriate for manual therapy, traction, and exercises as recommended by his primary care physician, or does Mark require further diagnostic imaging or referral to a different specialist? Clinically, you need to decide if you will treat Mark, treat and then refer him to another specialist, or refer him without physical therapy treatment.

Given the severity of Mark's pain, a positive straight leg raise in the affected and contralateral lower extremity, weakness, and reflex alterations in multiple nerve roots, there is concern for a severe rupture of one of his lumbar discs. Often, severe discs can be treated with exercise and traction in combination with the medications that Mark has already been prescribed. It is essential that you, as the Doctor of Physical Therapy, recognize the more severe and concerning symptoms of bladder incontinence and Mark's report of his legs “going numb” when he tries to urinate or attempts a bowel movement. These symptoms are red flag symptoms and could be indicative of cauda equina syndrome, and while rare, are an actual emergency. Mark needs to be referred to the Emergency Department immediately for further testing. Mark’s wife took him immediately to the nearest emergency department, where they performed an MRI and determined Mark did have a massive disc herniation, creating cord and nerve root compression. It was recommended that he have immediate, emergent surgery for decompression.

In the case studies above, critical thinking was pivotal in the patient outcomes. The critical thinking process involved gathering comprehensive information, identifying patterns, generating hypotheses, evaluating evidence, consulting with colleagues, and refining the diagnosis and treatment plan. All healthcare professionals must prioritize critical thinking as an essential skill. Critical thinking commands respect and is highly sought-after in 21st-century professional practice. With healthcare systems growing in complexity, practitioners are tasked with seamlessly blending healthcare expertise with ever-evolving technological advancements. Proficiency in critical thinking is ultimately the responsibility of each clinician.

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