critical thinking cycle

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The Clinical Reasoning Cycle: The 8 Phases and their Significance

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Clinical Reasoning and Critical Thinking: Integrated and Complementary

The Modality Principle: Rationale and Limitations

What is Clinical Reasoning and Why is it Important?

Applying the Principle of Temporal Contiguity

A concept called the Clinical Reasoning Cycle, promoted by Tracy-Levett Jones, a professor of Nursing at Newcastle, organizes the clinical reasoning process into several steps. It walks every healthcare professional, especially physicians and nurses, through systematic steps that involve logical considerations. Adopting this cycle facilitates the “thinking” behind the patient’s management plan, allowing the healthcare professional to go through a series of systematic phases, ultimately leading to a final decision that considers what is best for the patient in a particular situation.

Various Phases of the Clinical Reasoning Cycle

There are eight phases of clinical reasoning and one must note that this process, though divided into phases, is a continuum. In reality, one does not always move from one step or phase to the next, but rather move back and forth from one phase to another until an accurate assessment of a patient’s health status is made.

Adapted from Tracy Levett-Jones, et al. (2010)

The various phases of clinical reasoning include:

Consideration of facts from the patient or situation

This is the phase where you are first presented with a clinical case. Here you receive the presenting information and current medical status of the patient, for example, a new-born admitted in the NICU on account of neonatal jaundice.

Collection of information

In this phase, you carefully consider the past medical history of the patient, the history of presenting complaints, the current treatment plan, results of investigations done, and current vital signs. You then analyse the findings using your established knowledge of physiology, pharmacology, pathology, culture, and ethics to establish cues and draw information.

Processing gathered information

This is a critical stage and the core of clinical reasoning. Here, you process the data on the patient’s current health status in relation to pathophysiological and pharmacological patterns, know what details are relevant, and determine potential outcomes for possible decisions you make.

Identify the problem

With a solid information processing phase, you will be able to determine the reason behind the patient’s current state.

Establish goals

Here, you determine the treatment goals for the patient’s situation.Treatment plans should not be open-ended or without a time-oriented goal. Know what step to take, and how fast you want the desired outcome.

Take action

Now, you implement the actions steps needed to meet the patient’s treatment goals. This will, of course, involve other members of the healthcare team, so everyone should be updated about the treatment goals for the particular patient.

At this phase, you evaluate the effectiveness of the course of action you have taken. This will allow you to determine whether to readjust or continue the line of action.

This phase of clinical reasoning fortifies the skill. At this phase, you reflect on new things you learned about the case, what you could have done differently to achieve a better outcome, and what should be avoided in similar occurrences in the future.

Following these phases of the clinical reasoning cycle will facilitate problem-solving and decision making, allowing you as a health care professional to provide the best care for your patients.

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How to think effectively: Six stages of critical thinking

Credit: Elder / Paul

• Researchers propose six levels of critical thinkers: Unreflective thinkers, Challenged thinkers, Beginning thinkers, Practicing thinkers, Advanced thinkers, and Master thinkers.
• The framework comes from educational psychologists Linda Elder and Richard Paul.
• Teaching critical thinking skills is a crucial challenge in our times.

The coronavirus has not only decimated our populations, its spread has also attacked the very nature of truth and stoked inherent tensions between many different groups of people, both at local and international levels. Spawning widespread conspiracy theories and obfuscation by governments, the virus has also been a vivid demonstration of the need for teaching critical thinking skills necessary to survive in the 21st century. The stage theory of critical thinking development, devised by psychologists Linda Elder and Richard Paul , can help us gauge the sophistication of our current mental approaches and provides a roadmap to the thinking of others.

The researchers identified six predictable levels of critical thinkers, from ones lower in depth and effort to the advanced mind-masters, who are always steps ahead.

As the scientists write , moving up on this pyramid of thinking “is dependent upon a necessary level of commitment on the part of an individual to develop as a critical thinker.” Using your mind more effectively is not automatic and “is unlikely to take place “subconsciously.” In other words – you have to put in the work and keep doing it, or you’ll lose the faculty.

Here’s how the stages of intellectual development break down:

Unreflective thinker

These are people who don’t reflect about thinking and the effect it has on their lives. As such, they form opinions and make decisions based on prejudices and misconceptions while their thinking doesn’t improve.

Unreflective thinkers lack crucial skills that would allow them to parse their thought processes. They also do not apply standards like accuracy, relevance, precision, and logic in a consistent fashion.

How many such people are out there? You probably can guess based on social media comments. As Elder and Paul write , “it is perfectly possible for students to graduate from high school, or even college, and still be largely unreflective thinkers.”

Challenged thinker

This next level up thinker has awareness of the importance of thinking on their existence and knows that deficiencies in thinking can bring about major issues. As the psychologists explain, to solve a problem, you must first admit you have one.

People at this intellectual stage begin to understand that “high quality thinking requires deliberate reflective thinking about thinking”, and can acknowledge that their own mental processes might have many flaws. They might not be able to identify all the flaws, however.

A challenged thinker may have a sense that solid thinking involves navigating assumptions, inferences, and points of view, but only on an initial level. They may also be able to spot some instances of their own self-deception. The true difficulty for thinkers of this category is in not “believing that their thinking is better than it actually is, making it more difficult to recognize the problems inherent in poor thinking,” explain the researchers.

Thinkers at this level can go beyond the nascent intellectual humility and actively look to take control of their thinking across areas of their lives. They know that their own thinking can have blind spots and other problems and take steps to address those, but in a limited capacity.

Beginning thinker

Beginning thinkers place more value in reason, becoming self-aware in their thoughts. They may also be able to start looking at the concepts and biases underlying their ideas. Additionally, such thinkers develop higher internal standards of clarity, accuracy and logic, realizing that their ego plays a key role in their decisions.

Another big aspect that differentiates this stronger thinker – some ability to take criticism of their mental approach, even though they still have work to do and might lack clear enough solutions to the issues they spot.

Practicing thinker

This more experienced kind of thinker not only appreciates their own deficiencies, but has skills to deal with them. A thinker of this level will practice better thinking habits and will analyze their mental processes with regularity.

While they might be able to express their mind’s strengths and weaknesses, as a negative, practicing thinkers might still not have a systematic way of gaining insight into their thoughts and can fall prey to egocentric and self-deceptive reasoning.

How do you get to this stage? An important trait to gain, say the psychologists, is “intellectual perseverance.” This quality can provide “the impetus for developing a realistic plan for systematic practice (with a view to taking greater command of one’s thinking).”

“We must teach in such a way that students come to understand the power in knowing that whenever humans reason, they have no choice but to use certain predictable structures of thought: that thinking is inevitably driven by the questions, that we seek answers to questions for some purpose, that to answer questions, we need information, that to use information we must interpret it (i.e., by making inferences), and that our inferences, in turn, are based on assumptions, and have implications, all of which involves ideas or concepts within some point of view,” explain Elder and Paul.

One doesn’t typically get to this stage until college and beyond, estimate the scientists. This higher-level thinker would have strong habits that would allow them to analyze their thinking with insight about different areas of life. They would be fair-minded and able to spot the prejudicial aspects in the points of view of others and their own understanding.

While they’d have a good handle on the role of their ego in the idea flow, such thinkers might still not be able to grasp all the influences that affect their mentality.

Advanced thinker

The advanced thinker is at ease with self-critique and does so systematically, looking to improve. Among key traits required for this level are “intellectual insight” to develop new thought habits, “ intellectual integrity” to “recognize areas of inconsistency and contradiction in one’s life,” intellectual empathy ” to put oneself in the place of others in order to genuinely understand them, and the “ intellectual courage” to confront ideas and beliefs they don’t necessarily believe in and have negative emotions towards.

Master thinker

This is the super-thinker, the one who is totally in control of how they process information and make decisions. Such people constantly seek to improve their thought skills, and through experience “regularly raise their thinking to the level of conscious realization.”

A master thinker achieves great insights into deep mental levels, strongly committed to being fair and gaining control over their own egocentrism.

Such a high-level thinker also exhibits superior practical knowledge and insight, always re-examining their assumptions for weaknesses, logic, and biases.

And, of course, a master thinker wouldn’t get upset with being intellectually confronted and spends a considerable amount of time analyzing their own responses.

“Why is this so important? Precisely because the human mind, left to its own, pursues that which is immediately easy, that which is comfortable, and that which serves its selfish interests. At the same time, it naturally resists that which is difficult to understand, that which involves complexity, that which requires entering the thinking and predicaments of others,” write the researchers.

So how do you become a master thinker? The psychologists think most students will never get there. But a lifetime of practicing the best intellectual traits can get you to that point when “people of good sense seek out master thinkers, for they recognize and value the ability of master thinkers to think through complex issues with judgment and insight.”

The significance of critical thinking in our daily lives, especially in these confusing times, so rife with quick and often-misleading information, cannot be overstated. The decisions we make today can truly be life and death.

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What Are Critical Thinking Skills and Why Are They Important?

Learn what critical thinking skills are, why they’re important, and how to develop and apply them in your workplace and everyday life.

We often use critical thinking skills without even realizing it. When you make a decision, such as which cereal to eat for breakfast, you're using critical thinking to determine the best option for you that day.

Critical thinking is like a muscle that can be exercised and built over time. It is a skill that can help propel your career to new heights. You'll be able to solve workplace issues, use trial and error to troubleshoot ideas, and more.

We'll take you through what it is and some examples so you can begin your journey in mastering this skill.

What is critical thinking?

Critical thinking is the ability to interpret, evaluate, and analyze facts and information that are available, to form a judgment or decide if something is right or wrong.

More than just being curious about the world around you, critical thinkers make connections between logical ideas to see the bigger picture. Building your critical thinking skills means being able to advocate your ideas and opinions, present them in a logical fashion, and make decisions for improvement.

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Why is critical thinking important?

Critical thinking is useful in many areas of your life, including your career. It makes you a well-rounded individual, one who has looked at all of their options and possible solutions before making a choice.

According to the University of the People in California, having critical thinking skills is important because they are [ 1 ]:

Crucial for the economy

Essential for improving language and presentation skills

Very helpful in promoting creativity

Important for self-reflection

The basis of science and democracy 

Critical thinking skills are used every day in a myriad of ways and can be applied to situations such as a CEO approaching a group project or a nurse deciding in which order to treat their patients.

Examples of common critical thinking skills

Critical thinking skills differ from individual to individual and are utilized in various ways. Examples of common critical thinking skills include:

Identification of biases: Identifying biases means knowing there are certain people or things that may have an unfair prejudice or influence on the situation at hand. Pointing out these biases helps to remove them from contention when it comes to solving the problem and allows you to see things from a different perspective.

Research: Researching details and facts allows you to be prepared when presenting your information to people. You’ll know exactly what you’re talking about due to the time you’ve spent with the subject material, and you’ll be well-spoken and know what questions to ask to gain more knowledge. When researching, always use credible sources and factual information.

Open-mindedness: Being open-minded when having a conversation or participating in a group activity is crucial to success. Dismissing someone else’s ideas before you’ve heard them will inhibit you from progressing to a solution, and will often create animosity. If you truly want to solve a problem, you need to be willing to hear everyone’s opinions and ideas if you want them to hear yours.

Analysis: Analyzing your research will lead to you having a better understanding of the things you’ve heard and read. As a true critical thinker, you’ll want to seek out the truth and get to the source of issues. It’s important to avoid taking things at face value and always dig deeper.

Problem-solving: Problem-solving is perhaps the most important skill that critical thinkers can possess. The ability to solve issues and bounce back from conflict is what helps you succeed, be a leader, and effect change. One way to properly solve problems is to first recognize there’s a problem that needs solving. By determining the issue at hand, you can then analyze it and come up with several potential solutions.

How to develop critical thinking skills

You can develop critical thinking skills every day if you approach problems in a logical manner. Here are a few ways you can start your path to improvement:

1. Ask questions.

Be inquisitive about everything. Maintain a neutral perspective and develop a natural curiosity, so you can ask questions that develop your understanding of the situation or task at hand. The more details, facts, and information you have, the better informed you are to make decisions.

2. Practice active listening.

Utilize active listening techniques, which are founded in empathy, to really listen to what the other person is saying. Critical thinking, in part, is the cognitive process of reading the situation: the words coming out of their mouth, their body language, their reactions to your own words. Then, you might paraphrase to clarify what they're saying, so both of you agree you're on the same page.

3. Develop your logic and reasoning.

This is perhaps a more abstract task that requires practice and long-term development. However, think of a schoolteacher assessing the classroom to determine how to energize the lesson. There's options such as playing a game, watching a video, or challenging the students with a reward system. Using logic, you might decide that the reward system will take up too much time and is not an immediate fix. A video is not exactly relevant at this time. So, the teacher decides to play a simple word association game.

Scenarios like this happen every day, so next time, you can be more aware of what will work and what won't. Over time, developing your logic and reasoning will strengthen your critical thinking skills.

Learn tips and tricks on how to become a better critical thinker and problem solver through online courses from notable educational institutions on Coursera. Start with Introduction to Logic and Critical Thinking from Duke University or Mindware: Critical Thinking for the Information Age from the University of Michigan.

Article sources

University of the People, “ Why is Critical Thinking Important?: A Survival Guide , https://www.uopeople.edu/blog/why-is-critical-thinking-important/.” Accessed May 18, 2023.

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Coursera staff.

Editorial Team

Coursera’s editorial team is comprised of highly experienced professional editors, writers, and fact...

This content has been made available for informational purposes only. Learners are advised to conduct additional research to ensure that courses and other credentials pursued meet their personal, professional, and financial goals.

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• Critical Thinking

Q&A: What is critical thinking and when would you use critical thinking in the clinical setting?

(Write 2-3 paragraphs)

In literature ‘critical thinking’ is often used, and perhaps confused, with problem-solving and clinical decision-making skills and clinical reasoning. In practice, problem-solving tends to focus on the identification and resolution of a problem, whilst critical thinking goes beyond this to incorporate asking skilled questions and critiquing solutions.

Critical thinking has been defined in many ways, but is essentially the process of deliberate, systematic and logical thinking, while considering bias or assumptions that may affect your thinking or assessment of a situation. In healthcare, the clinical setting whether acute care sector or aged care critical thinking has generally been defined as reasoned, reflective thinking which can evaluate the given evidence and its significance to the patient’s situation. Critical thinking occasionally involves suspension of one’s immediate judgment to adequately evaluate and appraise a situation, including questioning whether the current practice is evidence-based. Skills such as interpretation, analysis, evaluation, inference, explanation, and self-regulation are required to interpret thinking and the situation. A lack of critical thinking may manifest as a failure to anticipate the consequences of one’s actions.

Critical thinking is that mode of thinking – about any subject, content, or problem — in which the thinker improves the quality of his or her thinking by skillfully taking charge of the structures inherent in thinking and imposing intellectual standards upon them.

The Paul-Elder framework has three components:

• The elements of thought (reasoning)
• The intellectual standards that should be applied to the elements of reasoning
• The intellectual traits associated with a cultivated critical thinker that result from the consistent and disciplined application of the intellectual standards to the elements of thought.

Critical thinking can be defined as, “the art of analysing and evaluating thinking with a view to improving it”. The eight Parts or Elements of Thinking involved in critical thinking:

• All reasoning has a purpose (goals, objectives).
• All reasoning is an attempt to figure something out, to settle some question, to solve some problem .
• All reasoning is based on assumptions (line of reasoning, information taken for granted).
• All reasoning is done from some point of view.
• All reasoning is based on data, information and evidence .
• All reasoning is expressed through, and shaped by, concepts and ideas .
• All reasoning contains inferences or interpretations by which we draw conclusions and give meaning to data.
• All reasoning leads somewhere or has implications and consequence.

Q&A: To become a nurse requires that you learn to think like a nurse. What makes the thinking of a nurse different from a doctor, a dentist or an engineer?

It is how we view the health care consumer or aged care consumer, and the type of problems nurses deal with in clinical practice when we engage in health care patient centred care. To think like a nurse requires that we learn the content of nursing; the ideas, concepts, ethics and theories of nursing and develop our intellectual capacities and skills so that we become disciplined, self-directed, critical thinkers.

As a nurse you are required to think about the entire patient/s and what you have learnt as a nurse including; ideas, theories, and concepts in nursing. It is important that we develop our skills so that we become highly proficient critical thinkers in nursing.

In nursing, critical thinkers need to be:

Nurses need to use language that will clearly communicate a lot of information that is key to good nursing care, for handover and escalation of care for improving patient safety and reducing adverse outcomes, some organisations use the iSoBAR (identify–situation–observations–background–agreed plan–read back) format. Firstly, the “i”, for “identify yourself and the patient”, placed the patient’s identity, rather than the diagnosis, in primary position and provided a method of introduction. (This is particularly important when teams are widely spread geographically.) The prompt, “S” (“situation”) “o” for “observations”, was included to provide an adequate baseline of factual information on which to devise a plan of care. and “B” (“background”), “A” “agreed plan” and “R” “read back” to reinforce the transfer of information and accountability.

In clinical practice experienced nurses engage in multiple clinical reasoning episodes for each patient in their care. An experienced nurse may enter a patient’s room and immediately observe significant data, draw conclusions about the patient and initiate appropriate care. Because of their knowledge, skill and experience the expert nurse may appear to perform these processes in a way that seems automatic or instinctive. However, clinical reasoning is a learnt skill.

Key critical thinking skills – the clinical reasoning cycle / critical thinking process

To support nursing students in the clinical setting, breakdown the critical thinking process into phases;

• Decide/identify

This is a dynamic process and nurses often combine one or more of the phases, move back and forth between them before reaching a decision, reaching outcomes and then evaluating outcomes.

For nursing students to learn to manage complex clinical scenarios effectively, it is essential to understand the process and steps of clinical reasoning. Nursing students need to learn rules that determine how cues shape clinical decisions and the connections between cues and outcomes.

Start with the Patient – what is the issue? Holistic approach – describe or list the facts, people.

Collect information – Handover report, medical and nursing, allied health notes. Results, patient history and medications.

• New information – patient assessment

Process Information – Interpret- data, signs and symptoms, normal and abnormal.

• Analyse – relevant from non-relevant information, narrow down the information
• Evaluate – deductions or form opinions and outcomes

Identify Problems – Analyse the facts and interferences to make a definitive diagnosis of the patients’ problem.

Establish Goals – Describe what you want to happen, desired outcomes and timeframe.

Take action – Select a course of action between alternatives available.

Evaluate Outcomes – The effectiveness of the actions and outcomes. Has the situation changed or improved?

Reflect on process and new learning – What have you learnt and what would you do differently next time.

Scenario: Apply the clinical reasoning cycle, see below, to a scenario that occurred with a patient in your clinical practice setting. This could be the doctor’s orders, the patient’s vital signs or a change in the patient’s condition.

(Write 3-5 paragraphs)

Important skills for critical thinking

Some skills are more important than others when it comes to critical thinking. The skills that are most important are:

• Interpreting – Understanding and explaining the meaning of information, or a particular event.
• Analysing – Investigating a course of action, that is based upon data that is objective and subjective.
• Evaluating – This is how you assess the value of the information that you have. Is the information relevant, reliable and credible?

This skill is also needed to determine if outcomes have been fully reached.

Based upon those three skills, you can use clinical reasoning to determine what the problem is.

These decisions have to be based upon sound reasoning:

• Explaining – Clearly and concisely explaining your conclusions. The nurse needs to be able to give a sound rationale for their answers.
• Self-regulating – You have to monitor your own thought processes. This means that you must reflect on the process that lead to the conclusion. Be on alert for bias and improper assumptions.

Critical thinking pitfalls

Errors that occur in critical thinking in nursing can cause incorrect conclusions. This is particularly dangerous in nursing because an incorrect conclusion can lead to incorrect clinical actions.

Illogical Processes

A common illogical thought process is known as “appeal to tradition”. This is what people are doing when they say it’s always been done like this. Creative, new approaches are not tried because of tradition.

All people have biases. Critical thinkers are able to look at their biases and not let them compromise their thinking processes.

Biases can complicate decision making, communication and ultimately effect patient care.

Closed Minded

Being closed-minded in nursing is dangerous because it ignores other team members points of view. Essential input from other experts, as well as patients and their families are also ignored which ultimately impacts on patient care. This means that fewer clinical options are explored, and fewer innovative ideas are used for critical thinking to guide decision making.

So, no matter if you are an intensive care nurse, community health nurse or a nurse practitioner, you should always keep in mind the importance of critical thinking in the nursing clinical setting.

It is essential for nurses to develop this skill: not only to have knowledge but to be able to apply knowledge in anticipation of patients’ needs using evidence-based care guidelines.

American Management Association (2012). ‘AMA 2012 Critical Skills Survey: Executive Summary’. (2012). American Management Association. http://playbook.amanet.org/wp-content/uploads/2013/03/2012-Critical-Skills-Survey-pdf.pdf   Accessed 5 May 2020.

Korn, M. (2014). ‘Bosses Seek ‘Critical Thinking,’ but What Is That?,’ The Wall Street Journal . https://www.wsj.com/articles/bosses-seek-critical-thinking-but-what-is-that-1413923730?tesla=y&mg=reno64-wsj&url=http://online.wsj.com/article/SB12483389912594473586204580228373641221834.html#livefyre-comment Accessed 5 May 2020.

School of Nursing and Midwifery Faculty of Health, University of Newcastle. (2009). Clinical reasoning. Instructors resources. https://www.newcastle.edu.au/__data/assets/pdf_file/0010/86536/Clinical-Reasoning-Instructor-Resources.pdf  Accessed 11 May 2020

The Value of Critical Thinking in Nursing + Examples. Nurse Journal social community for nurses worldwide. 2020.  https://nursejournal.org/community/the-value-of-critical-thinking-in-nursing/ Accessed 8 May 2020.

Paul And Elder (2009) Have Defined Critical Thinking As: The Art of Analysing And Evaluating …

https://www.chegg.com/homework-help/questions-and-answers/paul-elder-2009-defined-critical-thinking-art-analyzing-evaluating-thinking-view-improving-q23582096 Accessed 8 May 2020 .

Cody, W.K. (2002). Critical thinking and nursing science: judgment, or vision? Nursing Science Quarterly, 15(3), 184-189.

Facione, P. (2011). Critical thinking: What it is and why it counts. Insight Assessment , ISBN 13: 978-1-891557-07-1.

McGrath, J. (2005). Critical thinking and evidence- based practice. Journal of Professional Nursing, 21(6), 364-371.

Porteous, J., Stewart-Wynne, G., Connolly, M. and Crommelin, P. (2009). iSoBAR — a concept and handover checklist: the National Clinical Handover Initiative. Med J Aust 2009; 190 (11): S152.

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Critical Thinking

Critical thinking is a widely accepted educational goal. Its definition is contested, but the competing definitions can be understood as differing conceptions of the same basic concept: careful thinking directed to a goal. Conceptions differ with respect to the scope of such thinking, the type of goal, the criteria and norms for thinking carefully, and the thinking components on which they focus. Its adoption as an educational goal has been recommended on the basis of respect for students’ autonomy and preparing students for success in life and for democratic citizenship. “Critical thinkers” have the dispositions and abilities that lead them to think critically when appropriate. The abilities can be identified directly; the dispositions indirectly, by considering what factors contribute to or impede exercise of the abilities. Standardized tests have been developed to assess the degree to which a person possesses such dispositions and abilities. Educational intervention has been shown experimentally to improve them, particularly when it includes dialogue, anchored instruction, and mentoring. Controversies have arisen over the generalizability of critical thinking across domains, over alleged bias in critical thinking theories and instruction, and over the relationship of critical thinking to other types of thinking.

2.1 Dewey’s Three Main Examples

2.2 dewey’s other examples, 2.3 further examples, 2.4 non-examples, 3. the definition of critical thinking, 4. its value, 5. the process of thinking critically, 6. components of the process, 7. contributory dispositions and abilities, 8.1 initiating dispositions, 8.2 internal dispositions, 9. critical thinking abilities, 10. required knowledge, 11. educational methods, 12.1 the generalizability of critical thinking, 12.2 bias in critical thinking theory and pedagogy, 12.3 relationship of critical thinking to other types of thinking, other internet resources, related entries.

Use of the term ‘critical thinking’ to describe an educational goal goes back to the American philosopher John Dewey (1910), who more commonly called it ‘reflective thinking’. He defined it as

active, persistent and careful consideration of any belief or supposed form of knowledge in the light of the grounds that support it, and the further conclusions to which it tends. (Dewey 1910: 6; 1933: 9)

and identified a habit of such consideration with a scientific attitude of mind. His lengthy quotations of Francis Bacon, John Locke, and John Stuart Mill indicate that he was not the first person to propose development of a scientific attitude of mind as an educational goal.

In the 1930s, many of the schools that participated in the Eight-Year Study of the Progressive Education Association (Aikin 1942) adopted critical thinking as an educational goal, for whose achievement the study’s Evaluation Staff developed tests (Smith, Tyler, & Evaluation Staff 1942). Glaser (1941) showed experimentally that it was possible to improve the critical thinking of high school students. Bloom’s influential taxonomy of cognitive educational objectives (Bloom et al. 1956) incorporated critical thinking abilities. Ennis (1962) proposed 12 aspects of critical thinking as a basis for research on the teaching and evaluation of critical thinking ability.

Since 1980, an annual international conference in California on critical thinking and educational reform has attracted tens of thousands of educators from all levels of education and from many parts of the world. Also since 1980, the state university system in California has required all undergraduate students to take a critical thinking course. Since 1983, the Association for Informal Logic and Critical Thinking has sponsored sessions in conjunction with the divisional meetings of the American Philosophical Association (APA). In 1987, the APA’s Committee on Pre-College Philosophy commissioned a consensus statement on critical thinking for purposes of educational assessment and instruction (Facione 1990a). Researchers have developed standardized tests of critical thinking abilities and dispositions; for details, see the Supplement on Assessment . Educational jurisdictions around the world now include critical thinking in guidelines for curriculum and assessment.

For details on this history, see the Supplement on History .

2. Examples and Non-Examples

Before considering the definition of critical thinking, it will be helpful to have in mind some examples of critical thinking, as well as some examples of kinds of thinking that would apparently not count as critical thinking.

Dewey (1910: 68–71; 1933: 91–94) takes as paradigms of reflective thinking three class papers of students in which they describe their thinking. The examples range from the everyday to the scientific.

Transit : “The other day, when I was down town on 16th Street, a clock caught my eye. I saw that the hands pointed to 12:20. This suggested that I had an engagement at 124th Street, at one o’clock. I reasoned that as it had taken me an hour to come down on a surface car, I should probably be twenty minutes late if I returned the same way. I might save twenty minutes by a subway express. But was there a station near? If not, I might lose more than twenty minutes in looking for one. Then I thought of the elevated, and I saw there was such a line within two blocks. But where was the station? If it were several blocks above or below the street I was on, I should lose time instead of gaining it. My mind went back to the subway express as quicker than the elevated; furthermore, I remembered that it went nearer than the elevated to the part of 124th Street I wished to reach, so that time would be saved at the end of the journey. I concluded in favor of the subway, and reached my destination by one o’clock.” (Dewey 1910: 68–69; 1933: 91–92)

Ferryboat : “Projecting nearly horizontally from the upper deck of the ferryboat on which I daily cross the river is a long white pole, having a gilded ball at its tip. It suggested a flagpole when I first saw it; its color, shape, and gilded ball agreed with this idea, and these reasons seemed to justify me in this belief. But soon difficulties presented themselves. The pole was nearly horizontal, an unusual position for a flagpole; in the next place, there was no pulley, ring, or cord by which to attach a flag; finally, there were elsewhere on the boat two vertical staffs from which flags were occasionally flown. It seemed probable that the pole was not there for flag-flying.

“I then tried to imagine all possible purposes of the pole, and to consider for which of these it was best suited: (a) Possibly it was an ornament. But as all the ferryboats and even the tugboats carried poles, this hypothesis was rejected. (b) Possibly it was the terminal of a wireless telegraph. But the same considerations made this improbable. Besides, the more natural place for such a terminal would be the highest part of the boat, on top of the pilot house. (c) Its purpose might be to point out the direction in which the boat is moving.

“In support of this conclusion, I discovered that the pole was lower than the pilot house, so that the steersman could easily see it. Moreover, the tip was enough higher than the base, so that, from the pilot’s position, it must appear to project far out in front of the boat. Moreover, the pilot being near the front of the boat, he would need some such guide as to its direction. Tugboats would also need poles for such a purpose. This hypothesis was so much more probable than the others that I accepted it. I formed the conclusion that the pole was set up for the purpose of showing the pilot the direction in which the boat pointed, to enable him to steer correctly.” (Dewey 1910: 69–70; 1933: 92–93)

Bubbles : “In washing tumblers in hot soapsuds and placing them mouth downward on a plate, bubbles appeared on the outside of the mouth of the tumblers and then went inside. Why? The presence of bubbles suggests air, which I note must come from inside the tumbler. I see that the soapy water on the plate prevents escape of the air save as it may be caught in bubbles. But why should air leave the tumbler? There was no substance entering to force it out. It must have expanded. It expands by increase of heat, or by decrease of pressure, or both. Could the air have become heated after the tumbler was taken from the hot suds? Clearly not the air that was already entangled in the water. If heated air was the cause, cold air must have entered in transferring the tumblers from the suds to the plate. I test to see if this supposition is true by taking several more tumblers out. Some I shake so as to make sure of entrapping cold air in them. Some I take out holding mouth downward in order to prevent cold air from entering. Bubbles appear on the outside of every one of the former and on none of the latter. I must be right in my inference. Air from the outside must have been expanded by the heat of the tumbler, which explains the appearance of the bubbles on the outside. But why do they then go inside? Cold contracts. The tumbler cooled and also the air inside it. Tension was removed, and hence bubbles appeared inside. To be sure of this, I test by placing a cup of ice on the tumbler while the bubbles are still forming outside. They soon reverse” (Dewey 1910: 70–71; 1933: 93–94).

Dewey (1910, 1933) sprinkles his book with other examples of critical thinking. We will refer to the following.

Weather : A man on a walk notices that it has suddenly become cool, thinks that it is probably going to rain, looks up and sees a dark cloud obscuring the sun, and quickens his steps (1910: 6–10; 1933: 9–13).

Disorder : A man finds his rooms on his return to them in disorder with his belongings thrown about, thinks at first of burglary as an explanation, then thinks of mischievous children as being an alternative explanation, then looks to see whether valuables are missing, and discovers that they are (1910: 82–83; 1933: 166–168).

Typhoid : A physician diagnosing a patient whose conspicuous symptoms suggest typhoid avoids drawing a conclusion until more data are gathered by questioning the patient and by making tests (1910: 85–86; 1933: 170).

Blur : A moving blur catches our eye in the distance, we ask ourselves whether it is a cloud of whirling dust or a tree moving its branches or a man signaling to us, we think of other traits that should be found on each of those possibilities, and we look and see if those traits are found (1910: 102, 108; 1933: 121, 133).

Suction pump : In thinking about the suction pump, the scientist first notes that it will draw water only to a maximum height of 33 feet at sea level and to a lesser maximum height at higher elevations, selects for attention the differing atmospheric pressure at these elevations, sets up experiments in which the air is removed from a vessel containing water (when suction no longer works) and in which the weight of air at various levels is calculated, compares the results of reasoning about the height to which a given weight of air will allow a suction pump to raise water with the observed maximum height at different elevations, and finally assimilates the suction pump to such apparently different phenomena as the siphon and the rising of a balloon (1910: 150–153; 1933: 195–198).

Diamond : A passenger in a car driving in a diamond lane reserved for vehicles with at least one passenger notices that the diamond marks on the pavement are far apart in some places and close together in others. Why? The driver suggests that the reason may be that the diamond marks are not needed where there is a solid double line separating the diamond lane from the adjoining lane, but are needed when there is a dotted single line permitting crossing into the diamond lane. Further observation confirms that the diamonds are close together when a dotted line separates the diamond lane from its neighbour, but otherwise far apart.

Rash : A woman suddenly develops a very itchy red rash on her throat and upper chest. She recently noticed a mark on the back of her right hand, but was not sure whether the mark was a rash or a scrape. She lies down in bed and thinks about what might be causing the rash and what to do about it. About two weeks before, she began taking blood pressure medication that contained a sulfa drug, and the pharmacist had warned her, in view of a previous allergic reaction to a medication containing a sulfa drug, to be on the alert for an allergic reaction; however, she had been taking the medication for two weeks with no such effect. The day before, she began using a new cream on her neck and upper chest; against the new cream as the cause was mark on the back of her hand, which had not been exposed to the cream. She began taking probiotics about a month before. She also recently started new eye drops, but she supposed that manufacturers of eye drops would be careful not to include allergy-causing components in the medication. The rash might be a heat rash, since she recently was sweating profusely from her upper body. Since she is about to go away on a short vacation, where she would not have access to her usual physician, she decides to keep taking the probiotics and using the new eye drops but to discontinue the blood pressure medication and to switch back to the old cream for her neck and upper chest. She forms a plan to consult her regular physician on her return about the blood pressure medication.

Candidate : Although Dewey included no examples of thinking directed at appraising the arguments of others, such thinking has come to be considered a kind of critical thinking. We find an example of such thinking in the performance task on the Collegiate Learning Assessment (CLA+), which its sponsoring organization describes as

a performance-based assessment that provides a measure of an institution’s contribution to the development of critical-thinking and written communication skills of its students. (Council for Aid to Education 2017)

A sample task posted on its website requires the test-taker to write a report for public distribution evaluating a fictional candidate’s policy proposals and their supporting arguments, using supplied background documents, with a recommendation on whether to endorse the candidate.

Immediate acceptance of an idea that suggests itself as a solution to a problem (e.g., a possible explanation of an event or phenomenon, an action that seems likely to produce a desired result) is “uncritical thinking, the minimum of reflection” (Dewey 1910: 13). On-going suspension of judgment in the light of doubt about a possible solution is not critical thinking (Dewey 1910: 108). Critique driven by a dogmatically held political or religious ideology is not critical thinking; thus Paulo Freire (1968 [1970]) is using the term (e.g., at 1970: 71, 81, 100, 146) in a more politically freighted sense that includes not only reflection but also revolutionary action against oppression. Derivation of a conclusion from given data using an algorithm is not critical thinking.

What is critical thinking? There are many definitions. Ennis (2016) lists 14 philosophically oriented scholarly definitions and three dictionary definitions. Following Rawls (1971), who distinguished his conception of justice from a utilitarian conception but regarded them as rival conceptions of the same concept, Ennis maintains that the 17 definitions are different conceptions of the same concept. Rawls articulated the shared concept of justice as

a characteristic set of principles for assigning basic rights and duties and for determining… the proper distribution of the benefits and burdens of social cooperation. (Rawls 1971: 5)

Bailin et al. (1999b) claim that, if one considers what sorts of thinking an educator would take not to be critical thinking and what sorts to be critical thinking, one can conclude that educators typically understand critical thinking to have at least three features.

• It is done for the purpose of making up one’s mind about what to believe or do.
• The person engaging in the thinking is trying to fulfill standards of adequacy and accuracy appropriate to the thinking.
• The thinking fulfills the relevant standards to some threshold level.

One could sum up the core concept that involves these three features by saying that critical thinking is careful goal-directed thinking. This core concept seems to apply to all the examples of critical thinking described in the previous section. As for the non-examples, their exclusion depends on construing careful thinking as excluding jumping immediately to conclusions, suspending judgment no matter how strong the evidence, reasoning from an unquestioned ideological or religious perspective, and routinely using an algorithm to answer a question.

If the core of critical thinking is careful goal-directed thinking, conceptions of it can vary according to its presumed scope, its presumed goal, one’s criteria and threshold for being careful, and the thinking component on which one focuses. As to its scope, some conceptions (e.g., Dewey 1910, 1933) restrict it to constructive thinking on the basis of one’s own observations and experiments, others (e.g., Ennis 1962; Fisher & Scriven 1997; Johnson 1992) to appraisal of the products of such thinking. Ennis (1991) and Bailin et al. (1999b) take it to cover both construction and appraisal. As to its goal, some conceptions restrict it to forming a judgment (Dewey 1910, 1933; Lipman 1987; Facione 1990a). Others allow for actions as well as beliefs as the end point of a process of critical thinking (Ennis 1991; Bailin et al. 1999b). As to the criteria and threshold for being careful, definitions vary in the term used to indicate that critical thinking satisfies certain norms: “intellectually disciplined” (Scriven & Paul 1987), “reasonable” (Ennis 1991), “skillful” (Lipman 1987), “skilled” (Fisher & Scriven 1997), “careful” (Bailin & Battersby 2009). Some definitions specify these norms, referring variously to “consideration of any belief or supposed form of knowledge in the light of the grounds that support it and the further conclusions to which it tends” (Dewey 1910, 1933); “the methods of logical inquiry and reasoning” (Glaser 1941); “conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication” (Scriven & Paul 1987); the requirement that “it is sensitive to context, relies on criteria, and is self-correcting” (Lipman 1987); “evidential, conceptual, methodological, criteriological, or contextual considerations” (Facione 1990a); and “plus-minus considerations of the product in terms of appropriate standards (or criteria)” (Johnson 1992). Stanovich and Stanovich (2010) propose to ground the concept of critical thinking in the concept of rationality, which they understand as combining epistemic rationality (fitting one’s beliefs to the world) and instrumental rationality (optimizing goal fulfillment); a critical thinker, in their view, is someone with “a propensity to override suboptimal responses from the autonomous mind” (2010: 227). These variant specifications of norms for critical thinking are not necessarily incompatible with one another, and in any case presuppose the core notion of thinking carefully. As to the thinking component singled out, some definitions focus on suspension of judgment during the thinking (Dewey 1910; McPeck 1981), others on inquiry while judgment is suspended (Bailin & Battersby 2009, 2021), others on the resulting judgment (Facione 1990a), and still others on responsiveness to reasons (Siegel 1988). Kuhn (2019) takes critical thinking to be more a dialogic practice of advancing and responding to arguments than an individual ability.

In educational contexts, a definition of critical thinking is a “programmatic definition” (Scheffler 1960: 19). It expresses a practical program for achieving an educational goal. For this purpose, a one-sentence formulaic definition is much less useful than articulation of a critical thinking process, with criteria and standards for the kinds of thinking that the process may involve. The real educational goal is recognition, adoption and implementation by students of those criteria and standards. That adoption and implementation in turn consists in acquiring the knowledge, abilities and dispositions of a critical thinker.

Conceptions of critical thinking generally do not include moral integrity as part of the concept. Dewey, for example, took critical thinking to be the ultimate intellectual goal of education, but distinguished it from the development of social cooperation among school children, which he took to be the central moral goal. Ennis (1996, 2011) added to his previous list of critical thinking dispositions a group of dispositions to care about the dignity and worth of every person, which he described as a “correlative” (1996) disposition without which critical thinking would be less valuable and perhaps harmful. An educational program that aimed at developing critical thinking but not the correlative disposition to care about the dignity and worth of every person, he asserted, “would be deficient and perhaps dangerous” (Ennis 1996: 172).

Dewey thought that education for reflective thinking would be of value to both the individual and society; recognition in educational practice of the kinship to the scientific attitude of children’s native curiosity, fertile imagination and love of experimental inquiry “would make for individual happiness and the reduction of social waste” (Dewey 1910: iii). Schools participating in the Eight-Year Study took development of the habit of reflective thinking and skill in solving problems as a means to leading young people to understand, appreciate and live the democratic way of life characteristic of the United States (Aikin 1942: 17–18, 81). Harvey Siegel (1988: 55–61) has offered four considerations in support of adopting critical thinking as an educational ideal. (1) Respect for persons requires that schools and teachers honour students’ demands for reasons and explanations, deal with students honestly, and recognize the need to confront students’ independent judgment; these requirements concern the manner in which teachers treat students. (2) Education has the task of preparing children to be successful adults, a task that requires development of their self-sufficiency. (3) Education should initiate children into the rational traditions in such fields as history, science and mathematics. (4) Education should prepare children to become democratic citizens, which requires reasoned procedures and critical talents and attitudes. To supplement these considerations, Siegel (1988: 62–90) responds to two objections: the ideology objection that adoption of any educational ideal requires a prior ideological commitment and the indoctrination objection that cultivation of critical thinking cannot escape being a form of indoctrination.

Despite the diversity of our 11 examples, one can recognize a common pattern. Dewey analyzed it as consisting of five phases:

• suggestions , in which the mind leaps forward to a possible solution;
• an intellectualization of the difficulty or perplexity into a problem to be solved, a question for which the answer must be sought;
• the use of one suggestion after another as a leading idea, or hypothesis , to initiate and guide observation and other operations in collection of factual material;
• the mental elaboration of the idea or supposition as an idea or supposition ( reasoning , in the sense on which reasoning is a part, not the whole, of inference); and
• testing the hypothesis by overt or imaginative action. (Dewey 1933: 106–107; italics in original)

The process of reflective thinking consisting of these phases would be preceded by a perplexed, troubled or confused situation and followed by a cleared-up, unified, resolved situation (Dewey 1933: 106). The term ‘phases’ replaced the term ‘steps’ (Dewey 1910: 72), thus removing the earlier suggestion of an invariant sequence. Variants of the above analysis appeared in (Dewey 1916: 177) and (Dewey 1938: 101–119).

The variant formulations indicate the difficulty of giving a single logical analysis of such a varied process. The process of critical thinking may have a spiral pattern, with the problem being redefined in the light of obstacles to solving it as originally formulated. For example, the person in Transit might have concluded that getting to the appointment at the scheduled time was impossible and have reformulated the problem as that of rescheduling the appointment for a mutually convenient time. Further, defining a problem does not always follow after or lead immediately to an idea of a suggested solution. Nor should it do so, as Dewey himself recognized in describing the physician in Typhoid as avoiding any strong preference for this or that conclusion before getting further information (Dewey 1910: 85; 1933: 170). People with a hypothesis in mind, even one to which they have a very weak commitment, have a so-called “confirmation bias” (Nickerson 1998): they are likely to pay attention to evidence that confirms the hypothesis and to ignore evidence that counts against it or for some competing hypothesis. Detectives, intelligence agencies, and investigators of airplane accidents are well advised to gather relevant evidence systematically and to postpone even tentative adoption of an explanatory hypothesis until the collected evidence rules out with the appropriate degree of certainty all but one explanation. Dewey’s analysis of the critical thinking process can be faulted as well for requiring acceptance or rejection of a possible solution to a defined problem, with no allowance for deciding in the light of the available evidence to suspend judgment. Further, given the great variety of kinds of problems for which reflection is appropriate, there is likely to be variation in its component events. Perhaps the best way to conceptualize the critical thinking process is as a checklist whose component events can occur in a variety of orders, selectively, and more than once. These component events might include (1) noticing a difficulty, (2) defining the problem, (3) dividing the problem into manageable sub-problems, (4) formulating a variety of possible solutions to the problem or sub-problem, (5) determining what evidence is relevant to deciding among possible solutions to the problem or sub-problem, (6) devising a plan of systematic observation or experiment that will uncover the relevant evidence, (7) carrying out the plan of systematic observation or experimentation, (8) noting the results of the systematic observation or experiment, (9) gathering relevant testimony and information from others, (10) judging the credibility of testimony and information gathered from others, (11) drawing conclusions from gathered evidence and accepted testimony, and (12) accepting a solution that the evidence adequately supports (cf. Hitchcock 2017: 485).

Checklist conceptions of the process of critical thinking are open to the objection that they are too mechanical and procedural to fit the multi-dimensional and emotionally charged issues for which critical thinking is urgently needed (Paul 1984). For such issues, a more dialectical process is advocated, in which competing relevant world views are identified, their implications explored, and some sort of creative synthesis attempted.

If one considers the critical thinking process illustrated by the 11 examples, one can identify distinct kinds of mental acts and mental states that form part of it. To distinguish, label and briefly characterize these components is a useful preliminary to identifying abilities, skills, dispositions, attitudes, habits and the like that contribute causally to thinking critically. Identifying such abilities and habits is in turn a useful preliminary to setting educational goals. Setting the goals is in its turn a useful preliminary to designing strategies for helping learners to achieve the goals and to designing ways of measuring the extent to which learners have done so. Such measures provide both feedback to learners on their achievement and a basis for experimental research on the effectiveness of various strategies for educating people to think critically. Let us begin, then, by distinguishing the kinds of mental acts and mental events that can occur in a critical thinking process.

• Observing : One notices something in one’s immediate environment (sudden cooling of temperature in Weather , bubbles forming outside a glass and then going inside in Bubbles , a moving blur in the distance in Blur , a rash in Rash ). Or one notes the results of an experiment or systematic observation (valuables missing in Disorder , no suction without air pressure in Suction pump )
• Feeling : One feels puzzled or uncertain about something (how to get to an appointment on time in Transit , why the diamonds vary in spacing in Diamond ). One wants to resolve this perplexity. One feels satisfaction once one has worked out an answer (to take the subway express in Transit , diamonds closer when needed as a warning in Diamond ).
• Wondering : One formulates a question to be addressed (why bubbles form outside a tumbler taken from hot water in Bubbles , how suction pumps work in Suction pump , what caused the rash in Rash ).
• Imagining : One thinks of possible answers (bus or subway or elevated in Transit , flagpole or ornament or wireless communication aid or direction indicator in Ferryboat , allergic reaction or heat rash in Rash ).
• Inferring : One works out what would be the case if a possible answer were assumed (valuables missing if there has been a burglary in Disorder , earlier start to the rash if it is an allergic reaction to a sulfa drug in Rash ). Or one draws a conclusion once sufficient relevant evidence is gathered (take the subway in Transit , burglary in Disorder , discontinue blood pressure medication and new cream in Rash ).
• Knowledge : One uses stored knowledge of the subject-matter to generate possible answers or to infer what would be expected on the assumption of a particular answer (knowledge of a city’s public transit system in Transit , of the requirements for a flagpole in Ferryboat , of Boyle’s law in Bubbles , of allergic reactions in Rash ).
• Experimenting : One designs and carries out an experiment or a systematic observation to find out whether the results deduced from a possible answer will occur (looking at the location of the flagpole in relation to the pilot’s position in Ferryboat , putting an ice cube on top of a tumbler taken from hot water in Bubbles , measuring the height to which a suction pump will draw water at different elevations in Suction pump , noticing the spacing of diamonds when movement to or from a diamond lane is allowed in Diamond ).
• Consulting : One finds a source of information, gets the information from the source, and makes a judgment on whether to accept it. None of our 11 examples include searching for sources of information. In this respect they are unrepresentative, since most people nowadays have almost instant access to information relevant to answering any question, including many of those illustrated by the examples. However, Candidate includes the activities of extracting information from sources and evaluating its credibility.
• Identifying and analyzing arguments : One notices an argument and works out its structure and content as a preliminary to evaluating its strength. This activity is central to Candidate . It is an important part of a critical thinking process in which one surveys arguments for various positions on an issue.
• Judging : One makes a judgment on the basis of accumulated evidence and reasoning, such as the judgment in Ferryboat that the purpose of the pole is to provide direction to the pilot.
• Deciding : One makes a decision on what to do or on what policy to adopt, as in the decision in Transit to take the subway.

By definition, a person who does something voluntarily is both willing and able to do that thing at that time. Both the willingness and the ability contribute causally to the person’s action, in the sense that the voluntary action would not occur if either (or both) of these were lacking. For example, suppose that one is standing with one’s arms at one’s sides and one voluntarily lifts one’s right arm to an extended horizontal position. One would not do so if one were unable to lift one’s arm, if for example one’s right side was paralyzed as the result of a stroke. Nor would one do so if one were unwilling to lift one’s arm, if for example one were participating in a street demonstration at which a white supremacist was urging the crowd to lift their right arm in a Nazi salute and one were unwilling to express support in this way for the racist Nazi ideology. The same analysis applies to a voluntary mental process of thinking critically. It requires both willingness and ability to think critically, including willingness and ability to perform each of the mental acts that compose the process and to coordinate those acts in a sequence that is directed at resolving the initiating perplexity.

Consider willingness first. We can identify causal contributors to willingness to think critically by considering factors that would cause a person who was able to think critically about an issue nevertheless not to do so (Hamby 2014). For each factor, the opposite condition thus contributes causally to willingness to think critically on a particular occasion. For example, people who habitually jump to conclusions without considering alternatives will not think critically about issues that arise, even if they have the required abilities. The contrary condition of willingness to suspend judgment is thus a causal contributor to thinking critically.

Now consider ability. In contrast to the ability to move one’s arm, which can be completely absent because a stroke has left the arm paralyzed, the ability to think critically is a developed ability, whose absence is not a complete absence of ability to think but absence of ability to think well. We can identify the ability to think well directly, in terms of the norms and standards for good thinking. In general, to be able do well the thinking activities that can be components of a critical thinking process, one needs to know the concepts and principles that characterize their good performance, to recognize in particular cases that the concepts and principles apply, and to apply them. The knowledge, recognition and application may be procedural rather than declarative. It may be domain-specific rather than widely applicable, and in either case may need subject-matter knowledge, sometimes of a deep kind.

Reflections of the sort illustrated by the previous two paragraphs have led scholars to identify the knowledge, abilities and dispositions of a “critical thinker”, i.e., someone who thinks critically whenever it is appropriate to do so. We turn now to these three types of causal contributors to thinking critically. We start with dispositions, since arguably these are the most powerful contributors to being a critical thinker, can be fostered at an early stage of a child’s development, and are susceptible to general improvement (Glaser 1941: 175)

8. Critical Thinking Dispositions

Educational researchers use the term ‘dispositions’ broadly for the habits of mind and attitudes that contribute causally to being a critical thinker. Some writers (e.g., Paul & Elder 2006; Hamby 2014; Bailin & Battersby 2016a) propose to use the term ‘virtues’ for this dimension of a critical thinker. The virtues in question, although they are virtues of character, concern the person’s ways of thinking rather than the person’s ways of behaving towards others. They are not moral virtues but intellectual virtues, of the sort articulated by Zagzebski (1996) and discussed by Turri, Alfano, and Greco (2017).

On a realistic conception, thinking dispositions or intellectual virtues are real properties of thinkers. They are general tendencies, propensities, or inclinations to think in particular ways in particular circumstances, and can be genuinely explanatory (Siegel 1999). Sceptics argue that there is no evidence for a specific mental basis for the habits of mind that contribute to thinking critically, and that it is pedagogically misleading to posit such a basis (Bailin et al. 1999a). Whatever their status, critical thinking dispositions need motivation for their initial formation in a child—motivation that may be external or internal. As children develop, the force of habit will gradually become important in sustaining the disposition (Nieto & Valenzuela 2012). Mere force of habit, however, is unlikely to sustain critical thinking dispositions. Critical thinkers must value and enjoy using their knowledge and abilities to think things through for themselves. They must be committed to, and lovers of, inquiry.

A person may have a critical thinking disposition with respect to only some kinds of issues. For example, one could be open-minded about scientific issues but not about religious issues. Similarly, one could be confident in one’s ability to reason about the theological implications of the existence of evil in the world but not in one’s ability to reason about the best design for a guided ballistic missile.

Facione (1990a: 25) divides “affective dispositions” of critical thinking into approaches to life and living in general and approaches to specific issues, questions or problems. Adapting this distinction, one can usefully divide critical thinking dispositions into initiating dispositions (those that contribute causally to starting to think critically about an issue) and internal dispositions (those that contribute causally to doing a good job of thinking critically once one has started). The two categories are not mutually exclusive. For example, open-mindedness, in the sense of willingness to consider alternative points of view to one’s own, is both an initiating and an internal disposition.

Using the strategy of considering factors that would block people with the ability to think critically from doing so, we can identify as initiating dispositions for thinking critically attentiveness, a habit of inquiry, self-confidence, courage, open-mindedness, willingness to suspend judgment, trust in reason, wanting evidence for one’s beliefs, and seeking the truth. We consider briefly what each of these dispositions amounts to, in each case citing sources that acknowledge them.

• Attentiveness : One will not think critically if one fails to recognize an issue that needs to be thought through. For example, the pedestrian in Weather would not have looked up if he had not noticed that the air was suddenly cooler. To be a critical thinker, then, one needs to be habitually attentive to one’s surroundings, noticing not only what one senses but also sources of perplexity in messages received and in one’s own beliefs and attitudes (Facione 1990a: 25; Facione, Facione, & Giancarlo 2001).
• Habit of inquiry : Inquiry is effortful, and one needs an internal push to engage in it. For example, the student in Bubbles could easily have stopped at idle wondering about the cause of the bubbles rather than reasoning to a hypothesis, then designing and executing an experiment to test it. Thus willingness to think critically needs mental energy and initiative. What can supply that energy? Love of inquiry, or perhaps just a habit of inquiry. Hamby (2015) has argued that willingness to inquire is the central critical thinking virtue, one that encompasses all the others. It is recognized as a critical thinking disposition by Dewey (1910: 29; 1933: 35), Glaser (1941: 5), Ennis (1987: 12; 1991: 8), Facione (1990a: 25), Bailin et al. (1999b: 294), Halpern (1998: 452), and Facione, Facione, & Giancarlo (2001).
• Self-confidence : Lack of confidence in one’s abilities can block critical thinking. For example, if the woman in Rash lacked confidence in her ability to figure things out for herself, she might just have assumed that the rash on her chest was the allergic reaction to her medication against which the pharmacist had warned her. Thus willingness to think critically requires confidence in one’s ability to inquire (Facione 1990a: 25; Facione, Facione, & Giancarlo 2001).
• Courage : Fear of thinking for oneself can stop one from doing it. Thus willingness to think critically requires intellectual courage (Paul & Elder 2006: 16).
• Open-mindedness : A dogmatic attitude will impede thinking critically. For example, a person who adheres rigidly to a “pro-choice” position on the issue of the legal status of induced abortion is likely to be unwilling to consider seriously the issue of when in its development an unborn child acquires a moral right to life. Thus willingness to think critically requires open-mindedness, in the sense of a willingness to examine questions to which one already accepts an answer but which further evidence or reasoning might cause one to answer differently (Dewey 1933; Facione 1990a; Ennis 1991; Bailin et al. 1999b; Halpern 1998, Facione, Facione, & Giancarlo 2001). Paul (1981) emphasizes open-mindedness about alternative world-views, and recommends a dialectical approach to integrating such views as central to what he calls “strong sense” critical thinking. In three studies, Haran, Ritov, & Mellers (2013) found that actively open-minded thinking, including “the tendency to weigh new evidence against a favored belief, to spend sufficient time on a problem before giving up, and to consider carefully the opinions of others in forming one’s own”, led study participants to acquire information and thus to make accurate estimations.
• Willingness to suspend judgment : Premature closure on an initial solution will block critical thinking. Thus willingness to think critically requires a willingness to suspend judgment while alternatives are explored (Facione 1990a; Ennis 1991; Halpern 1998).
• Trust in reason : Since distrust in the processes of reasoned inquiry will dissuade one from engaging in it, trust in them is an initiating critical thinking disposition (Facione 1990a, 25; Bailin et al. 1999b: 294; Facione, Facione, & Giancarlo 2001; Paul & Elder 2006). In reaction to an allegedly exclusive emphasis on reason in critical thinking theory and pedagogy, Thayer-Bacon (2000) argues that intuition, imagination, and emotion have important roles to play in an adequate conception of critical thinking that she calls “constructive thinking”. From her point of view, critical thinking requires trust not only in reason but also in intuition, imagination, and emotion.
• Seeking the truth : If one does not care about the truth but is content to stick with one’s initial bias on an issue, then one will not think critically about it. Seeking the truth is thus an initiating critical thinking disposition (Bailin et al. 1999b: 294; Facione, Facione, & Giancarlo 2001). A disposition to seek the truth is implicit in more specific critical thinking dispositions, such as trying to be well-informed, considering seriously points of view other than one’s own, looking for alternatives, suspending judgment when the evidence is insufficient, and adopting a position when the evidence supporting it is sufficient.

Some of the initiating dispositions, such as open-mindedness and willingness to suspend judgment, are also internal critical thinking dispositions, in the sense of mental habits or attitudes that contribute causally to doing a good job of critical thinking once one starts the process. But there are many other internal critical thinking dispositions. Some of them are parasitic on one’s conception of good thinking. For example, it is constitutive of good thinking about an issue to formulate the issue clearly and to maintain focus on it. For this purpose, one needs not only the corresponding ability but also the corresponding disposition. Ennis (1991: 8) describes it as the disposition “to determine and maintain focus on the conclusion or question”, Facione (1990a: 25) as “clarity in stating the question or concern”. Other internal dispositions are motivators to continue or adjust the critical thinking process, such as willingness to persist in a complex task and willingness to abandon nonproductive strategies in an attempt to self-correct (Halpern 1998: 452). For a list of identified internal critical thinking dispositions, see the Supplement on Internal Critical Thinking Dispositions .

Some theorists postulate skills, i.e., acquired abilities, as operative in critical thinking. It is not obvious, however, that a good mental act is the exercise of a generic acquired skill. Inferring an expected time of arrival, as in Transit , has some generic components but also uses non-generic subject-matter knowledge. Bailin et al. (1999a) argue against viewing critical thinking skills as generic and discrete, on the ground that skilled performance at a critical thinking task cannot be separated from knowledge of concepts and from domain-specific principles of good thinking. Talk of skills, they concede, is unproblematic if it means merely that a person with critical thinking skills is capable of intelligent performance.

Despite such scepticism, theorists of critical thinking have listed as general contributors to critical thinking what they variously call abilities (Glaser 1941; Ennis 1962, 1991), skills (Facione 1990a; Halpern 1998) or competencies (Fisher & Scriven 1997). Amalgamating these lists would produce a confusing and chaotic cornucopia of more than 50 possible educational objectives, with only partial overlap among them. It makes sense instead to try to understand the reasons for the multiplicity and diversity, and to make a selection according to one’s own reasons for singling out abilities to be developed in a critical thinking curriculum. Two reasons for diversity among lists of critical thinking abilities are the underlying conception of critical thinking and the envisaged educational level. Appraisal-only conceptions, for example, involve a different suite of abilities than constructive-only conceptions. Some lists, such as those in (Glaser 1941), are put forward as educational objectives for secondary school students, whereas others are proposed as objectives for college students (e.g., Facione 1990a).

The abilities described in the remaining paragraphs of this section emerge from reflection on the general abilities needed to do well the thinking activities identified in section 6 as components of the critical thinking process described in section 5 . The derivation of each collection of abilities is accompanied by citation of sources that list such abilities and of standardized tests that claim to test them.

Observational abilities : Careful and accurate observation sometimes requires specialist expertise and practice, as in the case of observing birds and observing accident scenes. However, there are general abilities of noticing what one’s senses are picking up from one’s environment and of being able to articulate clearly and accurately to oneself and others what one has observed. It helps in exercising them to be able to recognize and take into account factors that make one’s observation less trustworthy, such as prior framing of the situation, inadequate time, deficient senses, poor observation conditions, and the like. It helps as well to be skilled at taking steps to make one’s observation more trustworthy, such as moving closer to get a better look, measuring something three times and taking the average, and checking what one thinks one is observing with someone else who is in a good position to observe it. It also helps to be skilled at recognizing respects in which one’s report of one’s observation involves inference rather than direct observation, so that one can then consider whether the inference is justified. These abilities come into play as well when one thinks about whether and with what degree of confidence to accept an observation report, for example in the study of history or in a criminal investigation or in assessing news reports. Observational abilities show up in some lists of critical thinking abilities (Ennis 1962: 90; Facione 1990a: 16; Ennis 1991: 9). There are items testing a person’s ability to judge the credibility of observation reports in the Cornell Critical Thinking Tests, Levels X and Z (Ennis & Millman 1971; Ennis, Millman, & Tomko 1985, 2005). Norris and King (1983, 1985, 1990a, 1990b) is a test of ability to appraise observation reports.

Emotional abilities : The emotions that drive a critical thinking process are perplexity or puzzlement, a wish to resolve it, and satisfaction at achieving the desired resolution. Children experience these emotions at an early age, without being trained to do so. Education that takes critical thinking as a goal needs only to channel these emotions and to make sure not to stifle them. Collaborative critical thinking benefits from ability to recognize one’s own and others’ emotional commitments and reactions.

Questioning abilities : A critical thinking process needs transformation of an inchoate sense of perplexity into a clear question. Formulating a question well requires not building in questionable assumptions, not prejudging the issue, and using language that in context is unambiguous and precise enough (Ennis 1962: 97; 1991: 9).

Imaginative abilities : Thinking directed at finding the correct causal explanation of a general phenomenon or particular event requires an ability to imagine possible explanations. Thinking about what policy or plan of action to adopt requires generation of options and consideration of possible consequences of each option. Domain knowledge is required for such creative activity, but a general ability to imagine alternatives is helpful and can be nurtured so as to become easier, quicker, more extensive, and deeper (Dewey 1910: 34–39; 1933: 40–47). Facione (1990a) and Halpern (1998) include the ability to imagine alternatives as a critical thinking ability.

Inferential abilities : The ability to draw conclusions from given information, and to recognize with what degree of certainty one’s own or others’ conclusions follow, is universally recognized as a general critical thinking ability. All 11 examples in section 2 of this article include inferences, some from hypotheses or options (as in Transit , Ferryboat and Disorder ), others from something observed (as in Weather and Rash ). None of these inferences is formally valid. Rather, they are licensed by general, sometimes qualified substantive rules of inference (Toulmin 1958) that rest on domain knowledge—that a bus trip takes about the same time in each direction, that the terminal of a wireless telegraph would be located on the highest possible place, that sudden cooling is often followed by rain, that an allergic reaction to a sulfa drug generally shows up soon after one starts taking it. It is a matter of controversy to what extent the specialized ability to deduce conclusions from premisses using formal rules of inference is needed for critical thinking. Dewey (1933) locates logical forms in setting out the products of reflection rather than in the process of reflection. Ennis (1981a), on the other hand, maintains that a liberally-educated person should have the following abilities: to translate natural-language statements into statements using the standard logical operators, to use appropriately the language of necessary and sufficient conditions, to deal with argument forms and arguments containing symbols, to determine whether in virtue of an argument’s form its conclusion follows necessarily from its premisses, to reason with logically complex propositions, and to apply the rules and procedures of deductive logic. Inferential abilities are recognized as critical thinking abilities by Glaser (1941: 6), Facione (1990a: 9), Ennis (1991: 9), Fisher & Scriven (1997: 99, 111), and Halpern (1998: 452). Items testing inferential abilities constitute two of the five subtests of the Watson Glaser Critical Thinking Appraisal (Watson & Glaser 1980a, 1980b, 1994), two of the four sections in the Cornell Critical Thinking Test Level X (Ennis & Millman 1971; Ennis, Millman, & Tomko 1985, 2005), three of the seven sections in the Cornell Critical Thinking Test Level Z (Ennis & Millman 1971; Ennis, Millman, & Tomko 1985, 2005), 11 of the 34 items on Forms A and B of the California Critical Thinking Skills Test (Facione 1990b, 1992), and a high but variable proportion of the 25 selected-response questions in the Collegiate Learning Assessment (Council for Aid to Education 2017).

Experimenting abilities : Knowing how to design and execute an experiment is important not just in scientific research but also in everyday life, as in Rash . Dewey devoted a whole chapter of his How We Think (1910: 145–156; 1933: 190–202) to the superiority of experimentation over observation in advancing knowledge. Experimenting abilities come into play at one remove in appraising reports of scientific studies. Skill in designing and executing experiments includes the acknowledged abilities to appraise evidence (Glaser 1941: 6), to carry out experiments and to apply appropriate statistical inference techniques (Facione 1990a: 9), to judge inductions to an explanatory hypothesis (Ennis 1991: 9), and to recognize the need for an adequately large sample size (Halpern 1998). The Cornell Critical Thinking Test Level Z (Ennis & Millman 1971; Ennis, Millman, & Tomko 1985, 2005) includes four items (out of 52) on experimental design. The Collegiate Learning Assessment (Council for Aid to Education 2017) makes room for appraisal of study design in both its performance task and its selected-response questions.

Consulting abilities : Skill at consulting sources of information comes into play when one seeks information to help resolve a problem, as in Candidate . Ability to find and appraise information includes ability to gather and marshal pertinent information (Glaser 1941: 6), to judge whether a statement made by an alleged authority is acceptable (Ennis 1962: 84), to plan a search for desired information (Facione 1990a: 9), and to judge the credibility of a source (Ennis 1991: 9). Ability to judge the credibility of statements is tested by 24 items (out of 76) in the Cornell Critical Thinking Test Level X (Ennis & Millman 1971; Ennis, Millman, & Tomko 1985, 2005) and by four items (out of 52) in the Cornell Critical Thinking Test Level Z (Ennis & Millman 1971; Ennis, Millman, & Tomko 1985, 2005). The College Learning Assessment’s performance task requires evaluation of whether information in documents is credible or unreliable (Council for Aid to Education 2017).

Argument analysis abilities : The ability to identify and analyze arguments contributes to the process of surveying arguments on an issue in order to form one’s own reasoned judgment, as in Candidate . The ability to detect and analyze arguments is recognized as a critical thinking skill by Facione (1990a: 7–8), Ennis (1991: 9) and Halpern (1998). Five items (out of 34) on the California Critical Thinking Skills Test (Facione 1990b, 1992) test skill at argument analysis. The College Learning Assessment (Council for Aid to Education 2017) incorporates argument analysis in its selected-response tests of critical reading and evaluation and of critiquing an argument.

Judging skills and deciding skills : Skill at judging and deciding is skill at recognizing what judgment or decision the available evidence and argument supports, and with what degree of confidence. It is thus a component of the inferential skills already discussed.

Lists and tests of critical thinking abilities often include two more abilities: identifying assumptions and constructing and evaluating definitions.

In addition to dispositions and abilities, critical thinking needs knowledge: of critical thinking concepts, of critical thinking principles, and of the subject-matter of the thinking.

We can derive a short list of concepts whose understanding contributes to critical thinking from the critical thinking abilities described in the preceding section. Observational abilities require an understanding of the difference between observation and inference. Questioning abilities require an understanding of the concepts of ambiguity and vagueness. Inferential abilities require an understanding of the difference between conclusive and defeasible inference (traditionally, between deduction and induction), as well as of the difference between necessary and sufficient conditions. Experimenting abilities require an understanding of the concepts of hypothesis, null hypothesis, assumption and prediction, as well as of the concept of statistical significance and of its difference from importance. They also require an understanding of the difference between an experiment and an observational study, and in particular of the difference between a randomized controlled trial, a prospective correlational study and a retrospective (case-control) study. Argument analysis abilities require an understanding of the concepts of argument, premiss, assumption, conclusion and counter-consideration. Additional critical thinking concepts are proposed by Bailin et al. (1999b: 293), Fisher & Scriven (1997: 105–106), Black (2012), and Blair (2021).

According to Glaser (1941: 25), ability to think critically requires knowledge of the methods of logical inquiry and reasoning. If we review the list of abilities in the preceding section, however, we can see that some of them can be acquired and exercised merely through practice, possibly guided in an educational setting, followed by feedback. Searching intelligently for a causal explanation of some phenomenon or event requires that one consider a full range of possible causal contributors, but it seems more important that one implements this principle in one’s practice than that one is able to articulate it. What is important is “operational knowledge” of the standards and principles of good thinking (Bailin et al. 1999b: 291–293). But the development of such critical thinking abilities as designing an experiment or constructing an operational definition can benefit from learning their underlying theory. Further, explicit knowledge of quirks of human thinking seems useful as a cautionary guide. Human memory is not just fallible about details, as people learn from their own experiences of misremembering, but is so malleable that a detailed, clear and vivid recollection of an event can be a total fabrication (Loftus 2017). People seek or interpret evidence in ways that are partial to their existing beliefs and expectations, often unconscious of their “confirmation bias” (Nickerson 1998). Not only are people subject to this and other cognitive biases (Kahneman 2011), of which they are typically unaware, but it may be counter-productive for one to make oneself aware of them and try consciously to counteract them or to counteract social biases such as racial or sexual stereotypes (Kenyon & Beaulac 2014). It is helpful to be aware of these facts and of the superior effectiveness of blocking the operation of biases—for example, by making an immediate record of one’s observations, refraining from forming a preliminary explanatory hypothesis, blind refereeing, double-blind randomized trials, and blind grading of students’ work. It is also helpful to be aware of the prevalence of “noise” (unwanted unsystematic variability of judgments), of how to detect noise (through a noise audit), and of how to reduce noise: make accuracy the goal, think statistically, break a process of arriving at a judgment into independent tasks, resist premature intuitions, in a group get independent judgments first, favour comparative judgments and scales (Kahneman, Sibony, & Sunstein 2021). It is helpful as well to be aware of the concept of “bounded rationality” in decision-making and of the related distinction between “satisficing” and optimizing (Simon 1956; Gigerenzer 2001).

Critical thinking about an issue requires substantive knowledge of the domain to which the issue belongs. Critical thinking abilities are not a magic elixir that can be applied to any issue whatever by somebody who has no knowledge of the facts relevant to exploring that issue. For example, the student in Bubbles needed to know that gases do not penetrate solid objects like a glass, that air expands when heated, that the volume of an enclosed gas varies directly with its temperature and inversely with its pressure, and that hot objects will spontaneously cool down to the ambient temperature of their surroundings unless kept hot by insulation or a source of heat. Critical thinkers thus need a rich fund of subject-matter knowledge relevant to the variety of situations they encounter. This fact is recognized in the inclusion among critical thinking dispositions of a concern to become and remain generally well informed.

Experimental educational interventions, with control groups, have shown that education can improve critical thinking skills and dispositions, as measured by standardized tests. For information about these tests, see the Supplement on Assessment .

What educational methods are most effective at developing the dispositions, abilities and knowledge of a critical thinker? In a comprehensive meta-analysis of experimental and quasi-experimental studies of strategies for teaching students to think critically, Abrami et al. (2015) found that dialogue, anchored instruction, and mentoring each increased the effectiveness of the educational intervention, and that they were most effective when combined. They also found that in these studies a combination of separate instruction in critical thinking with subject-matter instruction in which students are encouraged to think critically was more effective than either by itself. However, the difference was not statistically significant; that is, it might have arisen by chance.

Most of these studies lack the longitudinal follow-up required to determine whether the observed differential improvements in critical thinking abilities or dispositions continue over time, for example until high school or college graduation. For details on studies of methods of developing critical thinking skills and dispositions, see the Supplement on Educational Methods .

12. Controversies

Scholars have denied the generalizability of critical thinking abilities across subject domains, have alleged bias in critical thinking theory and pedagogy, and have investigated the relationship of critical thinking to other kinds of thinking.

McPeck (1981) attacked the thinking skills movement of the 1970s, including the critical thinking movement. He argued that there are no general thinking skills, since thinking is always thinking about some subject-matter. It is futile, he claimed, for schools and colleges to teach thinking as if it were a separate subject. Rather, teachers should lead their pupils to become autonomous thinkers by teaching school subjects in a way that brings out their cognitive structure and that encourages and rewards discussion and argument. As some of his critics (e.g., Paul 1985; Siegel 1985) pointed out, McPeck’s central argument needs elaboration, since it has obvious counter-examples in writing and speaking, for which (up to a certain level of complexity) there are teachable general abilities even though they are always about some subject-matter. To make his argument convincing, McPeck needs to explain how thinking differs from writing and speaking in a way that does not permit useful abstraction of its components from the subject-matters with which it deals. He has not done so. Nevertheless, his position that the dispositions and abilities of a critical thinker are best developed in the context of subject-matter instruction is shared by many theorists of critical thinking, including Dewey (1910, 1933), Glaser (1941), Passmore (1980), Weinstein (1990), Bailin et al. (1999b), and Willingham (2019).

McPeck’s challenge prompted reflection on the extent to which critical thinking is subject-specific. McPeck argued for a strong subject-specificity thesis, according to which it is a conceptual truth that all critical thinking abilities are specific to a subject. (He did not however extend his subject-specificity thesis to critical thinking dispositions. In particular, he took the disposition to suspend judgment in situations of cognitive dissonance to be a general disposition.) Conceptual subject-specificity is subject to obvious counter-examples, such as the general ability to recognize confusion of necessary and sufficient conditions. A more modest thesis, also endorsed by McPeck, is epistemological subject-specificity, according to which the norms of good thinking vary from one field to another. Epistemological subject-specificity clearly holds to a certain extent; for example, the principles in accordance with which one solves a differential equation are quite different from the principles in accordance with which one determines whether a painting is a genuine Picasso. But the thesis suffers, as Ennis (1989) points out, from vagueness of the concept of a field or subject and from the obvious existence of inter-field principles, however broadly the concept of a field is construed. For example, the principles of hypothetico-deductive reasoning hold for all the varied fields in which such reasoning occurs. A third kind of subject-specificity is empirical subject-specificity, according to which as a matter of empirically observable fact a person with the abilities and dispositions of a critical thinker in one area of investigation will not necessarily have them in another area of investigation.

The thesis of empirical subject-specificity raises the general problem of transfer. If critical thinking abilities and dispositions have to be developed independently in each school subject, how are they of any use in dealing with the problems of everyday life and the political and social issues of contemporary society, most of which do not fit into the framework of a traditional school subject? Proponents of empirical subject-specificity tend to argue that transfer is more likely to occur if there is critical thinking instruction in a variety of domains, with explicit attention to dispositions and abilities that cut across domains. But evidence for this claim is scanty. There is a need for well-designed empirical studies that investigate the conditions that make transfer more likely.

It is common ground in debates about the generality or subject-specificity of critical thinking dispositions and abilities that critical thinking about any topic requires background knowledge about the topic. For example, the most sophisticated understanding of the principles of hypothetico-deductive reasoning is of no help unless accompanied by some knowledge of what might be plausible explanations of some phenomenon under investigation.

Critics have objected to bias in the theory, pedagogy and practice of critical thinking. Commentators (e.g., Alston 1995; Ennis 1998) have noted that anyone who takes a position has a bias in the neutral sense of being inclined in one direction rather than others. The critics, however, are objecting to bias in the pejorative sense of an unjustified favoring of certain ways of knowing over others, frequently alleging that the unjustly favoured ways are those of a dominant sex or culture (Bailin 1995). These ways favour:

• reinforcement of egocentric and sociocentric biases over dialectical engagement with opposing world-views (Paul 1981, 1984; Warren 1998)
• distancing from the object of inquiry over closeness to it (Martin 1992; Thayer-Bacon 1992)
• indifference to the situation of others over care for them (Martin 1992)
• orientation to thought over orientation to action (Martin 1992)
• being reasonable over caring to understand people’s ideas (Thayer-Bacon 1993)
• being neutral and objective over being embodied and situated (Thayer-Bacon 1995a)
• doubting over believing (Thayer-Bacon 1995b)
• reason over emotion, imagination and intuition (Thayer-Bacon 2000)
• solitary thinking over collaborative thinking (Thayer-Bacon 2000)
• written and spoken assignments over other forms of expression (Alston 2001)
• attention to written and spoken communications over attention to human problems (Alston 2001)
• winning debates in the public sphere over making and understanding meaning (Alston 2001)

A common thread in this smorgasbord of accusations is dissatisfaction with focusing on the logical analysis and evaluation of reasoning and arguments. While these authors acknowledge that such analysis and evaluation is part of critical thinking and should be part of its conceptualization and pedagogy, they insist that it is only a part. Paul (1981), for example, bemoans the tendency of atomistic teaching of methods of analyzing and evaluating arguments to turn students into more able sophists, adept at finding fault with positions and arguments with which they disagree but even more entrenched in the egocentric and sociocentric biases with which they began. Martin (1992) and Thayer-Bacon (1992) cite with approval the self-reported intimacy with their subject-matter of leading researchers in biology and medicine, an intimacy that conflicts with the distancing allegedly recommended in standard conceptions and pedagogy of critical thinking. Thayer-Bacon (2000) contrasts the embodied and socially embedded learning of her elementary school students in a Montessori school, who used their imagination, intuition and emotions as well as their reason, with conceptions of critical thinking as

thinking that is used to critique arguments, offer justifications, and make judgments about what are the good reasons, or the right answers. (Thayer-Bacon 2000: 127–128)

Alston (2001) reports that her students in a women’s studies class were able to see the flaws in the Cinderella myth that pervades much romantic fiction but in their own romantic relationships still acted as if all failures were the woman’s fault and still accepted the notions of love at first sight and living happily ever after. Students, she writes, should

be able to connect their intellectual critique to a more affective, somatic, and ethical account of making risky choices that have sexist, racist, classist, familial, sexual, or other consequences for themselves and those both near and far… critical thinking that reads arguments, texts, or practices merely on the surface without connections to feeling/desiring/doing or action lacks an ethical depth that should infuse the difference between mere cognitive activity and something we want to call critical thinking. (Alston 2001: 34)

Some critics portray such biases as unfair to women. Thayer-Bacon (1992), for example, has charged modern critical thinking theory with being sexist, on the ground that it separates the self from the object and causes one to lose touch with one’s inner voice, and thus stigmatizes women, who (she asserts) link self to object and listen to their inner voice. Her charge does not imply that women as a group are on average less able than men to analyze and evaluate arguments. Facione (1990c) found no difference by sex in performance on his California Critical Thinking Skills Test. Kuhn (1991: 280–281) found no difference by sex in either the disposition or the competence to engage in argumentative thinking.

The critics propose a variety of remedies for the biases that they allege. In general, they do not propose to eliminate or downplay critical thinking as an educational goal. Rather, they propose to conceptualize critical thinking differently and to change its pedagogy accordingly. Their pedagogical proposals arise logically from their objections. They can be summarized as follows:

• Focus on argument networks with dialectical exchanges reflecting contesting points of view rather than on atomic arguments, so as to develop “strong sense” critical thinking that transcends egocentric and sociocentric biases (Paul 1981, 1984).
• Foster closeness to the subject-matter and feeling connected to others in order to inform a humane democracy (Martin 1992).
• Develop “constructive thinking” as a social activity in a community of physically embodied and socially embedded inquirers with personal voices who value not only reason but also imagination, intuition and emotion (Thayer-Bacon 2000).
• In developing critical thinking in school subjects, treat as important neither skills nor dispositions but opening worlds of meaning (Alston 2001).
• Attend to the development of critical thinking dispositions as well as skills, and adopt the “critical pedagogy” practised and advocated by Freire (1968 [1970]) and hooks (1994) (Dalgleish, Girard, & Davies 2017).

A common thread in these proposals is treatment of critical thinking as a social, interactive, personally engaged activity like that of a quilting bee or a barn-raising (Thayer-Bacon 2000) rather than as an individual, solitary, distanced activity symbolized by Rodin’s The Thinker . One can get a vivid description of education with the former type of goal from the writings of bell hooks (1994, 2010). Critical thinking for her is open-minded dialectical exchange across opposing standpoints and from multiple perspectives, a conception similar to Paul’s “strong sense” critical thinking (Paul 1981). She abandons the structure of domination in the traditional classroom. In an introductory course on black women writers, for example, she assigns students to write an autobiographical paragraph about an early racial memory, then to read it aloud as the others listen, thus affirming the uniqueness and value of each voice and creating a communal awareness of the diversity of the group’s experiences (hooks 1994: 84). Her “engaged pedagogy” is thus similar to the “freedom under guidance” implemented in John Dewey’s Laboratory School of Chicago in the late 1890s and early 1900s. It incorporates the dialogue, anchored instruction, and mentoring that Abrami (2015) found to be most effective in improving critical thinking skills and dispositions.

What is the relationship of critical thinking to problem solving, decision-making, higher-order thinking, creative thinking, and other recognized types of thinking? One’s answer to this question obviously depends on how one defines the terms used in the question. If critical thinking is conceived broadly to cover any careful thinking about any topic for any purpose, then problem solving and decision making will be kinds of critical thinking, if they are done carefully. Historically, ‘critical thinking’ and ‘problem solving’ were two names for the same thing. If critical thinking is conceived more narrowly as consisting solely of appraisal of intellectual products, then it will be disjoint with problem solving and decision making, which are constructive.

Bloom’s taxonomy of educational objectives used the phrase “intellectual abilities and skills” for what had been labeled “critical thinking” by some, “reflective thinking” by Dewey and others, and “problem solving” by still others (Bloom et al. 1956: 38). Thus, the so-called “higher-order thinking skills” at the taxonomy’s top levels of analysis, synthesis and evaluation are just critical thinking skills, although they do not come with general criteria for their assessment (Ennis 1981b). The revised version of Bloom’s taxonomy (Anderson et al. 2001) likewise treats critical thinking as cutting across those types of cognitive process that involve more than remembering (Anderson et al. 2001: 269–270). For details, see the Supplement on History .

As to creative thinking, it overlaps with critical thinking (Bailin 1987, 1988). Thinking about the explanation of some phenomenon or event, as in Ferryboat , requires creative imagination in constructing plausible explanatory hypotheses. Likewise, thinking about a policy question, as in Candidate , requires creativity in coming up with options. Conversely, creativity in any field needs to be balanced by critical appraisal of the draft painting or novel or mathematical theory.

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Advanced practice: critical thinking and clinical reasoning

Sadie Diamond-Fox

Senior Lecturer in Advanced Critical Care Practice, Northumbria University, Advanced Critical Care Practitioner, Newcastle upon Tyne Hospitals NHS Foundation Trust, and Co-Lead, Advanced Critical/Clinical Care Practitioners Academic Network (ACCPAN)

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Advanced Critical Care Practitioner, South Tees Hospitals NHS Foundation Trust

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Clinical reasoning is a multi-faceted and complex construct, the understanding of which has emerged from multiple fields outside of healthcare literature, primarily the psychological and behavioural sciences. The application of clinical reasoning is central to the advanced non-medical practitioner (ANMP) role, as complex patient caseloads with undifferentiated and undiagnosed diseases are now a regular feature in healthcare practice. This article explores some of the key concepts and terminology that have evolved over the last four decades and have led to our modern day understanding of this topic. It also considers how clinical reasoning is vital for improving evidence-based diagnosis and subsequent effective care planning. A comprehensive guide to applying diagnostic reasoning on a body systems basis will be explored later in this series.

The Multi-professional Framework for Advanced Clinical Practice highlights clinical reasoning as one of the core clinical capabilities for advanced clinical practice in England ( Health Education England (HEE), 2017 ). This is also identified in other specialist core capability frameworks and training syllabuses for advanced clinical practitioner (ACP) roles ( Faculty of Intensive Care Medicine, 2018 ; Royal College of Emergency Medicine, 2019 ; HEE, 2020 ; HEE et al, 2020 ).

Rencic et al (2020) defined clinical reasoning as ‘a complex ability, requiring both declarative and procedural knowledge, such as physical examination and communication skills’. A plethora of literature exists surrounding this topic, with a recent systematic review identifying 625 papers, spanning 47 years, across the health professions ( Young et al, 2020 ). A diverse range of terms are used to refer to clinical reasoning within the healthcare literature ( Table 1 ), which can make defining their influence on their use within the clinical practice and educational arenas somewhat challenging.

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How to develop critical thinking skills

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What are critical thinking skills?

How to develop critical thinking skills: 12 tips, how to practice critical thinking skills at work, become your own best critic.

A client requests a tight deadline on an intense project. Your childcare provider calls in sick on a day full of meetings. Payment from a contract gig is a month behind. 

Your day-to-day will always have challenges, big and small. And no matter the size and urgency, they all ask you to use critical thinking to analyze the situation and arrive at the right solution. 

Critical thinking includes a wide set of soft skills that encourage continuous learning, resilience , and self-reflection. The more you add to your professional toolbelt, the more equipped you’ll be to tackle whatever challenge presents itself. Here’s how to develop critical thinking, with examples explaining how to use it.

Critical thinking skills are the skills you use to analyze information, imagine scenarios holistically, and create rational solutions. It’s a type of emotional intelligence that stimulates effective problem-solving and decision-making . 

When you fine-tune your critical thinking skills, you seek beyond face-value observations and knee-jerk reactions. Instead, you harvest deeper insights and string together ideas and concepts in logical, sometimes out-of-the-box , ways. 

Imagine a team working on a marketing strategy for a new set of services. That team might use critical thinking to balance goals and key performance indicators , like new customer acquisition costs, average monthly sales, and net profit margins. They understand the connections between overlapping factors to build a strategy that stays within budget and attracts new sales. 

Looking for ways to improve critical thinking skills? Start by brushing up on the following soft skills that fall under this umbrella: 

• Analytical thinking: Approaching problems with an analytical eye includes breaking down complex issues into small chunks and examining their significance. An example could be organizing customer feedback to identify trends and improve your product offerings. 
• Open-mindedness: Push past cognitive biases and be receptive to different points of view and constructive feedback . Managers and team members who keep an open mind position themselves to hear new ideas that foster innovation . 
• Creative thinking: With creative thinking , you can develop several ideas to address a single problem, like brainstorming more efficient workflow best practices to boost productivity and employee morale . 
• Self-reflection: Self-reflection lets you examine your thinking and assumptions to stimulate healthier collaboration and thought processes. Maybe a bad first impression created a negative anchoring bias with a new coworker. Reflecting on your own behavior stirs up empathy and improves the relationship. 
• Evaluation: With evaluation skills, you tackle the pros and cons of a situation based on logic rather than emotion. When prioritizing tasks , you might be tempted to do the fun or easy ones first, but evaluating their urgency and importance can help you make better decisions. 

There’s no magic method to change your thinking processes. Improvement happens with small, intentional changes to your everyday habits until a more critical approach to thinking is automatic. 

Here are 12 tips for building stronger self-awareness and learning how to improve critical thinking: 

1. Be cautious

There’s nothing wrong with a little bit of skepticism. One of the core principles of critical thinking is asking questions and dissecting the available information. You might surprise yourself at what you find when you stop to think before taking action. 

Before making a decision, use evidence, logic, and deductive reasoning to support your own opinions or challenge ideas. It helps you and your team avoid falling prey to bad information or resistance to change .

2. Ask open-ended questions

“Yes” or “no” questions invite agreement rather than reflection. Instead, ask open-ended questions that force you to engage in analysis and rumination. Digging deeper can help you identify potential biases, uncover assumptions, and arrive at new hypotheses and possible solutions. 

3. Do your research

No matter your proficiency, you can always learn more. Turning to different points of view and information is a great way to develop a comprehensive understanding of a topic and make informed decisions. You’ll prioritize reliable information rather than fall into emotional or automatic decision-making. 

4. Consider several opinions

You might spend so much time on your work that it’s easy to get stuck in your own perspective, especially if you work independently on a remote team . Make an effort to reach out to colleagues to hear different ideas and thought patterns. Their input might surprise you.

If or when you disagree, remember that you and your team share a common goal. Divergent opinions are constructive, so shift the focus to finding solutions rather than defending disagreements. 

5. Learn to be quiet

Active listening is the intentional practice of concentrating on a conversation partner instead of your own thoughts. It’s about paying attention to detail and letting people know you value their opinions, which can open your mind to new perspectives and thought processes.

If you’re brainstorming with your team or having a 1:1 with a coworker , listen, ask clarifying questions, and work to understand other peoples’ viewpoints. Listening to your team will help you find fallacies in arguments to improve possible solutions.

6. Schedule reflection

Whether waking up at 5 am or using a procrastination hack, scheduling time to think puts you in a growth mindset . Your mind has natural cognitive biases to help you simplify decision-making, but squashing them is key to thinking critically and finding new solutions besides the ones you might gravitate toward. Creating time and calm space in your day gives you the chance to step back and visualize the biases that impact your decision-making. 

7. Cultivate curiosity

With so many demands and job responsibilities, it’s easy to seek solace in routine. But getting out of your comfort zone helps spark critical thinking and find more solutions than you usually might.

If curiosity doesn’t come naturally to you, cultivate a thirst for knowledge by reskilling and upskilling . Not only will you add a new skill to your resume , but expanding the limits of your professional knowledge might motivate you to ask more questions. 

You don’t have to develop critical thinking skills exclusively in the office. Whether on your break or finding a hobby to do after work, playing strategic games or filling out crosswords can prime your brain for problem-solving. 

9. Write it down

Recording your thoughts with pen and paper can lead to stronger brain activity than typing them out on a keyboard. If you’re stuck and want to think more critically about a problem, writing your ideas can help you process information more deeply.

The act of recording ideas on paper can also improve your memory . Ideas are more likely to linger in the background of your mind, leading to deeper thinking that informs your decision-making process. 

10. Speak up

Take opportunities to share your opinion, even if it intimidates you. Whether at a networking event with new people or a meeting with close colleagues, try to engage with people who challenge or help you develop your ideas. Having conversations that force you to support your position encourages you to refine your argument and think critically. 

11. Stay humble

Ideas and concepts aren’t the same as real-life actions. There may be such a thing as negative outcomes, but there’s no such thing as a bad idea. At the brainstorming stage , don’t be afraid to make mistakes.

Sometimes the best solutions come from off-the-wall, unorthodox decisions. Sit in your creativity , let ideas flow, and don’t be afraid to share them with your colleagues. Putting yourself in a creative mindset helps you see situations from new perspectives and arrive at innovative conclusions. 

12. Embrace discomfort

Get comfortable feeling uncomfortable . It isn’t easy when others challenge your ideas, but sometimes, it’s the only way to see new perspectives and think critically.

By willingly stepping into unfamiliar territory, you foster the resilience and flexibility you need to become a better thinker. You’ll learn how to pick yourself up from failure and approach problems from fresh angles. 

Thinking critically is easier said than done. To help you understand its impact (and how to use it), here are two scenarios that require critical thinking skills and provide teachable moments. 

Scenario #1: Unexpected delays and budget

Imagine your team is working on producing an event. Unexpectedly, a vendor explains they’ll be a week behind on delivering materials. Then another vendor sends a quote that’s more than you can afford. Unless you develop a creative solution, the team will have to push back deadlines and go over budget, potentially costing the client’s trust. 

Here’s how you could approach the situation with creative thinking:

• Analyze the situation holistically: Determine how the delayed materials and over-budget quote will impact the rest of your timeline and financial resources . That way, you can identify whether you need to build an entirely new plan with new vendors, or if it’s worth it to readjust time and resources. 
• Identify your alternative options: With careful assessment, your team decides that another vendor can’t provide the same materials in a quicker time frame. You’ll need to rearrange assignment schedules to complete everything on time. 
• Collaborate and adapt: Your team has an emergency meeting to rearrange your project schedule. You write down each deliverable and determine which ones you can and can’t complete by the deadline. To compensate for lost time, you rearrange your task schedule to complete everything that doesn’t need the delayed materials first, then advance as far as you can on the tasks that do. 
• Check different resources: In the meantime, you scour through your contact sheet to find alternative vendors that fit your budget. Accounting helps by providing old invoices to determine which vendors have quoted less for previous jobs. After pulling all your sources, you find a vendor that fits your budget. 
• Maintain open communication: You create a special Slack channel to keep everyone up to date on changes, challenges, and additional delays. Keeping an open line encourages transparency on the team’s progress and boosts everyone’s confidence. 

Scenario #2: Differing opinions 

A conflict arises between two team members on the best approach for a new strategy for a gaming app. One believes that small tweaks to the current content are necessary to maintain user engagement and stay within budget. The other believes a bold revamp is needed to encourage new followers and stronger sales revenue. 

Here’s how critical thinking could help this conflict:

• Listen actively: Give both team members the opportunity to present their ideas free of interruption. Encourage the entire team to ask open-ended questions to more fully understand and develop each argument. 
• Flex your analytical skills: After learning more about both ideas, everyone should objectively assess the benefits and drawbacks of each approach. Analyze each idea's risk, merits, and feasibility based on available data and the app’s goals and objectives. 
• Identify common ground: The team discusses similarities between each approach and brainstorms ways to integrate both idea s, like making small but eye-catching modifications to existing content or using the same visual design in new media formats. 
• Test new strategy: To test out the potential of a bolder strategy, the team decides to A/B test both approaches. You create a set of criteria to evenly distribute users by different demographics to analyze engagement, revenue, and customer turnover. 
• Monitor and adapt: After implementing the A/B test, the team closely monitors the results of each strategy. You regroup and optimize the changes that provide stronger results after the testing. That way, all team members understand why you’re making the changes you decide to make.

You can’t think your problems away. But you can equip yourself with skills that help you move through your biggest challenges and find innovative solutions. Learning how to develop critical thinking is the start of honing an adaptable growth mindset. 

Now that you have resources to increase critical thinking skills in your professional development, you can identify whether you embrace change or routine, are open or resistant to feedback, or turn to research or emotion will build self-awareness. From there, tweak and incorporate techniques to be a critical thinker when life presents you with a problem.

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Elizabeth Perry, ACC

Elizabeth Perry is a Coach Community Manager at BetterUp. She uses strategic engagement strategies to cultivate a learning community across a global network of Coaches through in-person and virtual experiences, technology-enabled platforms, and strategic coaching industry partnerships. With over 3 years of coaching experience and a certification in transformative leadership and life coaching from Sofia University, Elizabeth leverages transpersonal psychology expertise to help coaches and clients gain awareness of their behavioral and thought patterns, discover their purpose and passions, and elevate their potential. She is a lifelong student of psychology, personal growth, and human potential as well as an ICF-certified ACC transpersonal life and leadership Coach.

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Five decades of research and theorization on clinical reasoning: a critical review

Shahram yazdani.

1 Department of Medical Education, School of Medical Education, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Maryam Hoseini Abardeh

Clinical reasoning is a complex cognitive process that is essential to evaluate and manage a patient’s medical problem. The aim of this paper was to provide a critical review of the research literature on clinical reasoning theories and models. To conduct our study, we applied the process of conducting a literature review in four stages in accordance with the approach of Carnwell and Daly. First, we defined the scope of the review as being limited to clinical reasoning theories and models in medical education. In the second stage, we conducted a search based on related words in PubMed, Google Scholar, PsycINFO, ERIC, ScienceDirect and Web of Science databases. In the third stage, we classified the results of the review into three categories, and in the fourth stage, we concluded and informed further studies. Based on the inclusion and exclusion criteria, 31 articles were eligible to be reviewed. Three theories and two models were recognized and classified into three categories. Several theories and models have been proposed in relation to clinical reasoning, but it seems that these theories and models could only explain part of this complex process and not the whole process. Therefore, to fulfill this gap, it may be helpful to build a Meta-model or Meta-theory, which unified all the models, and theories of clinical reasoning.

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Introduction

Clinical reasoning is a complex cognitive process that is essential to evaluate and manage a patient’s medical problem. 1 It includes the diagnosis of the patient problem, making a therapeutic decision and estimating the prognosis for the patient. 2 In describing the importance of clinical reasoning, it has been acknowledged that clinical reasoning is the central part of physician competence, 3 and stands at the heart of the clinical practice, 4 it has an important role in physicians’ abilities to make diagnoses and decisions. 1 Clinical reasoning has been the subject of academic and scientific research for decades; 5 and its theoretical underpinning has been studied from different perspectives. 6 Clinical reasoning is a challenging, promising, complex, multidimensional, mostly invisible, 7 and poorly understood process. 8 Researchers have explored its nature since 1980, 9 but due to the lack of theoretical models, it remains vague. Most used theoretical models have limited explanatory power, and are based on certain assumptions about what constitutes clinical reasoning. 10 In the literature of clinical reasoning, several competing theories and models have been raised. 1 , 11 – 13 Although most of the theoretical contributions on clinical reasoning belong to the 20th century, proposing new models are well continued into the 21st century, for example, Haring and her colleagues proposed a conceptual model for expert judgment of clinical reasoning of medical students. 14 However, there is no general agreement as to which of these is the best. 15 The purpose of this paper is to provide a critical review of the research literature on clinical reasoning theories and models and present a comprehensive view of main models and theories of clinical reasoning in medical education. A clearer understanding of clinical reasoning models and theories help medical teachers for teaching, planning, and assessment of clinical reasoning. This paper tries to clarify the current knowledge regarding the clinical reasoning models and theories and present a classification of the main theories and models.

Materials and methods

Grant noted, “A critical review aims to demonstrate that the writer has extensively researched the literature and critically evaluated its quality.” 16 It included a degree of analysis and conceptual innovation. 16 In this study, we applied the process of conducting a literature review according to Carnwell and Daly. 17 They proposed a “four-stage” method that included: 1) “Defining the scope of the review,” 2) “Identifying and selecting the sources of relevant information,” 3) “Organizing the results of the review into categories,” and 4) “Concluding and informing further studies.” 17

Step 1: defining the scope of the review

The scope of this review was limited to the main clinical reasoning theories and models proposed in medical education literature. We concentrated our review on published works in scholarly journals between the years 1970 and 2018.

Step 2: identifying and selecting the sources of relevant information

At this stage, each of the two reviewers conducted a separate search based on keywords – “clinical reasoning,” “diagnostic reasoning,” “clinical reasoning theory,” “clinical reasoning model,” “script theory,” “hypothetico–deductive model,” “cognitive continuum theory,” and “dual processing theory” – in PubMed, Google Scholar, PsycINFO, ERIC, ScienceDirect and Web of Science databases. The results were pooled and extensive literature were found (n=305) which was from 1970 to 2018, but due to lack of access to the full text of some articles, and after removing duplicated studies, the title and abstract of articles from 1974 up to 2018 have been reviewed by researchers (n=170) ( Table 1 ).

Scientific studies about clinical reasoning that has been title and abstract reviewed

Then, the articles that presented theories or models of clinical reasoning in medicine or provided evidence in relation to them were selected to full-text study. Studies were eligible for this critical review if they presented a model or a theory of clinical reasoning, or related critiqued models and theories or the studies that add some features to the theories and models of clinical reasoning (n=47). The inclusion criteria of selecting studies were: 1) published articles in English and Persian and 2) published articles in the field of medicine. Studies were excluded if they provided clinical reasoning models or theories in other fields (like nursing and optometry), examined the clinical reasoning in the field of artificial intelligence (like clinical decision support systems), and/or examined brain biology and brain functions (like fMRI studies).

Step 3: organizing the results of the review into categories

After excluding irrelevant studies, a total of 31 documents were initially selected for review which is shown in PRISMA flowchart below ( Figure 1 ).

PRISMA flowchart.

Models and theories which were extracted from studies, classified to three categories and each category, based on Carnwel and Daly approach, reviewed in three steps: first, we present a summary of the models and theories, and then reflect other author’s views and finally, we present our view ( Table 2 ). 17 If a model or theory explains about the process of clinical reasoning our first category owns it while models and theories which clarified the formation of knowledge structures and their application during the clinical reasoning process belongs to the second category, and our third category consisted models and theories which consider more than one processing modes of clinical reasoning.

The list of 31 related literatures that included in the review

First category: theories and models based on the process of clinical reasoning

This category includes the models and theories that explain the clinical reasoning process, between models and theories that we reviewed, only hypothetico-deductive model was eligible to get placed in the first category as the most reputed model that explains the clinical reasoning process. This model was proposed by Elstein (1978), and, according to this model, the physicians primarily generate a limited number of diagnostic hypotheses or problem formulations in the process of solving a diagnostic problem and then testing them. These hypotheses guide further patient information. 18 , 19 Unlike the findings of hypothetico-deductive model that claim: “primarily generated and tested hypotheses by expert and novice are the same,” Patel believed that it is not consistent in other domains, like physics. 19

Higgs argued that this model posits the idea that the process of clinical reasoning is largely a sequential process. 20 Charlin pointed out that the psychological mechanisms involved in the generation and testing of relevant hypotheses are unfamiliar, 12 and Holyoak argued that this model does not distinguish between novice and expert clinical reasoning strategies. 21 Loftus believed that the collected information and the way they interpreted, distorted by the used hypothesis. 5 This model as an adequate description of the process of clinical reasoning has challenged by the case specificity findings. 7

Nevertheless, some researchers defend hypothetico-deductive model, Elstein argued that the small set of solutions that generated in this model transformed an unstructured problem to structured one and it is an effective way to solve diagnostic problems. 18 This model is recommended by medical experts as a useful reasoning strategy for medical students. 22 Hypothetico-deductive model is applicable when data are vague or reveal over time, 22 and is a representation of clinical reasoning. 20 This model represents a description of the mental processes used by physicians and has repeatedly been validated by empirical studies and is the basis for modern clinical education. 12

Hypothetico-deductive model assumes the physician starts hypothesizing after collecting patient information and then tests hypotheses, while we believe the physician starts hypothesizing initially from his/her clinical encounter. The initial hypotheses can be strong or weak, depending on whether the physician is an expert or novice, the difference between the novice and the expert lies in the quality of the hypotheses they made. Therefore, since the initial hypothesis of an expert has good quality, hypothesis testing will be fast and efficient. The simplicity of this model in describing the process of clinical reasoning is both strength and the weakness of it, as a strength, because it simply portrays the start point of the process of clinical reasoning so it can be used to design the teaching plan and evaluate clinical reasoning. As a weakness, because it considers the process of diagnostic reasoning very simple, while even for a novice, this process does not occur so easily, and other factors (such as the individual’s knowledge structure, the context, the health system, etc.) affect the process of clinical reasoning, but this model does not consider these factors.

Second category: theories and models based on the knowledge structure

For this category, we considered theories and models that explain the formation of knowledge structures in the clinical reasoning process, by this description and the inclusion criteria just one theory and one model of clinical reasoning gain eligibility to include, the “illness script theory” and the “pattern recognition model.”

The illness script theory proposed by Barrows and Feltovich consists of three components: 1) enabling conditions, 2) fault, and 3) consequences. 23 The first component is the factors such as age, sex, current medication, previous medical history, occupation, risk behavior, hereditary, and environment affect the probability of someone gets a disease, are the patient’s contextual and background factors that refer to “Enabling conditions.” These “Enabling conditions” can cause the latter pathophysiological malfunctioning that called “fault” which is the second component of illness script. Consequences of this fault are complaints, signs, and symptoms that consist of the third component. 24 Illness scripts are the list-like structures, 25 which conceptualized as a specific representation of clinical knowledge. 26 Script concordance test designed according to this theory. 27

While we were studying about Illness script theory, we realized that we could categorize studies into two broad groups. The first group is the studies that deal with the concept of the script, the schema, and the illness script, and their features, distinctions, and components ( Table 3 ). 24 , 26 – 28

The studies that deal with the concept of “script,” “schema,” and “illness script,” and their features, distinctions, and components

The second group deals with the formation and development of the illness script during the acquisition of expertise and changes in the physician’s knowledge structure ( Table 4 ). 23 , 25 , 26 , 29

The studies that deal with the formation and development of “illness script” during the acquisition of expertise and changes in the physician’s knowledge structure

The first group of studies also looked at the distinction between the concept of the script and the schema, but this distinction was not clear in the literature. The schemas and scripts are stored in long-term memory. 30

Schema as a knowledge structure has an “if/then” formatting and occurs sequentially, in the sense that this sequence divided into two branches: “if” and “then,” so we can claim out that its format is algorithmic. This algorithm starts with a hypothesis in a person’s mind or something that a person thinks about and then continues with inquiries and searches that a physician has performed and then with the findings that a physician has reached, and finish with the decisions that he/she has finally taken ( Figure 2 ).

Generic flow of events in a typical schema. D1: Decision No 1; D5: Decision No 6; F1: Finding No 1; F5: Finding No 5; H1: Hypothesis No 1; H2: Hypothesis No 2; I1: Inquiry No 1; I3: Inquiry No 3.

In terms of the structure of the script, we also agree with Schmidt’s view that the scripts are list-like structures, but unlike Charlin, who believed that “the script describes the structure of clinical knowledge,” we believe that the script is not necessarily the structure of clinical knowledge, but a knowledge structure that has clinical applications. The script is schemas for common situations, which include a packet or a list of expectations of what people see or do at a given location. The schemas and scripts are stored in long-term memory, and if physicians encounter a clinical case that matches with them, they will retrieve it from long-term memory and move it to short-term memory ( Figure 3 ).

Script as a routinized pathway of previously used schema. D1: Decision No 1; D5: Decision No 6; F1: Finding No 1; F5: Finding No 5; H1: Hypothesis No 1; H2: Hypothesis No 2; I1: Inquiry No 1; I3: Inquiry No 3.

Pattern recognition model

In the pattern recognition model, a physician directly compares the pattern of the patient’s problem with disease patterns and if found them similar to each other, then select the pattern that matches it. 31 Experienced practitioners often use pattern recognition to achieve a medical diagnosis. 32 Norman and his colleagues argue that pattern recognition is the most usual form of nonanalytic processes. 11 However, Elstein proposed some questions about this model, as followed:

• When dose a person use a pattern recognition model?
• When is this method preferable to the hypothetico-deductive method?
• What guarantees that the choice of a pattern or an illness script is correct?
• What happens if the pattern or script stored in the knowledge base is wrong? 33

This model considers the complexity of cognitive processes involved in clinical reasoning to be insignificant. 34

Based on the definition of the pattern recognition model, it only mentions the existence of patterns in mind, but does not explain how the construction of these patterns occurred. The studies which designed to prove that the pattern recognition model happens in reality are in a limited field of expertise, like radiology, dermatology, and pathology. 7 So the pattern recognition model is not extendable to all medical specialties.

Third category: compilation theories and model

Some of the included documents were about “dual processing” and “cognitive continuum” theories that explain two modes of reasoning – “analytical” and “non-analytical,” these modes are the characteristics of both first and second category, so we cannot involve them in one of them, therefore they form our third category.

The dual-processing theories commonly have two different processing modes in which they refer to: System 1 and System 2. 13 System 1 described as a fast, automatic and intuitive mode, which shares similarities through perception, while System 2 is slow and analytic mode that applies rules without inferring emotions. 7

Croskerry believed that dual-processing theory is an applicable model in multiple domains of health care like decision-making and it can be useful in teaching decision theory or in making a platform to future research. 35 Pelaccia et al noted that in the framework of this theory, the pattern recognition and hypothetico-deductive models are the basis of the intuitive system and the analytic system, respectively. 1

Evans and Stanovich criticized this theory in five major themes: 1) various theorists have proposed multiple and vague definitions for this theory, 2) there is no consistency in associated attribute clusters with dual systems, 3) distinctions are referred to the continuum of processing and not to discrete processing; 4) the apparent dual-process phenomenon can present by single-process accounts; and 5) the evidence base for the dual-processing theory is ambiguous or unconvincing. 36

In the reviewing of the literature, we found out that some of the researchers established their models based on dual-processing theory like Marcum, 34 Croskerry, 35 , 37 and Lucchiari and Pravettoni. 10

Dual-processing theory employs many of the seemingly contradictory features that have been proposed for clinical reasoning in the literature (such as fast, slow, reflective, etc.). It seems that, in reality, a physician does not use just intuitive or analytic systems and the mind of physician operates in the space between them, while the dual-processing theory ignores this.

The theories and models that have been proposed following this theory have led to the introduction of cognitive concepts such as metacognition and perception and their role in the process of clinical reasoning. This theory has relatively clarified the role of emotions and their place of influence in the process of clinical reasoning, and has also contributed to clarifying the concept of intuition in clinical reasoning.

The second theory that has placed in third categories is cognitive continuum, as Hammond claimed, this theory considered two poles, an intuitive cognition and an analytical cognition, in which various modes or forms of cognition have relational order on a continuum, and this assumption rejected the dual-processing approach. 38 Hamm believed, this theory does not explain the information processing that is the basis of analysis and intuition, but based on analytical and intuitive cognitive attributes it gives us various techniques in describing cognitive modes. Also, he believed that this theory did not offer an instruction about thinking analytically or intuitively, and it just presented a general framework. Cognitive continuum theory described the features of cognition and their correlation with the characteristics of the task. 39 Custers noted that this theory illustrates the cognitive processes and the cognitive tasks on a continuum, and this theory can be used to provide advice on how to structure clinical tasks in an educational setting. 40 In criticizing cognitive continuum theory, we did totally agree with Hamm and Custers.

The present study was conducted to critically review theories and models of clinical reasoning that have often been raised in the medical education literature within five decades (1970–2018). Several theories and models presented in relation to clinical reasoning and it seems that they can explain only part of the complex process, but not the whole process. For example, the models and theories of the first category in our study just address the process of clinical reasoning and do not pay attention to knowledge structures and cognition; in the second category, they just focused on knowledge structures and their formations during clinical reasoning process and do not clarify the process of clinical reasoning. In addition, the dual processing and cognitive continuum theories that form the third category just covered the cognition part of the clinical reasoning. Therefore, to fulfill this gap, it may be helpful to build a Meta-model or Meta-theory, which unified all the models, and theories of clinical reasoning. Although our focus was on the main models and theories of clinical reasoning in the field of medical education, but we acknowledge that there are other models and theories of clinical reasoning in the literature and their absence can be the bias of this study.

Acknowledgment

This work was part of a PhD dissertation, funded and financially supported by the Shahid Beheshti University of Medical Sciences, Tehran, Iran.

The authors report no conflicts of interest in this work.

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Advanced practice: critical thinking and clinical reasoning

Affiliations.

• 1 Advanced Critical Care Practitioner, Newcastle upon Tyne NHS Foundation Trust / Senior Lecturer in Advanced Critical Care Practice, Department of Nursing, Midwifery and Health, Northumbria University.
• 2 Advanced Critical Care Practitioner, South Tees Hospitals NHS Foundation Trust.
• PMID: 33983801
• DOI: 10.12968/bjon.2021.30.9.526

Clinical reasoning is a multi-faceted and complex construct, the understanding of which has emerged from multiple fields outside of healthcare literature, primarily the psychological and behavioural sciences. The application of clinical reasoning is central to the advanced non-medical practitioner (ANMP) role, as complex patient caseloads with undifferentiated and undiagnosed diseases are now a regular feature in healthcare practice. This article explores some of the key concepts and terminology that have evolved over the last four decades and have led to our modern day understanding of this topic. It also considers how clinical reasoning is vital for improving evidence-based diagnosis and subsequent effective care planning. A comprehensive guide to applying diagnostic reasoning on a body systems basis will be explored later in this series.

Keywords: Advanced practice; Clinical reasoning; Consultation; Critical thinking; Diagnostic accuracy.

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Critical thinking

Advice and resources to help you develop your critical voice.

Developing critical thinking skills is essential to your success at University and beyond.  We all need to be critical thinkers to help us navigate our way through an information-rich world. 

Whatever your discipline, you will engage with a wide variety of sources of information and evidence.  You will develop the skills to make judgements about this evidence to form your own views and to present your views clearly.

One of the most common types of feedback received by students is that their work is ‘too descriptive’.  This usually means that they have just stated what others have said and have not reflected critically on the material.  They have not evaluated the evidence and constructed an argument.

What is critical thinking?

Critical thinking is the art of making clear, reasoned judgements based on interpreting, understanding, applying and synthesising evidence gathered from observation, reading and experimentation. Burns, T., & Sinfield, S. (2016)  Essential Study Skills: The Complete Guide to Success at University (4th ed.) London: SAGE, p94.

Being critical does not just mean finding fault.  It means assessing evidence from a variety of sources and making reasoned conclusions.  As a result of your analysis you may decide that a particular piece of evidence is not robust, or that you disagree with the conclusion, but you should be able to state why you have come to this view and incorporate this into a bigger picture of the literature.

Being critical goes beyond describing what you have heard in lectures or what you have read.  It involves synthesising, analysing and evaluating what you have learned to develop your own argument or position.

Critical thinking is important in all subjects and disciplines – in science and engineering, as well as the arts and humanities.  The types of evidence used to develop arguments may be very different but the processes and techniques are similar.  Critical thinking is required for both undergraduate and postgraduate levels of study.

What, where, when, who, why, how?

Purposeful reading can help with critical thinking because it encourages you to read actively rather than passively.  When you read, ask yourself questions about what you are reading and make notes to record your views.  Ask questions like:

• What is the main point of this paper/ article/ paragraph/ report/ blog?
• Who wrote it?
• Why was it written?
• When was it written?
• Has the context changed since it was written?
• Is the evidence presented robust?
• How did the authors come to their conclusions?
• Do you agree with the conclusions?
• What does this add to our knowledge?
• Why is it useful?

Our web page covering Reading at university includes a handout to help you develop your own critical reading form and a suggested reading notes record sheet.  These resources will help you record your thoughts after you read, which will help you to construct your argument. 

Reading at university

Developing an argument

Being a university student is about learning how to think, not what to think.  Critical thinking shapes your own values and attitudes through a process of deliberating, debating and persuasion.   Through developing your critical thinking you can move on from simply disagreeing to constructively assessing alternatives by building on doubts.

There are several key stages involved in developing your ideas and constructing an argument.  You might like to use a form to help you think about the features of critical thinking and to break down the stages of developing your argument.

Features of critical thinking (pdf)

Features of critical thinking (Word rtf)

Our webpage on Academic writing includes a useful handout ‘Building an argument as you go’.

Academic writing

You should also consider the language you will use to introduce a range of viewpoints and to evaluate the various sources of evidence.  This will help your reader to follow your argument.  To get you started, the University of Manchester's Academic Phrasebank has a useful section on Being Critical. 

Academic Phrasebank

Developing your critical thinking

Set yourself some tasks to help develop your critical thinking skills.  Discuss material presented in lectures or from resource lists with your peers.  Set up a critical reading group or use an online discussion forum.  Think about a point you would like to make during discussions in tutorials and be prepared to back up your argument with evidence.

For more suggestions:

Developing your critical thinking - ideas (pdf)

Developing your critical thinking - ideas (Word rtf)

Published guides

For further advice and more detailed resources please see the Critical Thinking section of our list of published Study skills guides.

Study skills guides  

This article was published on 2024-02-26

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Nurses are critical thinkers

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Margaret McCartney: Nurses must be allowed to exercise professional judgment

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The characteristic that distinguishes a professional nurse is cognitive rather than psychomotor ability. Nursing practice demands that practitioners display sound judgement and decision-making skills as critical thinking and clinical decision making is an essential component of nursing practice. Nurses’ ability to recognize and respond to signs of patient deterioration in a timely manner plays a pivotal role in patient outcomes (Purling & King 2012). Errors in clinical judgement and decision making are said to account for more than half of adverse clinical events (Tomlinson, 2015). The focus of the nurse clinical judgement has to be on quality evidence based care delivery, therefore, observational and reasoning skills will result in sound, reliable, clinical judgements. Clinical judgement, a concept which is critical to the nursing can be complex, because the nurse is required to use observation skills, identify relevant information, to identify the relationships among given elements through reasoning and judgement. Clinical reasoning is the process by which nurses observe patients status, process the information, come to an understanding of the patient problem, plan and implement interventions, evaluate outcomes, with reflection and learning from the process (Levett-Jones et al, 2010). At all times, nurses are responsible for their actions and are accountable for nursing judgment and action or inaction.

The speed and ability by which the nurses make sound clinical judgement is affected by their experience. Novice nurses may find this process difficult, whereas the experienced nurse should rely on her intuition, followed by fast action. Therefore education must begin at the undergraduate level to develop students’ critical thinking and clinical reasoning skills. Clinical reasoning is a learnt skill requiring determination and active engagement in deliberate practice design to improve performance. In order to acquire such skills, students need to develop critical thinking ability, as well as an understanding of how judgements and decisions are reached in complex healthcare environments.

As lifelong learners, nurses are constantly accumulating more knowledge, expertise, and experience, and it’s a rare nurse indeed who chooses to not apply his or her mind towards the goal of constant learning and professional growth. Institute of Medicine (IOM) report on the Future of Nursing, stated, that nurses must continue their education and engage in lifelong learning to gain the needed competencies for practice. American Nurses Association (ANA), Scope and Standards of Practice requires a nurse to remain involved in continuous learning and strengthening individual practice (p.26)

Alfaro-LeFevre, R. (2009). Critical thinking and clinical judgement: A practical approach to outcome-focused thinking. (4th ed.). St Louis: Elsevier

The future of nursing: Leading change, advancing health, (2010). https://campaignforaction.org/resource/future-nursing-iom-report

Levett-Jones, T., Hoffman, K. Dempsey, Y. Jeong, S., Noble, D., Norton, C., Roche, J., & Hickey, N. (2010). The ‘five rights’ of clinical reasoning: an educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients. Nurse Education Today. 30(6), 515-520.

NMC (2010) New Standards for Pre-Registration Nursing. London: Nursing and Midwifery Council.

Purling A. & King L. (2012). A literature review: graduate nurses’ preparedness for recognising and responding to the deteriorating patient. Journal of Clinical Nursing, 21(23–24), 3451–3465

Thompson, C., Aitken, l., Doran, D., Dowing, D. (2013). An agenda for clinical decision making and judgement in nursing research and education. International Journal of Nursing Studies, 50 (12), 1720 - 1726 Tomlinson, J. (2015). Using clinical supervision to improve the quality and safety of patient care: a response to Berwick and Francis. BMC Medical Education, 15(103)

Competing interests: No competing interests