how will you show critical thinking and decision making as a health consumer

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How do healthcare consumers make decisions?

Like consumers of other goods and services, healthcare consumers don’t always make decisions that are in their own best interests. Four experts — a psychologist, an organizational behaviorist, a behavioral economist, and a clinician — discuss the challenges of helping people make healthy choices.

• Erica Dawson
• Keith Chen Associate Professor of Economics, Yale School of Management
• Peter Salovey
• Lynn Sullivan

Peter Salovey: My work is from the perspective of a social psychologist, and I'm particularly interested in how we can apply the theories that social psychology as a discipline provides to guide us in figuring out what predicts engagement in prevention activities, care-seeking activities, and early detection for a whole range of health issues and diseases. But we're also very interested in looking at how that applied question feeds back to the theory of social psychology and might help us modify it.

The two areas we've worked in most intensely have to do with cancer prevention and HIV/AIDS prevention and early detection. We look at the framing of messages designed to encourage some kind of relevant health behavior — framing in terms of gain and loss terms — and then we use prospect theory to help predict under what conditions gain-frame versus loss-frame messages would be more or less effective in promoting those kind of behaviors. The behaviors can be getting a mammogram, using sunscreen at the beach, getting a Pap test, eating fruits and vegetables.

Erica Dawson: Can you give an example of gain and loss frames?

Salovey: Sure. Let's take mammography screening. Mammography is an interesting behavior. It involves psychological risk. It's uncertain. You don't know the outcome. Because it's an uncertain behavior, loss framing — making people think about the downside of not engaging in this behavior — may motivate them to take the risk, as compared to a gain-framing message — making them think about the benefit of engaging in this behavior. So a gain-frame message for mammography would be something like "If you get a mammogram, you can feel healthy." A loss-frame message might be "If you don't get a mammogram, you might have undetected breast cancer, and you'll leave your children orphaned and your husband widowed." Those aren't parallel and equivalent in their content otherwise, but they are examples of gain- and loss-frame messages.

We do some of this work in laboratory settings, but mostly in community settings. We work with the public health clinics; we've worked in the housing developments in New Haven, randomly assigning, for example, housing developments to different campaigns, based around gain- or loss-framing messages, and then tracking people for six months or a year to see if they engage in the desired behavior. We do the same thing at Hammonasset Beach on sunscreen.

More recently, the second issue that we've looked at is what we might call psychologically tailoring messages. There's a lot of work on tailored communications. In marketing, you often see strategies where there's something about the recipient of the message that is incorporated into the message. The old-fashioned one was where you'd get a note that says, "As an owner of a Volkswagen, maybe you've wondered whether upgrading to a Porsche would be a good thing." A Super Bowl ad versus an ad on daytime television. What we try to do is tailor health messages in the cancer and AIDS domain to psychological characteristics of the recipient. We've done this with many different kinds of characteristics, but one that we've had very good luck with is a construct developed by Tory Higgins at Columbia University called prevention versus promotion focus. Prevention focus has to do with a person's need for safety and security. Promotion focus is really a person's need or desire to accomplish things and achieve things. And different people emphasize one of those needs over the other. Some people are very oriented toward being safe and secure, others toward achieving and accomplishing. And you could imagine that if we could identify that difference in people, we could construct a campaign around not smoking or engaging in physical exercise or eating fruits and vegetables — those are some of our recent ones — that emphasizes not getting sick versus feeling as healthy as you can.

When we've designed campaigns that are consistent with someone's emphasis, someone's personal desire to prevent problems versus promote achievement, we're more likely to get behavior change.

Lynn Sullivan: If you look at something like promoting HIV testing — which is an area that I've become very involved with — and you look at whether it's best to have it as a gain or a loss framing, do you focus on the detection part of it, or the prevention part of it? My understanding is that they beg for different types of framing.

Salovey: We actually have done that study. We recruited about 500 women from a couple of the health clinics and housing developments in town, and exposed them to videotaped messages with print follow-up about the value of HIV testing. And we gain-framed them or loss-framed them; we did them in English and in Spanish. Now, I would have thought that HIV testing is best thought of as a detection behavior with some risk. You think you're healthy. You risk finding out that you're sick. And so it would be amenable to a loss-framed marketing strategy.

As it turned out, we got an interesting interaction. Some of the women felt that HIV testing was in fact a psychological risk for them: "I don't know my HIV status. I've been involved in behaviors that might have put me at risk. And if I take this test, I might find out something that will be unpleasant." For women who had those attitudes, the loss-frame videos and messages did work better. But for women who said, "You know, I don't think I've done anything to put me at risk. In my view, there isn't any possible way I could be HIV positive," for them, getting tested posed no risk. There's no uncertainty.

Sullivan: Are there any actual psychological gains to be had from testing for HIV?

Salovey: I would guess there are. Knowing that you're healthy, feeling even more relaxed — we always say in our messages, "You can have sex feeling more relaxed that you're not passing on HIV to a partner." Of course, the behaviors we want people to engage in are the same. We still want them to use condoms.

In any case, those people were more motivated to go get tested with gain-frame messages.

Sullivan: So does that mean that part of assessing that, off the bat, is to figure out whether they consider themselves at risk or not?

Salovey: For behaviors like that one, yes, absolutely. We think of behaviors as being risk-oriented, early-detection behaviors or risk-averse, prevention behaviors, but what you really have to look at is how individuals construe those behaviors.

We have studies where we have manipulated that construal. So, for example, we've described Pap testing as either a behavior that helps you detect early stages of cervical cancer or as a behavior that helps you prevent cancer — because it's detecting abnormalities, but we don't emphasize that.

Sullivan: It's the level of risk.

Salovey: And you get the interaction that you would expect in both of those studies. Construe it as a prevention strategy and gain-framing works better. Construe it as a detection strategy and loss-framing works better.

Keith Chen: That interaction would be particularly interesting to economists who are interested in the normative issues with respect to testing, because it also says that the framing has an interaction with the selection effect of who gets tested, right?

Salovey: Absolutely right.

Chen: So if you especially want to target an increased take-up of testing to those who are most at risk, you can provide information as to what frames will most efficaciously achieve that.

Salovey: Exactly right. You have to know something about your population.

Chen: How they do a personal risk assessment.

Salovey: And how they think about this behavior.

Sullivan: But part of the current challenge with the new CDC recommendation about routine HIV testing — that everyone should be tested, no matter what their risk is — is how you engage somebody who is coming in for their routine care, and all of a sudden you're saying, "The CDC recommends we test you for HIV." How do you gauge where they are, because this may not even be on their radar? So you have to figure out how to frame it.

Salovey: That may be why gain-framing works in that situation. They don't think they're at risk, so telling them, "You might have this disease, and if you have this disease, you might pass it on to others" has no meaning.

Sullivan: Right. So, say, "to keep you healthy"—

Salovey: "You want to feel good, psychologically. You want to feel reassured. You don't want to feel anxious. You want to have better sex." That's what you say to them.

Chen: It's the socially responsible thing to do.

Dawson: I'm guessing that a big part of the equation on who gets tested or not is individual differences in healthcare. We know that it's insurance driving when you get tested for things and how often.

Salovey: As a social psychologist, I'm much likelier to emphasize the way an individual thinks about a problem, and then the immediate social circumstances in which they find themselves. But these kinds of structural variables make a huge difference. If somebody else is paying for it, you're more likely to do it. If your physician is recommending it, you're more likely to do it. If it's normative in the community in which you live in — that is, everybody is going out and getting tested, why aren't you? These are huge variables in predicting this kind of behavior.

Chen: I'm an economist first, and then a behavioral economist. That's brought me to thinking about health prevention behaviors and testing behaviors because my research as a behavioral economist focuses primarily on the primitive judgment and decision-making questions. I've done a lot of work on loss aversion, and a lot of new work on cognitive dissonance. Relatively recently, what I've been researching and thinking a lot about is integrating traditional economic cost-and-benefit analysis of gathering information with psychological theories of very intuitive effects: subjects being averse to self-threatening information; subjects being averse to uncertainty in some situations, being attracted to uncertainty in other situations.

My recent work on mammography behavior tries to integrate these two into almost a meta-rational model of economic decision-making. Contrary to what we might think of as the most naïve economically rational model of information acquisition, people don't like information that's potentially disturbing or aversive, that says they're at risk of negative health consequences. At the same time, on some kind of meta-cognitive level, they appear to make cost-and-benefit analyses with respect to gathering information, taking into account both the rational effects that gathering information will have on both their ability to seek effective treatment and plan effective medical behaviors, and these kinds of disquieting psychic costs. And they weigh those against each other with respect to how they form beliefs.

For example, there has often been, in many medical studies, an unfortunately low correlation between risk factors and preventative behaviors that you'd recommend for people with those risk factors. So, those most at risk for certain types of cancers are more likely to smoke. There's sometimes very low correlation between breast cancer risk and mammography behavior, unfortunately.

What I find in some of my research, if you examine self-perceived risk of breast cancer, in the broad cross-section, you find that that is very complexly related to medically estimated risk of breast cancer. There's a relatively underexplored but known fact that self-perceived risk of breast cancer is an upside-down U-shape with respect to medically estimated risk of breast cancer. So, when their medically estimated risk of breast cancer is low, people seem relatively well calibrated — their self-perceived risk increases with their actual medical risk. However, at some point there's an inversion, and there's a large population of people who are at a very high risk for breast cancer who report feeling that they are at a low level of risk.

Salovey: Who don't realize they're at risk. Or who aren't willing to report it.

Chen: That is one of the critical points, because that raises questions of causality. What's driving this? One natural, psychological assumption would be, well, when the information is very, very bad, we're aversive to it, and so you could see this kind of inversion coming out of that. Another explanation could be things like differences in knowledge about what's risky. You could imagine a story, for example, where some people don't know that smoking has negative health consequences. That results in them both smoking more and reporting being at very low risk for, say, lung cancer. That kind of difference in health knowledge could drive this inverse relationship, as opposed to an underlying motivating social-psychological theory.

So what I do, in a lot of my work, is try to isolate those two effects by looking for exogenous factors, things which you have very little control over which affect your breast-cancer risk, and whether or not self-perceived breast cancer risk is affected by that. For example, I find that, controlling for all other factors, including education, income, race, and religious beliefs, if you look at the number of female relatives who the subject knows who have had breast cancer — and this is also controlling for prior testing — still, self-perceived risk for breast cancer is upside-down U-shaped. So, for example, with the first, second, and third female relatives you know who have had breast cancer, your self-perceived risk of breast cancer is increasing, but with your fourth, fifth, and sixth known female relatives who have breast cancer, your self-perceived risk of breast cancer actually declines.

And then once you investigate further, to try and tease out how people are making this belief-level cost-benefit analysis, you can see it has impact on meta-cognitive beliefs as well. So, for example, in a recent survey in San Francisco, approximately 12% of women strongly agree with the statement that people who pray to God are less likely to get breast cancer — in some sense, that God can protect one from breast cancer. Now, what's interesting is that your willingness to say "yes" to that actually steeply declines with the number of female relatives you know who have had breast cancer. So there appears to be in subjects this complex interplay between higher-order beliefs about what drives medical risk, their self-perceived costs and benefits from getting tested, and their final probability assessments about whether or not they're likely to need such testing. What my research shows is that there actually appears to be, although I don't want to push the conclusion too hard, kind of a meta-cognitive level on which people actually take into account the costs and benefits of holding beliefs.

Sullivan: So, in terms of that sense, the perception of risk — can you parse out what is modifiable risk and what is not modifiable? You can't actually take a family history, but let's take...

Dawson: Smoking, eating, alcohol...

Sullivan: Yes, alcohol intake, or something else that has been related to a higher breast cancer risk. Is there a difference in terms of their perceived risk based on whether it's something they can do something about or not? Because, certainly it seems like psychologically, you can say, eight of my female relatives have had breast cancer. That should be pretty compelling. But there may also be a sense of, well, there's nothing I can do about it. Whatever is going to happen to me is going to happen to me, whether I get tested or not.

Chen: This is actually preliminary work, so the results are a little bit weaker. But there do seem to be ways in which these kind of exogenous factors can actually shift your beliefs about the efficacy of things which you actually have control over. So, for example, even though people understand that male relatives having liver cancer has no relationship to whether or not you're likely to have breast cancer, it does have an effect on things like your belief that prayer can protect you from cancer. So, for example, if you had a grandfather who died of liver cancer, you're much less likely to report that prayer to God can protect one from breast cancer. And, in fact, what I find is that that seems to be a driver of your willingness to exercise your accuracy of knowledge. So people who have had, for example, a grandfather die of cancer are more motivated and hence report more accurately whether hair-dye contributes to breast cancer. They're more likely to be on top of the research.

Dawson: Keith, I think this is where some of our research might make contact. We're looking at not necessarily characteristics of individual people, but at the situation that they're in and the kind of disease that we're talking about. We've researched mainly in the context of different diseases that you can or cannot do something about, basically. We're trying in the lab to see how this influences which kind of information people will go after, which, in the long run, means they're going to end up with different knowledge packets.

People have known for a while that disease treatability is a factor in whether you decide to go get tested, which is pretty logical. A lot of different models include this factor, always in this linear sense, meaning that, if there's nothing you can do about a disease, testing just zeroes out. And we found, instead, that it does have an impact, and it's an interaction, essentially. It's multiplicative. If people believe that they're at risk for a disease that they have very little control over, not only do they not want to get diagnostic testing, but they avoid any information. So we left them in a room with pamphlets about this disease that they thought they were at risk for, just to see if they would browse and learn a little bit more about this unusual thing. And they actually seemed to be less likely to even gather any sort of information.

Chen: It ties really nicely into a cost-benefit analysis of information.

Dawson: Exactly. It suggests how that might look, in the long run.

Salovey: It also sounds a little like loss-aversion. You're avoiding information that at least would make you entertain a loss from some reference point.

Dawson: Yes. And it does seem to interact, as Keith was saying, with some sort of calculus about what's the purpose of doing this. So there is a sort of trade-off between severity of the disease, and treatability, and when people have a severe but treatable disease, that seems to trump. It may be more of a gain-frame, in that sense.

Salovey: Sure.

Sullivan: But I think with treatability, there are certain conditions that are very treatable, such as HIV, but, you know, populations in Africa don't have the access to treatment that we have here. The likelihood of them being tested...they just see the whole endeavor as being futile. Why find out if I have this, if I'm not going to have any access to treatment?

Salovey: Has it changed in the U.S.? Where 15 years ago, a positive HIV test felt like a death sentence to someone, and now it certainly isn't. Has that increased interest in testing?

Sullivan: It's interesting. I'm an HIV provider, but I'm also a general internist, so I see patients who are not known to be HIV infected, and then also care for a panel of patients who are infected. I started in this work in the mid-1990s, right on the verge of highly active anti-retroviral therapy coming into the scene. So the first part of my training was all watching patients die of this disease. My outpatient clinic was very small, because most patients were seen in the hospital and did not do well. And then, in 1996, everything shifted. All of a sudden our inpatient service shrunk and we had all the patients coming into the clinic. And there are patients I still follow, 12 years later, for whom HIV is about eighth on their problem list. I take care of the hypertension and the diabetes and I get mammograms, and all the other stuff. So my perspective has been that this is a really treatable disease. And for folks who get treatment, and get it early enough, a good portion can do really well.

I've also had the experience, as a general internist, of diagnosing several patients recently with HIV, and it is absolutely viewed as a death sentence. No matter how I frame it. Three patients said this to me: "I know people who have had this. They had to take piles and piles of pills. Am I going to get really skinny? Am I going to be in the hospital all the time?" I'm not saying that's everybody's perception across the board, but I've been struck, especially since my view of this disease has changed so dramatically in the last 10 years, how a lot of people still see it. And if they think that they're at risk for it, and have that perception of it being life-threatening... Certainly this is a life-altering diagnosis, but in many ways not a life-threatening diagnosis anymore.

Dawson: The real opportunity costs are in this sort of information avoidance. With some diseases, like Huntington's, you can't do anything about it, so who can blame them. But Lynn and I teamed up because we're both interested in the idea that there are many diseases where people underestimate the degree to which they can be controlled. They underestimate, in other words, the value of learning, of early detection and preventive care. And so people who see HIV as a death sentence are precisely the ones who may need early testing and detection, and precisely the ones who may be avoiding it.

Salovey: Exactly right. Keith used the example of breast cancer, earlier — you have eight relatives who have all died of breast cancer, so you feel there's nothing you can do. But, in fact, early detections can lead to treatment options that you wouldn't have if it's detected later, and that are less invasive.

Dawson: And I think that has a lot of very practical implications about how you frame persuasive messages. I think we tend to emphasize the consequences, one way or another. And I think that you should also emphasize what can be done — the possibilities, in essence, giving somebody a reason to want to come in. So getting them correctly gauged on treatability might offer some additional persuasion for early detection behaviors.

Salovey: I'll ask a question of Keith — isn't it true that you're finding some of the roots of the kinds of behavioral decisions that you're describing in work with monkeys?

Chen: Well, for example, a lot of your work on how loss- and gain-frames affect how people kind of process their decisions, very high-order, important decisions: I don't want to claim that these decisions aren't made on a very rational basis. But then, also, some of the effects that you identify, my work with monkeys shows that they appear to be very evolutionarily ancient. So, in other words, even though as human decision-makers, we seem very sensitive to gains and treatability, and things that the rational model tell us, many of the basic ways that we process that information appear to be very deeply ingrained and inherited.

Salovey: Does it trouble people, in some way, that you can look at monkey behavior and actually predict human behavior from it?

Chen: Actually, I've gotten largely positive responses. I haven't spoken with medical practitioners about the monkey work, which is funny, because they would probably be more receptive to it. But, for example, when I've spoken to quantitative hedge fund managers and people who are engaged in behavioral finance, when you tell them that many of the strategies that they're already trading on, the psychological biases that they look for in the average American stock investor —

Salovey: Can't sell a stock at a loss.

Chen: Yes, exactly. When you tell them that, in fact, much of the research suggests that this is a very ancient thing, they're very receptive to that, and in fact, if anything, kind of take the right message from that, that this suggests that these biases are going to be more robust in new settings, and aren't going to be easy to arbitrage out of the market.

Dawson: JDM [judgment and decision-making] research has always taken the approach about how you recognize these biases and then try to minimize the damage. But the fact that they're not going away is, I think, pretty informative. Some of the most exciting work coming out of the field now is capitalizing on them. So instead of trying to suppress them or correct them, you use them. Can you frame people's choices to help them make good choices, based on what they would be doing anyway?

Salovey: It's certainly true, and it's a disappointment to educators in all fields when they learn this, that simply teaching people about biases, about what in economics might traditionally have been called irrational behavior, doesn't change it.

Dawson: They don't see themselves as biased to start with. Peter, I don't know if you've tracked what George Lowenstein is up to, these days. He was just here giving a talk.

Salovey: George and I were graduate students together here at Yale. He was in the economics department and I was in the psychology department. And we ran studies in the same lab, literally. So we talked all the time about these kinds of things. This was 30 years ago.

Dawson: He's talking about this idea of asymmetric paternalism, where you structure people's choices to take advantage of what they're going to do anyway. And he looks, in particular, at the healthcare domain and preventive care, capitalizing on people's love of gambling, for example. We know they like small rewards frequently and the chance for a big pay-off. So he structured this reward system for people taking medicine. They're working with some pharmaceutical companies who have a financial interest in this working — it's in the interest of pharmaceutical companies to have patients take medicine that they need to be on consistently, and it's in the interest of the patient. And it seems to be really effective.

Sullivan: How do you build in the rewards for something as basic as medicine-taking?

Dawson: Well, right now it's money. It's a study, so they're actually paying them. What other rewards might be there, I don't know.

Salovey: Apparently, paying people for adhering to some medical recommendations may actually be a cost-effective strategy.

Sullivan: From a clinical standpoint, it's much easier to convince a patient to take a medication that makes them feel better. You know, one of the struggles with anti-retrovirals is that, in a lot of cases, it's not something that they can actually identify as making them feel better.

Chen: And that can help guide innovation policy. So, for example, from a health-benefit perspective, the marginal research dollar may be much better spent for, say, doing research on reducing the negative side effects from an effective drug than trying to push the marginal effectiveness of this drug even further.

Salovey: One of the constructs that I think is a little bit ignored in this area is the role of emotion and anticipated emotions. Sometimes I think about my own preventive behavior. When I bought the house that I live in now, we tested our basement for radon. It was five picocuries per liter, and four picocuries is the "action" level, so we're over the action level. And the action you can take is to put in, essentially, an exhaust fan. So the radon coming from the rocks and soil under your basement doesn't accumulate. If you put the fan in, picocuries per liter will drop to two.

Now, most of the literature on the link between radon exposure and lung cancer was done on uranium miners exposed to huge amounts of radon — I mean, a hundred picocuries. People were assuming a linear effect. And certainly if you've got substantial household radon, 20 or 30 —

Dawson: You're living in a mineshaft.

Salovey: — you should probably put the thing in. But why did I spend $1,000 putting this thing into my basement, when I was really just at the borderline, and, epidemiologically, the risk was still relatively low? The reason, I think, and this is introspection, this is not scientific, is that every time I open the door to my basement...

Chen: You're taking short breaths.

Salovey: Exactly. I find myself thinking about dying of lung cancer. It's like this automatic association.

Dawson: That could have been prevented.

Salovey: Right. And so that's where the emotions come in. I found myself getting anxious about the idea that I might be putting myself at risk. And then I started feeling guilty about putting my wife at risk. And at that time we had a cat, so when the cat would walk downstairs to the basement, I'm thinking I'm putting my cat at risk. For $1,000, I could buy an insurance policy against anticipated guilt and current anxiety having to do with dying of lung cancer from radon exposure in my basement. And is it worth $1,000 to me? And I'm not saying I actually had this train of thought, but is it worth $1,000 to me to not have to feel those emotions every time I open the door to my basement and walk down the stairs? And the answer is yes, that's a great investment.

To me, it's one of the relatively underexplored areas in health decision-making from the JDM perspective, but also from a delivery perspective and from a behavioral economics perspective: What is the role of emotion and anticipated emotion as a motivator of behavior? After all, we evolved a system of emotions because emotions energize behavior. They get us to do things. They help us survive. Run away when you're afraid. Fight when you're threatened.

Sullivan: I wonder what the spectrum is in terms of people's tolerance for anxiety about those things.

Salovey: There are certainly differences.

Sullivan: I'm on the same page as you. I'm a big believer that if I do a test, I'm going to actually use the data from the test. There's no point in doing a test if you're not going to actually do something with the data. But also I have a very low tolerance for anxiety. So I'd much rather put away whatever the issue is, even if some would say that the risk statistically is almost zip.

But I think other people, and certainly patients I see, have a much higher level of tolerance for anxiety. So I'm wondering about individual differences in what people can tolerate as far as anxiety about risk...

Dawson: This is another example of where you could use this natural tendency we have to do something and use it to your advantage. We know that people are pretty bad at forecasting how they're going to feel in response to certain events. They tend to think their reaction is going to be more dramatic, and that it's going to last longer, than it does. The classic example is, what is it going to be like if you don't get tenure? They think it's going to be horrible, for a really long time. But then if you ask people who were just denied, it's just not that bad.

So I'm wondering if you could capitalize on that forecasting bias. People may not feel anxious or upset or worried in the moment, but if they think they would down the line, you might be able to capitalize on their anticipated future states to convince them to take a test or stick to a treatment that could prevent that bad thing from happening.

Photographs by Julie Brown

Work Life is Atlassian’s flagship publication dedicated to unleashing the potential of every team through real-life advice, inspiring stories, and thoughtful perspectives from leaders around the world.

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Senior Quantitative Researcher, People Insights

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How to build critical thinking skills for better decision-making

It’s simple in theory, but tougher in practice – here are five tips to get you started.

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Have you heard the riddle about two coins that equal thirty cents, but one of them is not a nickel? What about the one where a surgeon says they can’t operate on their own son?

Those brain teasers tap into your critical thinking skills. But your ability to think critically isn’t just helpful for solving those random puzzles – it plays a big role in your career. 

An impressive 81% of employers say critical thinking carries a lot of weight when they’re evaluating job candidates. It ranks as the top competency companies consider when hiring recent graduates (even ahead of communication ). Plus, once you’re hired, several studies show that critical thinking skills are highly correlated with better job performance.

So what exactly are critical thinking skills? And even more importantly, how do you build and improve them? 

What is critical thinking?

Critical thinking is the ability to evaluate facts and information, remain objective, and make a sound decision about how to move forward.

Does that sound like how you approach every decision or problem? Not so fast. Critical thinking seems simple in theory but is much tougher in practice, which helps explain why 65% of employers say their organization has a need for more critical thinking. 

In reality, critical thinking doesn’t come naturally to a lot of us. In order to do it well, you need to:

• Remain open-minded and inquisitive, rather than relying on assumptions or jumping to conclusions
• Ask questions and dig deep, rather than accepting information at face value
• Keep your own biases and perceptions in check to stay as objective as possible
• Rely on your emotional intelligence to fill in the blanks and gain a more well-rounded understanding of a situation

So, critical thinking isn’t just being intelligent or analytical. In many ways, it requires you to step outside of yourself, let go of your own preconceived notions, and approach a problem or situation with curiosity and fairness.

It’s a challenge, but it’s well worth it. Critical thinking skills will help you connect ideas, make reasonable decisions, and solve complex problems.

7 critical thinking skills to help you dig deeper

Critical thinking is often labeled as a skill itself (you’ll see it bulleted as a desired trait in a variety of job descriptions). But it’s better to think of critical thinking less as a distinct skill and more as a collection or category of skills. 

To think critically, you’ll need to tap into a bunch of your other soft skills. Here are seven of the most important. 

Open-mindedness

It’s important to kick off the critical thinking process with the idea that anything is possible. The more you’re able to set aside your own suspicions, beliefs, and agenda, the better prepared you are to approach the situation with the level of inquisitiveness you need. 

That means not closing yourself off to any possibilities and allowing yourself the space to pull on every thread – yes, even the ones that seem totally implausible.

As Christopher Dwyer, Ph.D. writes in a piece for Psychology Today , “Even if an idea appears foolish, sometimes its consideration can lead to an intelligent, critically considered conclusion.” He goes on to compare the critical thinking process to brainstorming . Sometimes the “bad” ideas are what lay the foundation for the good ones. 

Open-mindedness is challenging because it requires more effort and mental bandwidth than sticking with your own perceptions. Approaching problems or situations with true impartiality often means:

• Practicing self-regulation : Giving yourself a pause between when you feel something and when you actually react or take action.
• Challenging your own biases: Acknowledging your biases and seeking feedback are two powerful ways to get a broader understanding. 

Critical thinking example

In a team meeting, your boss mentioned that your company newsletter signups have been decreasing and she wants to figure out why.

At first, you feel offended and defensive – it feels like she’s blaming you for the dip in subscribers. You recognize and rationalize that emotion before thinking about potential causes. You have a hunch about what’s happening, but you will explore all possibilities and contributions from your team members.

Observation

Observation is, of course, your ability to notice and process the details all around you (even the subtle or seemingly inconsequential ones). Critical thinking demands that you’re flexible and willing to go beyond surface-level information, and solid observation skills help you do that.

Your observations help you pick up on clues from a variety of sources and experiences, all of which help you draw a final conclusion. After all, sometimes it’s the most minuscule realization that leads you to the strongest conclusion.

Over the next week or so, you keep a close eye on your company’s website and newsletter analytics to see if numbers are in fact declining or if your boss’s concerns were just a fluke. 

Critical thinking hinges on objectivity. And, to be objective, you need to base your judgments on the facts – which you collect through research. You’ll lean on your research skills to gather as much information as possible that’s relevant to your problem or situation. 

Keep in mind that this isn’t just about the quantity of information – quality matters too. You want to find data and details from a variety of trusted sources to drill past the surface and build a deeper understanding of what’s happening. 

You dig into your email and website analytics to identify trends in bounce rates, time on page, conversions, and more. You also review recent newsletters and email promotions to understand what customers have received, look through current customer feedback, and connect with your customer support team to learn what they’re hearing in their conversations with customers.

The critical thinking process is sort of like a treasure hunt – you’ll find some nuggets that are fundamental for your final conclusion and some that might be interesting but aren’t pertinent to the problem at hand.

That’s why you need analytical skills. They’re what help you separate the wheat from the chaff, prioritize information, identify trends or themes, and draw conclusions based on the most relevant and influential facts. 

It’s easy to confuse analytical thinking with critical thinking itself, and it’s true there is a lot of overlap between the two. But analytical thinking is just a piece of critical thinking. It focuses strictly on the facts and data, while critical thinking incorporates other factors like emotions, opinions, and experiences. 

As you analyze your research, you notice that one specific webpage has contributed to a significant decline in newsletter signups. While all of the other sources have stayed fairly steady with regard to conversions, that one has sharply decreased.

You decide to move on from your other hypotheses about newsletter quality and dig deeper into the analytics. 

One of the traps of critical thinking is that it’s easy to feel like you’re never done. There’s always more information you could collect and more rabbit holes you could fall down.

But at some point, you need to accept that you’ve done your due diligence and make a decision about how to move forward. That’s where inference comes in. It’s your ability to look at the evidence and facts available to you and draw an informed conclusion based on those. 

When you’re so focused on staying objective and pursuing all possibilities, inference can feel like the antithesis of critical thinking. But ultimately, it’s your inference skills that allow you to move out of the thinking process and onto the action steps. 

You dig deeper into the analytics for the page that hasn’t been converting and notice that the sharp drop-off happened around the same time you switched email providers.

After looking more into the backend, you realize that the signup form on that page isn’t correctly connected to your newsletter platform. It seems like anybody who has signed up on that page hasn’t been fed to your email list. 

Communication

3 ways to improve your communication skills at work

If and when you identify a solution or answer, you can’t keep it close to the vest. You’ll need to use your communication skills to share your findings with the relevant stakeholders – like your boss, team members, or anybody who needs to be involved in the next steps.

Your analysis skills will come in handy here too, as they’ll help you determine what information other people need to know so you can avoid bogging them down with unnecessary details. 

In your next team meeting, you pull up the analytics and show your team the sharp drop-off as well as the missing connection between that page and your email platform. You ask the web team to reinstall and double-check that connection and you also ask a member of the marketing team to draft an apology email to the subscribers who were missed. 

Problem-solving

Critical thinking and problem-solving are two more terms that are frequently confused. After all, when you think critically, you’re often doing so with the objective of solving a problem.

The best way to understand how problem-solving and critical thinking differ is to think of problem-solving as much more narrow. You’re focused on finding a solution.

In contrast, you can use critical thinking for a variety of use cases beyond solving a problem – like answering questions or identifying opportunities for improvement. Even so, within the critical thinking process, you’ll flex your problem-solving skills when it comes time to take action. 

Once the fix is implemented, you monitor the analytics to see if subscribers continue to increase. If not (or if they increase at a slower rate than you anticipated), you’ll roll out some other tests like changing the CTA language or the placement of the subscribe form on the page.

5 ways to improve your critical thinking skills

Beyond the buzzwords: Why interpersonal skills matter at work

Think critically about critical thinking and you’ll quickly realize that it’s not as instinctive as you’d like it to be. Fortunately, your critical thinking skills are learned competencies and not inherent gifts – and that means you can improve them. Here’s how:

• Practice active listening: Active listening helps you process and understand what other people share. That’s crucial as you aim to be open-minded and inquisitive.
• Ask open-ended questions: If your critical thinking process involves collecting feedback and opinions from others, ask open-ended questions (meaning, questions that can’t be answered with “yes” or “no”). Doing so will give you more valuable information and also prevent your own biases from influencing people’s input.
• Scrutinize your sources: Figuring out what to trust and prioritize is crucial for critical thinking. Boosting your media literacy and asking more questions will help you be more discerning about what to factor in. It’s hard to strike a balance between skepticism and open-mindedness, but approaching information with questions (rather than unquestioning trust) will help you draw better conclusions. 
• Play a game: Remember those riddles we mentioned at the beginning? As trivial as they might seem, games and exercises like those can help you boost your critical thinking skills. There are plenty of critical thinking exercises you can do individually or as a team . 
• Give yourself time: Research shows that rushed decisions are often regrettable ones. That’s likely because critical thinking takes time – you can’t do it under the wire. So, for big decisions or hairy problems, give yourself enough time and breathing room to work through the process. It’s hard enough to think critically without a countdown ticking in your brain. 

Critical thinking really is critical

The ability to think critically is important, but it doesn’t come naturally to most of us. It’s just easier to stick with biases, assumptions, and surface-level information. 

But that route often leads you to rash judgments, shaky conclusions, and disappointing decisions. So here’s a conclusion we can draw without any more noodling: Even if it is more demanding on your mental resources, critical thinking is well worth the effort.

Advice, stories, and expertise about work life today.

Debunking common myths about healthcare consumerism

Until recently, consumerism in the U.S. healthcare industry has moved slowly. However, several converging forces are likely to change the situation soon and result in a more dynamic market. Higher deductibles and copayments, greater transparency into provider performance and costs, and the rise of network narrowing and provider-led health plans are prodding patients to become more involved in healthcare decision making than ever before.

As yet, most payors and providers have comparatively little data to assess how consumerism is likely to affect them. As a consequence, they can neither confirm nor refute a number of assumptions about healthcare consumerism that are often stated as fact.

Over the past eight years, we have conducted extensive research into healthcare consumerism. This year alone, we surveyed more than 11,000 people across the country about how they perceive their healthcare needs and wants, how they select providers, and how they make other healthcare decisions. Our results suggest that many of the assumptions currently being made about healthcare consumerism are no more than myths.

Appendix: Details about our research

The articles in this compendium leverage proprietary research and analyses that McKinsey’s Healthcare Systems and Services Practice, McKinsey Advanced Healthcare Analytics, and other groups within the firm have conducted over the past several years. This appendix describes the major tools and data sources used in these articles.

Consumer Health Insights (CHI) Survey

This unique annual survey, which has been conducted since 2007, provides information on the opinions, preferences, and behaviors of healthcare consumers, as well as the environmental factors that influence their healthcare choices. The survey also enables insights into the current market environment and can be used to make predictions about the choices and tradeoffs consumers are likely to make in the post-reform environment. The CHI survey collects descriptive information on all participants and their households.

In addition, it assesses a range of variables, including: A) respondents’ shopping behaviors; B) their attitudes regarding health, healthcare, and the purchase and use of healthcare services; C) their awareness of health reform; D) their opinions about shopping for health insurance and using an insurance exchange; E) their preferences for specific plan designs (including tradeoffs among coverage features, such as benefits, network, ancillaries, service options, cost sharing, brand, and price); F) their perceptions of the employer’s role in healthcare coverage; G) their attitudes about a broad range of related supplemental insurance products; H) their opinions, use, and loyalty levels regarding healthcare providers; and I) their attitudes and behaviors regarding pharmaceuticals and pharmacies.

The CHI survey included a total of 2,255 participants in 2015, 4,019 in 2014, and 6,934 in 2013.

Medicaid Consumer Survey

Quantitative consumer insights about the current Medicaid population and potential new entrants to the program have been difficult to come by. To help address this gap, McKinsey surveyed more than 1,419 consumers across the United States in 2015, focusing on current Medicaid members (both dual eligibles and non-dual enrollees) and people who are currently eligible for Medicaid but not enrolled. The results, weighted to reflect the age, gender, ethnicity, education, and income of each of the groups, revealed important insights about the current and future Medicaid population.

Medicare Consumer Survey

Our Medicare consumer survey was a national survey of 2,208 seniors who are covered by Medicare Advantage, Medicare fee-for-service, or Medicare supplement plans. The survey sought to understand what matters to these consumers and their decision-making process for both coverage- and care-related decisions.

Post-open enrollment period survey

McKinsey’s post-open enrollment period survey is a national survey of 3,007 uninsured and individually insured consumers. It was conducted February 21–24, 2015, shortly after the 2015 individual market open enrollment period (OEP) ended. This survey is part of the ongoing longitudinal research we began with four 2014 OEP surveys (which together had about 14,000 respondents), which were conducted between November 2013 and February 2014, enabling trend analysis.

Private exchange simulation

McKinsey’s private exchange simulation investigates what might happen if individuals currently covered under employer-sponsored insurance were given the option of selecting their own coverage (and other benefits) on a private online exchange. It assesses participants’ interest in private exchanges and tests their buying behavior given a range of plan options and ancillary benefits. In the past year, more than 2,400 consumers have participated in these online simulations.

Healthcare is different from other industries. Consumers don’t bring the same expectations about customer experience to healthcare that they bring to retail or technology companies.

Our findings indicate that consumers want the same qualities in healthcare companies that they value in non-healthcare settings. In this year’s Consumer Health Insights (CHI) survey, we asked participants to identify the non-healthcare companies with the strongest consumer focus. Apple and Amazon led the list. We then asked the participants to tell us what qualities gave such companies a strong customer focus, as well as what they valued in a consumer-focused healthcare company.

The answers to the two questions were surprisingly similar (Exhibit 1). For example, more than half the participants cited great customer service as important for nonhealthcare and healthcare companies alike. Other qualities that the participants identified as important for both sets of companies were delivering on expectations, making life easier, and offering great value.

Whether healthcare companies need to perform as well as Apple and Amazon on customer experience remains to be seen. However, the evidence suggests that just performing better than other current healthcare competitors will not be sufficient. Customer expectations are being set by non-healthcare industries, and meeting those expectations is likely to be critical to ensure satisfaction and loyalty.

Consumers know what they want from healthcare companies and what drives their decisions.

Most consumers have strong opinions about what matters to them when they make healthcare decisions or receive healthcare services. The evidence suggests, however, that there is often a disconnect between what consumers believe matters most and what influences their opinions most strongly. Given the intangible nature of health insurance and healthcare provision, it appears that some factors play a much greater role than most consumers realize. For example, as part of our 2014 CHI survey, we posed two questions about patient satisfaction to the participants who reported having been hospitalized within the previous three years. First, we asked them how satisfied they were with their hospital experience. Second, we asked them to rank the importance of various factors that might have influenced their satisfaction levels.

More than 90% of these participants said they had been at least somewhat satisfied with the care they received, and most of them rated the outcome achieved as the most important influence on their satisfaction. However, when we mapped the factors that participants said influenced their satisfaction against their reported levels of satisfaction, we found that the empathy and support provided by health professionals (especially nurses) had a stronger impact than outcomes did (Exhibit 2). Satisfaction levels were also strongly influenced by the information the participants had been given during and after treatment.

In general, our results suggest that people tend to overstate tangible factors (e.g., parking, pain management) and understate factors that are more emotional (e.g., empathy) or abstract (e.g., value).

Most consumers research their healthcare choices before making important decisions and then make fact-based choices based on their research.

Five different surveys we conducted recently suggest that many, if not most, healthcare consumers are not yet making research-based decisions. Our findings indicate, for example, that only a few consumers are currently researching provider costs or even the number of providers they can choose among. Although some (but far from most) consumers are beginning to research their health plan choices, many of them are not yet aware of key factors they should consider before selecting coverage.

Would you like to learn more about our Healthcare Systems & Services Practice ?

Provider choices. In this year’s CHI survey, only 22% of the participants said that they always ask about cost before going to a doctor or other healthcare provider. We also asked participants whether they had received certain services in the past year and, if so, whether they had researched costs in advance. Exhibit 3 shows the results. The participants who received maternity care were most likely to report that they had researched costs prospectively. In all cases, the participants were much more likely to say that they had “talked to someone” (e.g., a provider or insurance representative) to investigate costs than to look at websites. Furthermore, even among the subset of consumers who reported doing research on costs before undergoing an expensive, invasive procedure (e.g., cardiac or joint surgery), half still said that their doctor’s recommendation was the key factor that influenced their decision about where to seek care.

Cost is not the only factor most consumers are not yet actively investigating. In last year’s CHI survey, we asked the participants who reported having been hospitalized in the previous three years to tell us how many hospitals there were in their local area. More than half said there was only one local hospital when, in fact, there were a median of three hospitals within a 10-mile radius of their home and ten hospitals within a 20-mile radius.

Health plan choices. Soon after the close of the 2015 open enrollment period (OEP), we surveyed consumers who were eligible to purchase exchange plans to investigate the decisions they made about health insurance during the OEP. 1 1. Noam Bauman et al., “ Hospital networks: Evolution of the configurations on the 2015 exchanges ,” McKinsey Center for US Health System Reform intelligence brief, McKinsey on Healthcare , April 2015. Forty-four percent of those who said they have bought an exchange plan for the first time indicated that they did not understand the type of provider network included in their plan. Nineteen percent of those who had purchased an exchange plan last year also indicated they were unaware of their plan’s provider network. Only 12% of those who remained uninsured knew the size of the subsidy they were eligible for, and only 59% were aware of the penalty for not obtaining coverage.

Similarly, in our survey this year of Medicare members, we found that only 21% of those who had enrolled in a Medicare Advantage (MA) plan knew their plan’s Star rating. However, almost all of those who knew their plan’s rating had purchased a plan that had three or more stars.

Moreover, in a survey we conducted this year of Medicaid-eligible recipients, only 32% of those who were enrolled in a managed care program and did not have dual Medicare coverage indicated that they had done any research before selecting a carrier, even though they had the option of choosing among multiple carriers.

Now that consumers are paying more for their healthcare, premium price is the only truly important factor in purchase decisions.

During both the 2014 and 2015 OEPs, premium price was, indeed, an important factor for many consumers. However, a sizeable percentage of people did not buy the cheapest plan available to them.

In our 2015 post-OEP survey, for example, 49% of the participants who had purchased exchange plans and remembered the plans’ pricing said that they had selected products with premiums that were average or above-average relative to the other plans within the comparable metal tier. The higher-premium products these participants bought (in comparison with the less-expensive plans purchased by other respondents) were more likely to be based on preferred provider organizations, to include pharmacy benefit add-ons, or to cover alternative types of care (e.g., acupuncture, chiropractic).

A subsequent report released by the Department of Health and Human Services confirms that price is not the only factor that many people shopping for individual coverage consider. 2 2. For more, see Health insurance marketplaces 2015 open enrollment period: March enrollment report , ASPE issue brief, March 10, 2015, aspe.hss.gov. It found that 66% of the 8.84 million people who bought health insurance through the federally facilitated marketplace during the 2015 OEP could have purchased a health plan with a monthly premium of $50 or less (after the advanced premium tax credit was applied). However, only about half of these people bought the very-low-cost plans.

In our Medicare study, we asked participants to design their own plan, giving them trade-offs between premium prices and various cost-sharing and benefit options (e.g., premiums went up as deductibles went down). Only 15% of the participants selected a $0 premium plan. In contrast, almost two-thirds of them said they would be willing to pay a $50 premium per month if it would reduce their medical deductible to $0. Thirty percent of the participants said that they would be willing to pay more than they were currently paying if it would help them hold their deductible down or enabled them to buy ancillary products. The feature cited most often by those willing to pay higher premiums was having a $0 deductible for prescription drugs.

Similarly, in this year’s CHI survey, one-third of the participants said they were willing or very willing to pay up to 20% more for health insurance if it gave them more choices about where to seek care. Furthermore, in a private exchange simulation we conducted recently with individuals covered by employer-sponsored insurance, the participants spent, on average, 40% above the employer contribution level to obtain ancillary benefits, such as vision, life, and critical illness insurance. In fact, many of the private exchange simulation participants were willing to trade down on medical benefits so they could trade up on ancillary benefits (Exhibit 4).

Almost all consumers have a primary care provider (PCP) and are highly reluctant to change doctors.

In this year’s CHI survey, 82% of participants said that they had a regular PCP. However, the likelihood of having a PCP was age-related: 96% of the participants above age 65 reported having a PCP, compared with only 65% of those ages 18 to 34. The likelihood of having a PCP was also influenced by income (89% of those with incomes above $100,000 said that they had a PCP) and health status (90% of those with one or more chronic conditions had a PCP).

Among all of the participants who did have a regular PCP, 66% said that they would not change providers unless they or their doctor moved. However, 57% of them also indicated that they would be willing to switch doctors if their health plan no longer covered their PCP. Among this 57%, willingness to switch was influenced by the length of a participant’s relationship with the PCP: 72% of those who had been using that doctor for only one or two years were willing to make the change, compared with 53% of those who had been with their doctor for five or more years.

Other evidence from this year’s CHI suggests that many consumers are willing to consult providers other than a regular PCP. For example, 71% of all of the participants agreed with the statement: “There are many good primary care physicians that I would be satisfied seeing.” Forty-five percent of the participants said that they had made an appointment at least once with any available doctor within the same practice or facility as their regular PCP. Of those who had not done so, only 18% indicated that they were unwilling to consult any doctor but their PCP.

In addition, 16% of the participants said that they receive routine care from a multidoctor primary care clinic rather than an individual PCP. When asked why, nearly half of these participants cited accessibility (e.g., convenient locations, shorter waiting times, easier scheduling). Among the 84% of participants who did not receive care from a primary care clinic, 55% said they would be willing to do so if it cost no more than or less than what they currently pay (Exhibit 5).

Retail clinics will remain a niche health solution.

Awareness and utilization of other alternative-care options are also rising. In this year’s CHI survey, more than 80% of the participants were aware of healthcare services being offered through pharmacies and retail stores. About half of these participants, however, were unsure of the specific services being offered.

About two-thirds of the participants said they are willing to use healthcare services offered by a pharmacy or retail store. Twenty percent reported having already sought care in these settings within the past two years (up from 10% in our 2013 CHI survey). The chief reason given for using pharmacies and retail clinics for care was, once again, accessibility (convenient locations, not needing an appointment, convenient hours). More than three-quarters of the 2015 participants who had used these alternative-care options said they plan to do so again.

Just over half (51%) of those who reported having received healthcare services at a pharmacy or retail clinic indicated that they had done so for immunizations; 26% said they had sought treatment for a minor illness. Of the participants who said they had not yet used one of these alternative-care options, more than 60% indicated they were willing to do so for immunizations, minor illnesses, or nutritional/weight loss support (Exhibit 6).

Use of these alternative care options could grow substantially in the next few years, given their increasing numbers and expanding offerings. The number of retail clinic locations across the United States rose from 1,183 in 2010 to 1,866 in 2015. 3 3. Hiroko Tabuchi, "How CVS quit smoking and grew into a health care giant," the New York Times , July 11, 2015, nytimes.com. CVS, which operates about half of the retail clinics, has announced that it plans to have 1,500 clinics by 2017. Growth among other the major players is likely to accelerate now that Walmart is putting primary care practices within its stores, and Walgreens is partnering with Theranos to offer convenient, affordable blood testing.

Only young people are using technology to manage their health and healthcare needs.

In both this year’s and last year’s CHI surveys, we also asked participants about using technology to manage their health and healthcare needs. Not surprisingly, millennials (those between the ages of 18 and 34) were more likely to report using technology for these purposes, but a considerable number of the older participants were doing so as well (Exhibit 7). In all age groups, the top two activities were communicating with doctors and scheduling appointments. However, millennials were much more likely than older participants were to say that they were using social media to share wellness ideas and participate in online wellness groups.

We also asked participants about whether they had used website or apps for a number of health-related activities, and, if so, whether they thought those resources were more or less effective than phone or in-person communication. For two of the most common activities—communicating with a physician and scheduling appointments—the majority of participants age 65 and older (65% and 78%, respectively) thought that websites and apps were more effective.

Most people are willing to trust insurers to store their health records.

In our 2014 CHI survey, we asked the participants to imagine having some sort of health monitoring device. We then asked them two questions: Where would they be comfortable storing information from that device? And with whom would they be willing to share the data?

Apropos storage, the participants overwhelmingly chose PCPs (Exhibit 8). Only a minority of them said they were comfortable having health insurers, Google, or Apple store their health data, and even fewer people chose employers. Participants also named PCPs as the group with whom they were most comfortable sharing the data (Exhibit 8). In both cases, age had only a small impact on the answers received.

We believe that healthcare consumerism will soon enter the steep slope of the innovation S curve and become a much more significant force. Payors and providers need to begin making plans now if they want to be ready to respond to, and perhaps shape the evolution of, healthcare consumerism.

The data and insights we have amassed can help them do that. Our findings suggest, for example, that payors should think about what value proposition they want to offer to consumers. That value proposition can be, but doesn’t have to be, price related—consumers are open to other enticements. And payors should not assume they are the natural owners of consumers’ health records; they will have to find a way to earn greater consumer trust if they want to do that. Providers should not take patient loyalty for granted or underestimate the role that experience-related factors such as convenience and empathy play in consumer satisfaction and loyalty.

The results described in this article are only a fraction of the information we have amassed. Our findings also reveal important attitudinal differences based on age, gender, ethnicity, income, health status, and geography—differences that have important implications for both payors and providers. These findings have convinced us that both payors and providers need to better understand what really drives consumer decision making and focus on that (rather than just on what consumers say). This understanding must be based on very granular data to ensure its relevance to local healthcare players.

In addition, both payors and providers should think about the evolving role of new healthcare technologies in shaping consumer behaviors so they can take advantage—and not become victims—of them. Perhaps most important, both payors and providers should realize that consumers’ expectations are no different in healthcare than in any other industry. In fact, other industries will continue to shape these expectations—healthcare companies need to catch up, or they risk being disrupted.

Jenny Cordina is a principal in McKinsey’s Detroit office, Rohit Kumar is an associate principal in the Chicago office, and Christa Moss is a consultant in the Cleveland office.

The authors would like to thank Erica Coe, Elizabeth Jones, Katherine Linzer, Elina Onitskansky, Kyle Weber, and Emir Roach for their contributions to this article.

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An inside look into the global consumer health and wellness revolution, health & wellness.

Health and wellness is THE single most powerful consumer force of 2021.

To see where consumer health and wellness is headed, start with understanding the rising well-being revolution.

In contrast to the unpredictable nature of COVID-19, consumers are being very deliberate with their choices. 2021 has been a year of recalibration, reflection, and resilience. What matters to consumers, now? Meaningful and purposeful living, health management, strength and wellness, mental health and stability, happiness, social connection, environmental betterment, balance, and fulfillment.

Across the global consumer packaged goods (CPG) industry, a more holistic notion of health and wellness is flourishing. To think about consumer health and wellness just through the limited lens of diet culture, fandom fitness, and niche health crazes is already archaic. It is no longer just a section of a store or a segment of a person’s lifestyle. To consumers, health, wellness, and well-being are now in the everyday choices they make. It’s everything and everywhere, challenging meaningful relevance in every CPG category that a consumer chooses to buy.  Genevieve Aronson, Vice President of Global Thought Leadership

Select the resources you would like to download.

• Global Health and Wellness Report 2021

Well-being is the next chapter of total consumer health and wellness.

Well-being in definition is far more comprehensive than health or wellness, as it considers a broader universe of personal factors and speaks to the goals of a well-rounded life. Fueled by the informed ideology and mass influence of younger generations like Gen Z, who are hyper-aware of social and environmental issues, the expansive future of consumer health and wellness is proactive, highly personal, mindful, and motivated towards well-being. While maintaining your bar of excellence for value, taste, efficacy, and convenience, how will your company show up in this next chapter?

In this new NielsenIQ Global Health and Wellness report, we explore consumer sentiment across 17 diverse global markets and dive deep into NielsenIQ data to help companies better understand the global state of health, wellness, and well-being. We uncover how consumer needs have been reshaped around the world, what is trending, and what the budding opportunities are across the new, broadened spectrum of global well-being. This report brings to light a full view of total consumer health and wellness.

The Global State of Consumer Health and Wellness

The New Hierarchy of Total Consumer Health and Wellness Needs

What’s Next

The global state of total consumer health & wellness

It all starts with understanding the baseline state of total consumer health and wellness as it stands, today. Despite mass vaccination efforts across countries, the world is still in a pandemic, with millions still being infected and impacted by COVID-19. However, the virus is just one force driving change in the global health and wellness landscape.

Three major themes are converging:

As the cost of health care rises, socioeconomic issues build and consumers determine their own health and wellness journeys, businesses and governments become increasingly more interconnected. Coupled with the enduring COVID-19 impact, this trifecta of forces is paving the path forward.

How are consumers approaching healthy living?

Health and wellness is not a one-size-fits-all issue. Consumer behaviors vary drastically according to their proactive, reactive or passive decision-making tendencies.   

Nearly half of global consumers are proactive in their health decisions

of global consumers say they make proactive health and wellness choices on a regular basis

of global consumers say they are triggered to prioritize health when it’s necessary

of global consumers say they don’t prioritize health and wellness

Source: NielsenIQ Global Health & Wellness Study of 17 markets, September 2021

Top 10 reasons why health has become a proactive priority

NIQ data shows that the drivers of influence are diverse. For proactively engaged health-conscious consumers , their reasons range from the desire to live a longer, healthier life, and a desire to look and feel better post lockdown, to the sway of social media and the burden of rising costs of healthcare.

What countries are the most proactive, reactive or passive when it comes to caring for their own health and wellness needs?

Where are consumers shopping for health and wellness products, health and wellness buying is omni-present.

Health and wellness across the digital landscape is growing at a steady rate. NielsenIQ e-commerce measures of the U.S. market show that health-aligned products, such as over-the-counter remedies or nutritional drinks, are seeing sales (+31%) and buyer growth (+14%) exceeding that of the already booming industry topline (+27% in sales, 5% in buyer growth). Health and wellness products also seem particularly aligned to being purchased through subscription services, where sales have increased an impressive 50% year over year.

Growth in health & wellness products purchased on subscription

Growth in total cpg products purchased on subscription.

But, amid consecutive periods of strong sales growth, it begs the question of whether e-commerce gains have come at the direct cost of in-store performance. According to NielsenIQ’s U.S. Omnipanel, the answer to this question is promising for companies operating across brick-and-mortar and e-commerce spaces. 

For both U.S. health and beauty care products, as well as a subset of health-related food products, there has been incremental growth, or “market expansion” in both e-commerce and brick-and-mortar outlets. Even though expansion is much greater online, only 25% of e-commerce food dollar sales growth was due to shifted volume from other channels. This underscores that today’s buying behaviors are truly “omni”-present.

What are consumer expectations for companies and the products produced?

Consumers are expecting companies to do more.

Consumers are paying attention to what companies are doing. Across all retail sectors, consumers expect businesses and governments to play a more active role in their health and well-being journey. In fact, a majority (72%) of surveyed global consumers feel that companies have a big role to play in the availability and access of healthy food for all. In fact, a majority of global consumers (63%) would be more likely to buy from companies with a strong health mandate across their whole product portfolio.  

consumers feel that companies have a big role to play in the availability and access of healthy food for all.

companies have an obligation to ensure healthy products are less expensive than processed or unhealthy product choices.

expect product labels to be more specific and transparent.

There is a baseline consumer expectation for clean, simple, and sustainable goods

The concept of altruistic health and wellness, or care regimes which pay back to other causes and communities, is no longer in its infancy. For many consumers, there is a baseline expectation for companies to produce products with clean, simple, and sustainable ingredients, without compromise. Take note that today’s conscious consumers have dual expectations for products. Products need to meet altruistic needs while still delivering and advancing on the efficacy of traditional product benefits. Issues pertaining to the environment are especially top of mind for consumers right now. Consumers are prioritizing the health of the planet, in addition to the health of themselves.

of global consumers agree that environmental issues are having an adverse impact on their current and future health

Health and wellness is now a shared priority and responsibility.

The interests of governments and businesses are corralling around the common idea that all must play a more active role in supporting the long-term health of the planet and its consumers. Health and wellness is now a shared priority across consumers, companies and governments. What is your relationship to the proactive, reactive and passive ways consumers are approaching health and wellness? How are you showing up in the omni retail space to meet consumers where they both socialize and shop? How are you aligned to the expectations and motivations of today’s more conscious consumer?

The NielsenIQ hierarchy of total consumer health & wellness needs

Reinvented health priorities

Much like the expanse of factors that have impacted the global state of health and wellness, there are equally many ways in which consumers are re-inventing how they approach health-related decisions.

Following the onset of COVID-19, what do consumers deem to be important today? While we recognize that there is no blanket answer for this question, we do believe there is one universal hierarchy that empowers a deeper understanding of how consumers are currently prioritizing their health and wellness needs.

This hierarchy, applied to the current state of health and wellness, brings to light a total view of consumer health needs. It highlights unique differences in the innate order to which consumers are prioritizing their health needs: those that are protective, preservation-focused, aspirational, evolving, and altruistic in nature.

The hierarchy framework is fluid across consumer segmentations, geographic regions, key demographics, cultures, and categories. In practice, it will align with any personal health and wellness journey. The opportunity for companies looking to meet and exceed the growing expectations of health-conscious consumers is to figure out where your brand fits and sits along this fluid path. If most consumers prioritize more than one hierarchy level, so should companies. What are the current and future opportunities that exist for your company both up and down this hierarchy?

The NielsenIQ hierarchy of total health & wellness needs

Protective needs

Protective needs are the most basic and essential of consumer health and wellness need states. Consumers strive to thoroughly protect themselves against immediate threats to their own health and well-being.

63%  of surveyed consumers ranked protective needs of high importance to them and for,  71%  protective needs have become  more important  over the last 2 years.  

Opportunity example:  Over the past two years, antibacterial products and house cleaners were main staples. However, NIQ data shows that within the last year, the pace of innovation within the household cleaner category has slowed in the U.S., whereas household cleaners in the U.K. have seen 47% growth in the number of innovations that have hit the market this year compared to last.  

Trends to watch:  A new wave of immune building products 

Want to dive deeper into this need state?

• How consumers are arming themselves in their fight against health threats

Preservation needs

Preservation needs center around catering to current self-care and intrinsic well-being.

1 in 3 (35%)  surveyed consumers across the globe state that COVID-19 has had a negative impact on their mental health and physically speaking, living alongside the virus has taken its toll as well.  

Opportunity example:  Around the globe, preservation-focused priorities look very different   across markets. For example, NIQ found fluctuated rankings of sleep across countries, with China ranking sleep as a critically important priority and consumers in Italy identifying it as a lagging priority.  

Trends to watch:  The continued food as medicine movement and the rising tide of mental wellness.  

• How consumers are looking at their physical and mental well-being in 2021

Aspirational needs

Aspirational needs cater to the proactive measures people take to achieve specific health goals or to prevent future ailments in the long-term. 

61%  of global consumers say that aspirational needs have become more important to them in the last 2 years. 

Opportunity example:  Global consumers are continuing to recognize the benefits of a plant-based diet. NIQ data shows that over 6 in 10 surveyed consumers across the globe say they already buy or are more likely to buy plant-based products compared to 2 years ago. 

Trends to watch:  Regionalized diet trends in the US and the enduring popularity of plant-based products in new forms and across global regions.

• How consumers from around the globe aspire to live healthy lives in 2021

Evolving needs

Evolving needs aligned to new developments, innovative ingredients, seasonality, societal shifts, and the many different factors that dictate what products fall in and out of the healthy spotlight.

54%  of global consumers say they love to follow and try new health and wellness trends 

Opportunity example:  An NIQ analysis of the U.S. market shows 12 high-growth ingredients.  Collagen is shown to be a great example of an ingredient with strong growth and expansion potential. Today, collagen within the US has seen sales of $814M (Q2 2021) and can be found in over 97 categories, within the US market, with strong growth in food categories like broth and nutrition bars.   

Trends to watch : New-found interest in nootropics  

• How innovations are changing the face of global consumer health and wellness

Altruistic needs

Altruistic needs delve into selfless consumption that supports environmental, ethical, humanitarian, or other philanthropic causes.

67%  of global consumers say that environmental health and how their choices impact the planet is important to them  

Opportunity example:  NIQ Label Insight data shows that interest in low-waste hair care is growing; Shampoo and conditioner bars were the #9 most searched hair care trend in early 2021 with 135,000+ quarterly searches on Amazon alone.

Trends to watch:  Beyond clean labeling, the mainstreaming of “better for we” brings new causes that are growing in social gravity 

• How health-conscious consumers want to live in a healthy world

Lifestage and circumstance can sway priorities

There are interesting preferences and potential knowledge gaps that come to light when looking at how health needs are prioritized by cohorts of different genders, generations, and life stages. While the importance ranking of health needs do not vary drastically, the differences do reinforce the fluidity of the hierarchy applied to different contexts of consumer groups.

Knowing how demographic and socio-economic circumstances can alter individualized well-being, it’s important to explore granular factors at play within the consumer hierarchy of total health and wellness needs.

What’s next 

The evolution continues

As the ecosystem of health and wellness continues to evolve, the industry will bear witness to a wide range of influencing factors that will shape and shift the health-oriented consumer journey. Therefore, the priority placed on protective, preservation-focused, aspirational, evolving, and altruistic needs will bend to prevailing conditions.  

For example, pandemic influences that have propelled protective needs to the forefront, may be altered by shifting governance around access to public healthcare. Similarly, the way consumers approach their long-term aspirational health needs will be deeply influenced by the technologies they use to self-capture and track their biometrics. As changes like these continue to take hold of the industry, the order and definitions of today’s hierarchy of consumer health needs will morph over time.      What will health and wellness look like over the next 5 + years?  It’s hard to say. But, we’ve got our eyes on the below future forces:   

Future forces of change

1. rapid tech adoption.

Over the past 18 months, technology enabled safety and distance, it lowered physical touch points, and sustained social connection.  

Potential future outcomes  

• New waves of consumers who habitually track and manage their health, digitally—capturing biometrics on everything from exercise to sleep to medication consumption  
• Quantified-self tools begin to connect with other home devices (like smart speakers, e-textiles, smart toothbrushes and refrigerators)  
• Telehealth check-ups become more of the norm  
• Homes to serve as connected health hubs  

Example priority shift 

Preservation needs  will, in many cases, be managed autonomously and dynamically via connected, smart health devices.

2. Generational shifts

Over the next 10 years, economic, financial, and political power will shift more and more to Millennials and Gen Z who will need to support an increasingly aging population.

• Millennials and Gen Z will fuel more momentum behind lifestyles that emphasize product transparency, sustainability and eco-living  
• Boomers will continue to break generational norms by showcasing their ability to adopt new digital habits and rising interest in “aging in place” by maintaining independence at home   
• Consumer and government interests will converge around ways to enable those to age with dignity, given rising costs of elderly care  
• Technology and the role of robotics will play a bigger role in the care of seniors  

Example priority shift

Altruistic needs  will rise in importance and priority aligned to generations that feel most compelled to live sustainably and those who wish to prioritize and enable others to age with dignity.

3. New life outlooks

The global pandemic inspired a collective moment of self-reflection. Amidst uncertainty, pandemic lockdowns, and loss, many people around the world took stock of their own health, appraised their personal state of wellness and in the absence of a fully opened world, they looked inward to try to better understand their own needs, preferences and desires.  

• Consumers will think more critically about their values, their role in the world and their own reason for being  
• Post-pandemic life will involve new hobbies and newfound motivation and courage to pursue passions   
• Consumers will attempt to jump-start new routines and lifestyle shifts, taking a more proactive stance on personal health, wellness and motivated well-being 

Evolving needs   will  become a more regular focal point as consumers feel enlightened to try new and innovative ways to be healthy and well.

4. Omni-connected communities

There is movement to create healthier, safer, and more connected communities across the digital and physical worlds. 

• Physical urban centers will be reimagined to support public health and wellness—offering more green space, increased gathering spots for socialization and showcasing sustainable design  
• Digital, inclusive social communities will shine a light on previously marginalized communities, supporting issues of mental health or providing connective and social support for racially diverse communities  
• The metaverse will become a new social reality, where personalized avatars, healthcare digital identities, and digital smart cities will all be hallmarks of a health virtual arena of the future

Preservation needs  that center around mental health and social connections will grow in importance as social networks fragment across physical, digital, and immersive metaverse landscapes.

5. Biological revolution

Biological advancement pertaining to DNA testing, the modification of lab grown ingredients, exploration of plant-based alternatives, and the emergence of lab refined supplements will propel health and wellness innovation to new heights.

• There will be a divide among consumer groups who embrace or fear the risks of biotech advancements   
• Consumers will face a paradox of choice when it comes to new responses and defense strategies to ward off illness or better protect immune systems against immediate health threats

Protective needs  may capture less of the spotlight among consumers, as biotech advancements increase confidence in safeguards against imminent health threats.

6. Agtech advancement

Supply chain, safety, sustainability, and labor are all challenges and opportunities that face our current food system.

• New models like urban farms, vertical farming, and aquaculture will continue to flip the script and bring disruption in all areas of the value chain   
• There will be innovative opportunities to provide a bounty of locally grown fresh food to consumers, especially in food-insecure communities   

Altruistic needs  will extend to the realm of food supply chain as new agricultural advancements expand possibilities with sustainable or philanthropic production.

7. Policy, legislation & governance

Around the world, governmental awareness and action of the cost of unhealthy population is on the rise. 

• Through legislation, taxes, and governance, countries will continue to create an environment where those contributing to unhealthy outcomes will be encouraged to adapt and reformulate portfolios to help consumers make healthy choices  
• Stalwarts will live with the consequences of higher regulation as seen in the implementation of restrictive advertising practices, and sugar/fat taxes   
• Transparency and labeling will be critical within this context with stricter guidelines on how products are communicated and presented to consumers to allow for informed choices

Aspirational needs  will evolve with societal changes. With rising regulations and controls on some products, consumers will expect full transparency to enable them to make informed health choices. Aspirational energy will, over time, focus on proactive changes most within their control (I.e. lifestyle choices, technology).

An altruistic future within health and wellness is strong  

While we expect to see changes in health priorities across the spectrum of all consumer needs, there is one aspect of health and wellness that is ripe for immense future growth. Beyond profit, the future of health-focused products will center around people, the planet, purpose, and prosperity. Altruistic health needs, which may not be the top priority of all consumers, will grow to become a focal point of global wellness for years to come.    

To dive deeper on this notion of health and wellness within the context of altruism, NielsenIQ turned to  MotivBase , a valued member of the NielsenIQ Partner Network. Through extensively examining hundreds of thousands of anonymized consumer conversations across the U.S. and U.K. markets, MotivBase identified five microcultures to watch.

Micro-culture maturity in altruism shows ripe opportunity in the US and UK

Within the U.S., there is mainstream and universal consumer acceptance of the meaning of altruism. Comparatively, in the U.K., the topic is at a point of early consensus among consumers, meaning a universal consumer understanding of what altruism is, has yet to be fully formed. Why does this matter? Simply put, the maturation of a topic has meaningful impact on possible innovation paths to pursue.

The zone of innovation for altruism

According to MotivBase benchmark studies, the key​ time to launch a solution into​ market is when a demand space​ falls between 33% – 55% on the​ maturity curve. While microculture maturity in both the U.S. and U.K. is approaching this range in most cases, it’s interesting to note the varying growth trajectories predicted in each instance. These have a direct impact on how to align marketplace offerings to the ways in which consumers will converge or diverge in their thinking.  

Within the U.S.,  MotivBase concludes that there is a longer runway for altruistic innovation tied to the microculture of eating for optimal health, which has an estimated 37% maturity and expectations of 13% predicted growth among the number of people this topic will be relevant to. Now is an opportune time to innovate and build on current motivations and values, which are centered around social health, obesity, and the disparity in access to healthy and nutritious food in America.   

Worth noting, there is high levels of volatility among multiple altruistic microcultures in the U.S. In these volatile instances, consensus and meaning around a topic is pivoting on a dime and regular evaluation and continuous innovation will be necessary for continued relevance, and eventual success, among consumers. In these instances, current messaging and plans around a topic, such as mental health advocacy, should be re-evaluated.  

Within the U.K.,  there is a longer innovation runway for altruistic innovation tied to all five health and wellness microcultures. Not only are these contexts of high relevance to British consumers, each is predicted to rapidly grow in importance over the next 12-24 months. Either already within, or fast approaching, the optimal “zone of innovation” (range in current maturity of 33-55%), these microcultures are a breeding ground for product innovation. For example, when compared to the U.S., food as medicine is a key topic of uniquely greater importance to U.K. consumers seeking to eat optimally for their health. Companies seeking to improve their alignment to healthy eating should know that efforts around food insecurity are likely to matter less, compared to resources that educate and expand the horizons of functional or medicinal food ingredients.  

Looking ahead  

To consumers, health is everything and everywhere, and the companies who fail to address this are already at risk of falling behind the curve. Health and wellness shouldn’t be a subset or a secondary focus to any business initiative. Its relevance is now broad enough to bring opportunity to nearly every CPG category around the world.  

Companies need to understand global consumer needs. From what motivates consumers’ approach to self-care, to acknowledging the external forces at play that are driving the direction of the industry. Be connected to the consumer trajectory which is moving towards proactive, mindful and motivated well-being. Most importantly, recognize the role you play in the health and wellness ecosystem in order to make effective and market-leading decisions in the health and wellness space.  

With a forward look into the future, companies need to be flexible, yet focused on the changing needs of consumers as they move up and down the hierarchy of health and wellness needs. For organizations looking to gain a leading advantage, use the following points of inspiration to guide your thought processes:  

Key considerations for curating a better, healthier future

Challenge your current definition of health and wellness – it’s bigger and more encompassing than you think. 

The landscape is changing fast. Stay ahead by keeping up on the latest search and sought-after health, wellness, and well-being attributes among consumers. 

As health and wellness tools and resources become more digitized, personalization will be a critical component to success. 

Make it easy. In this highly competitive market, consumers are quick to seek alternatives, especially if finding what they want is hard. 

Innovation is ripe for opportunity and a key discipline to bring insights to life. While there is a strong appetite for altruistic innovation, companies must remember that products must still fulfill and meet a core need and the rules of efficacy still apply. 

In an environment of differentiated price elasticity, pricing analytics will be critically important. Consumers will continue to “vote with their wallets” and knowing their willingness to pay will be key.  

Embody trust via complete transparency – delivering on promises made on all aspects of your business will be key to building trust.  

Technology will continue to put the consumer in the driver’s seat of their own health journey. Embrace the changes ahead to stay lock step with the consumer tide.  

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• Volume 23, Issue 1
• Key Concepts for Informed Health Choices: a framework for helping people learn how to assess treatment claims and make informed choices
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• Iain Chalmers 1 , 2 ,
• Andrew D Oxman 1 ,
• Astrid Austvoll-Dahlgren 1 ,
• Selena Ryan-Vig 3 ,
• Sarah Pannell 4 ,
• Nelson Sewankambo 1 , 5 ,
• Daniel Semakula 1 , 5 ,
• Allen Nsangi 1 , 5 ,
• Loai Albarqouni 6 ,
• Paul Glasziou 6 ,
• http://orcid.org/0000-0002-7791-8552 Kamal Mahtani 4 ,
• http://orcid.org/0000-0003-4597-1276 David Nunan 4 ,
• Carl Heneghan 4 ,
• Douglas Badenoch 2
• 1 Centre for Informed Health Choices , Norwegian Institute of Public Health , Oslo , Norway
• 2 The James Lind Initiative , National Institute for Health Research , Oxford , UK
• 3 Students for Best Evidence , UK Cochrane Centre , Oxford , UK
• 4 Centre for Evidence Based Medicine , University of Oxford , Oxford , UK
• 5 Makerere University College of Medicine , Makerere University , Kampala , Uganda
• 6 Centre for Research in Evidence-Based Practice , Bond University , Robina , Queensland , Australia
• Correspondence to Sir Iain Chalmers, James Lind Initiative, Summertown Pavilion, Middle Way, Oxford OX2 7LG, UK; ichalmers{at}jameslind.net

https://doi.org/10.1136/ebmed-2017-110829

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• critical thinking
• critical appraisal
• causal inferences
• treatment claims
• epistemology

Introduction

We are surrounded by maelstroms of claims about the effects of treatments. Such claims may include strategies to prevent illness, such as changes in health behaviour or screening, therapeutic interventions, or public health and system interventions. Many causal claims are demonstrably wrong, and although some are well intentioned, others are deliberately misleading to serve interests other than the well-being of patients and the public. 1 Learning how to judge which claims to believe is a core competence needed by effective practitioners of Evidence-Based Healthcare (EBHC). 2

Short titles for the IHC Key Concepts

Recognising an unreliable basis for a claim.

Treatments can harm.*†

Anecdotes are unreliable evidence.*†

Association is not the same as causation.†

Common practice is not always evidence-based.*†

Newer is not necessarily better.*

Expert opinion is not always right.*†

Beware of conflicting interests.*

More is not necessarily better.

Earlier is not necessarily better.

Hope may lead to unrealistic expectations.

Explanations about how treatments work can be wrong.

Dramatic treatment effects are rare.

Understanding whether comparisons are fair and reliable

Comparisons are needed to identify treatment effects.*†

Comparison groups should be similar.*†

Peoples’ outcomes should be analysed in their original groups.

Comparison groups should be treated equally.

People should not know which treatment they get.*

Peoples’ outcomes should be assessed similarly.

All should be followed up.

Consider all the relevant fair comparisons.*†

Reviews of fair comparisons should be systematic.

Peer review and publication does not guarantee reliable information.

All fair comparisons and outcomes should be reported.

Subgroup analyses may be misleading.

Relative measures of effects can be misleading.

Average measures of effects can be misleading.

Fair comparisons with few people or outcome events can be misleading.*

Confidence intervals should be reported.

Do not confuse ‘statistical significance’ with ‘importance’.

Do not confuse ‘no evidence of a difference’ with ‘evidence of no difference’.

Making informed choices

Do the outcomes measured matter to you?

Are you very different from the people studied?

Are the treatments practical in your setting?

Do treatment comparisons reflect your circumstances?

How certain is the evidence?

Do the advantages outweigh the disadvantages?*†

*Concepts included in the IHC primary school resources (Nsangi et al , 2017).

†Concepts included in the IHC podcast (Semakula et al , 2017).

IHC, Informed Health Choices.

The concepts in the box were developed as the first step in the Informed Health Choices (IHC) project as a conceptual framework to guide the development and evaluation of learning resources for primary school children and their parents in Uganda. 5 6 We believe this to be the first framework with this objective. This paper describes the current status of the IHC Key Concepts List 7 and some of its uses.

What do we mean by ‘concepts’?

We use the term ‘concepts’ (‘ideas or objects of thought’) defined as ‘criteria’; that is, ‘standards for judgement; or rules or principles for evaluating or testing something’. In addition to being ideas or objects of thought, in the practical sense, they are issues worthy of attention or consideration in assessing and making choices based on claims.

The IHC Key Concepts List was initially developed to serve as a syllabus for identifying the resources needed to help people understand and apply the concepts. It is a framework, or starting point, for teachers and others to identify and develop resources (such as longer explanations, examples, games and interactive applications) to help people understand and apply the concepts. The IHC Key Concepts List currently includes 36 concepts ( box ), divided into three groups:

Recognising an unreliable basis for a claim.

Understanding whether treatment comparisons are fair and reliable.

Making informed choices.

The original List included 32 concepts divided into six groups. 7 The List is reviewed and amended annually, and an up-to-date List and explanations for each concept can be found on the Testing Treatments interactive and Informed Health Choices websites.

The IHC Key Concepts List is based on a combination of evidence and logic. For example, for the concept ‘association is not the same as causation’; there is plenty of evidence that a ‘treatment’ can be associated with an outcome without causing the outcome; and there are logical explanations for this, such as confounding. 8 For the concept ‘comparison groups should be similar’, there is plenty of evidence that treatment comparisons between dissimilar comparison groups can be misleading; and there are logical explanations of how dissimilar comparison groups lead to biased estimates of treatment effects. 9

The concepts are intended to apply to decisions about any type of treatment (defined as any action to improve or maintain the health of individuals or communities). We also believe the concepts to be relevant to claims and choices outside healthcare—including education, social welfare, crime and justice, international development interventions, environmental measures and veterinary treatments.

Developing the IHC List of Key Concepts

We used explicit and pragmatic criteria to determine which concepts to include in the List. 7 We used a systematic, transparent and iterative process, involving potential end users and experts within the field. The book Testing Treatments 4 was the initial source for creating a list of ‘candidate’ concepts. The List was supplemented by reviewing other books written for the general public 10 11 ; checklists for the general public, journalists and health professionals 12–17 ; and consideration of concepts related to assessing the certainty of evidence for treatment effects and making informed health choices. 18

We also invite people to submit suggestions through the TTi website ( http://en.testingtreatments.org/key-concepts-for-assessing-claims-about-treatment-effects/feedback-key-concepts/ ) or by submitting them directly (eg, when we present the Key Concepts at conferences) or through open workshops (eg, at the Global Evidence Summit in Cape Town in 2017).

Once a year, AA-D, AO and IC discuss each suggestion; decide by consensus how to respond; and record their response to each suggestion and their reasoning. This information is available on request and will be published in future updates.

The List includes several concepts relating to numerical or statistical information (Concepts 2.12–2.17). These concepts are included in the second group (understanding whether comparisons of treatments are fair and reliable) because they refer to ways in which people are commonly misled by statistical information. An explanation for each concept is provided in the full list. For example, there is an explanation of why the use of P values to indicate the probability of something having occurred by chance may be misleading and why confidence intervals are more informative (Concept 2.16). Statistical concepts that are relevant to treatment comparisons but which are not commonly misleading are outside the scope of the IHC Key Concepts List.

How does the framework provided by the IHC key concepts list differ from other frameworks?

One of the first lists of criteria for making causal inferences in healthcare was proposed in 1882 by Robert Koch for establishing the existence of an infectious pathogen. Subsequent lists of criteria for making causal inferences include those of Hill 8 and Susser. 19–21 More recently, a wide range of tip sheets and checklists have been published. 14–16 22 23 Although all these lists address some of the IHC Key Concepts, the latter differs in two respects.

First, the IHC working group has used a systematic, transparent, and iterative process to develop the IHC Key Concepts List with the intention of helping the general public, children and healthcare practitioners to assess the trustworthiness of claims about the effects of treatments. Some checklists—for example, the Cochrane Risk of Bias tool 24 and those for assessing the certainty of the evidence for estimates of effect (GRADE) 18 —have been developed systematically, transparently and iteratively, but they are intended primarily for those preparing systematic reviews or developing clinical practice guidelines.

Second, the IHC Key Concepts are not a guide for making causal inferences, a tip sheet, a checklist or a tool for those developing systematic reviews or guidelines. Rather, they have been developed to offer a coherent framework to serve as a starting point for teachers, learners and researchers to map out what people need to learn; determine how best to help people learn; and measure the extent to which they have learnt to assess treatment claims and to make informed health choices.

How can the IHC key concepts list be used?

The ihc learning resources and the claim evaluation tools database.

The aim of the IHC Project is to help people learn how to assess treatment claims and make informed choices. The project focused initially on primary school children in Uganda and their parents. Identification of the Key Concepts was the starting point for developing relevant resources and tests. Members of the IHC Project team developed a textbook, using a comic book story, to teach 12 of the key concepts to children ( box ). Selection of the 12 concepts was made in two stages. First, with input from primary school teachers, we selected the 24 concepts that teachers felt could be mastered by children aged 10–12 years. Second, because 24 concepts could not all be taught during the one term available for teaching, 12 concepts were selected after taking account importance and difficulty, as judged after pilot and user testing. A podcast was developed to teach nine of the concepts to parents of the primary school children ( box ).

Although there are over 400 studies of interventions and assessment tools that address at least one of the IHC Key Concepts, only four assessment tools included ≥10 Key Concepts. 25 The Claim Evaluation Tools database of multiple-choice questions was developed to address this gap. 26 The multiple-choice questions are designed to evaluate people’s ability to apply the IHC Key Concepts in an objective way. The database is open access to researchers or teachers. New questions for both new and old concepts will be added to the database as they become available. Questions from the database can be used by learners for self-assessment; by teachers to assess students using scenarios, and by researchers to evaluate interventions or map people’s abilities to apply the Key Concepts.

Questions from this database were used as the primary outcome measures in randomised trials of the primary school resources and the podcast. 27 28 In the first trial, half of over 10 000 children in 120 schools used the primary school resources over a school term. The study showed convincingly that young children, including those with poor reading skills, could be taught to apply those 12 concepts. 27 In the second trial, half of over 500 parents listened to the podcast, with stories explaining nine Key Concepts, and the other half listened to typical public service health announcements. 28 This trial showed convincingly that parents, including those with poor reading skills, could learn those nine concepts.

The Critical thinking and Appraisal Resource Library

The Critical thinking and Appraisal Resource Library (CARL) is a database currently containing over 500 open-access learning resources in a variety of formats—text, audio, video, webpages, cartoons and lesson materials—which has built on efforts beginning in 2011 to establish such an inventory. 29 After the initial IHC Key Concepts List had been published in 2015, 7 learning resources in CARL were coded so that they could be retrieved using each of the IHC Key Concepts. Resources included in CARL are currently accessible through the Testing Treatments interactive website.

Students 4 Best Evidence

Students 4 Best Evidence (S4BE) is a website for students worldwide interested in evidence-based healthcare. 30 The site features blogs written by over 400 students currently registered to blog. Blogs are being written on the IHC Key Concepts, each of them communicating the essential messages and providing illustrative examples ( http://www.students4bestevidence.net/tag/keyconcepts/ ). Encouragingly, students are offering to translate the Key Concepts into other languages and also write brief, informal reviews of the learning resources in CARL, which are then posted both on the S4BE website and on Testing Treatments interactive.

The James Lind Library

The James Lind Library contains material illustrating the development of fair tests of treatments in healthcare. Material in the Library illustrating one or more of the IHC Key Concepts has been appropriately coded so that it can be retrieved through CARL.

Ensuring coverage of an international core curriculum for teaching EBHC to professional learners

The IHC Key Concepts have recently been considered by 140 clinicians and teachers developing an international core curriculum for teaching EBHC (Loai Albarqouni, personal communication, August 2017). The curriculum items are mostly expressed as essential competences for healthcare workers practising EBHC. The IHC Key Concepts List has been useful in identifying gaps in the EBHC curriculum and in ensuring that it covers relevant key concepts. The online  supplementary appendix 1 shows how they relate to each other.

Supplementary file 1

The national science curriculum for schools in england.

Key Stage 3 of the National Science Curriculum for schools in England has been developed for children between ages 11 and 14. It covers conceptual understanding, scientific enquiry, and the uses and implications of science. The online  supplementary appendix 2 shows the relevance of some IHC Key Concepts to these themes, and how they can help learners to understand what working scientifically entails.

Supplementary file 2

Using Key Concepts and focusing on health is a good way to achieve these learning goals for three reasons. First, everyone is interested in health, so it makes these learning goals immediately relevant and engages learners. In addition, they focus on using science to inform decisions—something that is important to everyone—rather than on doing science. Second, they provide a coherent and sensible framework for identifying the key concepts that are most important for learners to understand and apply. Third, learning to apply the IHC Key Concepts can enable learners to recognise unreliable claims about treatments, to make better personal health choices and to participate in informed debate about health policies.

A spiral curriculum, other types of interventions and other frameworks for critical thinking

The IHC Key Concepts can be the starting point for developing a spiral curriculum ( http://www.informedhealthchoices.org/spiral-curriculum/ ) and additional learning resources for primary and secondary school children. The aim of the spiral curriculum is to guide what to teach and when; introducing basic concepts first, repeating and reinforcing those in subsequent cycles; and introducing more difficult concepts later. It helps to avoid the trap of trying to teach too much at once and provides milestones for what should have been learnt and by when—teaching all 24 concepts at one time was overwhelming for teachers and children. 5 31

Similarly, learning to apply the Key Concepts in the context of health could help improve critical thinking and decision making outside of health. It is uncertain to what extent this will be the case, but anecdotal evidence and some indirect evidence from pilot studies, 5 6 randomised trials 27 28 and process evaluations 6 31 support this hypothesis. Data collected in a process evaluation of the IHC primary school resources show that children and teachers also reported applying the Key Concepts to decisions that were not necessarily about treatments, such as recognising that new is not necessarily better when buying shoes and recognising other unreliable claims when shopping.

Indirect evidence from randomised trials of other strategies to teach critical thinking have found that developing critical thinking skills can benefit academic learning outcomes as well as wider reasoning and problem-solving capabilities, and that this is of particular benefit to pupils from poorer families. 32–34

Conclusions

The IHC Key Concepts List is a systematically developed collection of concepts to help people to assess whether treatment claims are trustworthy. The IHC Key Concepts continue to be developed, taking account of feedback and evaluation.

We have developed the IHC Key Concepts specifically for treatment claims and choices. However, criteria for making causal inferences about interventions and choices are similar for other types of interventions. Introducing the concepts to people at a young age not only helps to prepare patients and future health professionals to make informed choices in healthcare, but should also prepare them to make other types of informed choices as citizens, consumers and future policy-makers.

We invite all those interested in promoting critical thinking about causal claims—particularly about the effects of interventions—to consider applying the IHC Key Concepts List as a framework for conceptualising and promoting critical thinking, and for evaluating the effectiveness of alternative learning approaches.

Acknowledgments

The authors are grateful to Jeremy Howick for inviting IC, SR-V, SP, AA-D and ADO to present these ideas at the conference ‘Too much medicine: exploring the relevance of philosophy of medicine to medical research and practice’, 20 April 2017, Kellogg College, University of Oxford; and to Ruth Davis and David Spiegelhalter for comments on previous drafts of this manuscript.

• 3. ↵ Sciences AoM . Enhancing the use of scientific evidence to judge the potential benefits and harms of medicines , 2017 .
• Thornton H ,
• Chalmers I , et al
• Semakula D ,
• Rosenbaum S , et al
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• Needham G , et al
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• 14. ↵ CASP . Randomised controlled trial checklist . Oxford, UK : CASP . http://www.casp-uk.net/checklists .
• 15. ↵ The Common Wealth Fund . Tipsheet for reporting on drugs, devices and medical technologies . http://www.commonwealthfund.org/publications/other/2004/sep/tipsheet-for-reporting-on-drugs-devices-and-medical-technologies .
• Cook DJ , et al
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• 23. ↵ Centre SM . 10 best practice guidelines for reporting science & health stories , 2012 .
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• Coleman R , et al

Contributors IC suggested and organised the conference session on which the paper has been based, and coordinated the preparation of a first draft coauthored with ADO, AA-D, SR-V and SP. IC incorporated comments, and additional text contributed by other coauthors and redrafted the paper in the light of comments and suggestions from peer reviewers. CH prepared the final draft of the paper, which has been approved by all coauthors.

Funding IC and DB receive support through National Institute for Health Research funding for the James Lind Initiative. The IHC Key Concepts were developed as part of the Informed Health Choices Project, which is funded by the Research Council of Norway (project no: 220603/H10).

Competing interests DN has received expenses and fees for his media work. He holds grant funding from the NIHR School of Primary Care Research and the Royal College of General Practitioners. CH has received expenses and fees for his media work. He holds grant funding from the NIHR, the NIHR School of Primary Care Research, The Wellcome Trust and the WHO. IC declares no competing interest.

Provenance and peer review Commissioned; externally peer reviewed.

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/ Lessons Plans / Health Lesson Plans / Fostering Critical Thinking Skills for Consumer Health Decisions Lesson Plan

Fostering Critical Thinking Skills for Consumer Health Decisions Lesson Plan

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Lesson Plan #:AELP-COH0004 Submitted by: Brian F. Geiger, EdD Email: [email protected] School/University/Affiliation: University of Alabama at Birmingham School of Education Date: September 2, 1997

Grade Level(s): 9, 10, 11, 12

Subject(s):

• Health/Consumer Health

Duration: Two class sessions

Description:

This simple classroom activity can be used to develop consumer health skills among secondary school students. Students select sample advertisements for health products from the print and broadcast media.  Peers cooperate to identify the health information and evaluate intended messages.  Students present their conclusions orally to their peers, including suggestions to change the ads to help consumers to make informed purchase decisions.  This lesson should be used as one component of a unit on consumer health education.

Background Information for the Teacher:

This lesson was field tested during personal health classes with more than 250 undergraduate students during the academic years 1993-96 at a southeastern urban state university. Combining didactic presentation of health information with student exercises enriched health education instruction. The lesson was useful to encourage class participation by all students, particularly those who had been reluctant to join previous class discussions.

The purpose of the consumer health activity is to teach students basic criteria for evaluating advertisements for health-related products in commercial media. This lesson is compatible with the National Health Education Standards (JCNHES, 1995).

Standard 2 is students will demonstrate the ability to access valid health information and health-promoting products and services. Standard 4 is students will analyze the influence of culture, media, technology, and other factors on health.

Objective(s):

Students will:

1. correctly identify target audiences and intended uses of health-related products from manufacturers’ advertisements; 2. distinguish false from accurate information in selected print and broadcast advertisements; 3. determine information about product ingredients from ad content; 4. describe methods of product enhancement used in print and broadcast ads, e.g., food styling; and 5. suggest improvements to increase the amount of accurate health information in ads.

• printed advertisements for health products taken from magazines and newspapers
• videotaped television ads
• personal health text or other assigned reading on consumer health
• Questions to Evaluate Consumer Health Advertisements student worksheet

1. Assign a chapter on consumer health for students to read prior to evaluating advertisements. 2. Write on the chalkboard the words, buyer, seller, product, service, needs, emotions, and transaction. 3. Use previously recorded videotaped television ads featuring health-related products to explain simple marketing concepts including exchange of money to receive a health care product or service. Videotape ads for products that teens would be likely to purchase and those that can cause health problems including OTC medications, alcohol, and beverages with caffeine. 4. Present psychological approaches used to increase sales of health products, i.e., heighten emotions, satisfy present needs, promise quick results. 5. Describe the concept of selling new products by creating desires (perceived needs). 6. Invite students to bring to the next class session ads they have selected from print media featuring health products (e.g., aspirin, foods, weight loss products, exercise equipment, nutritional supplements). 7. Encourage students to work together with peers or adults to review a variety of publications, e.g., local newspaper, Jet, Teen Magazine, Tiger Beat, Glamour, Rolling Stone, Sports Illustrated. 8. Ask students to label each ad with the name of the source publication and date.

Next class session

1. During the next class session, divide the class into small groups of five-six students. 2. Encourage students to discuss their opinions and ideas within the small groups. 3. Establish ground rules for the small group work:

• each person participates
• take turns talking
• respect each other’s beliefs and opinions without criticism

4. Students will select two group members to act as the facilitator and recorder. 5. Review the 13 questions on the student worksheet, Questions to Evaluate Consumer Health Advertisements. 6. Each group will select an ad for a health product to evaluate and answer the following questions:

Assessment:

• Students will demonstrate their consumer health knowledge during group work to complete the exercise.
• Invite group facilitators to take turns presenting aloud their answers to the worksheet questions for different ads.
• Facilitate the class discussion about the content and format of ads for health products.

Useful Resources: * Joint Committee on the National Health Education Standards. 1995. * National Health Education Standards. Atlanta, GA:  American Cancer Society.

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Critical Thinking and Decision-Making  - What is Critical Thinking?

Critical thinking and decision-making  -, what is critical thinking, critical thinking and decision-making what is critical thinking.

Critical Thinking and Decision-Making: What is Critical Thinking?

Lesson 1: what is critical thinking, what is critical thinking.

Critical thinking is a term that gets thrown around a lot. You've probably heard it used often throughout the years whether it was in school, at work, or in everyday conversation. But when you stop to think about it, what exactly is critical thinking and how do you do it ?

Watch the video below to learn more about critical thinking.

Simply put, critical thinking is the act of deliberately analyzing information so that you can make better judgements and decisions . It involves using things like logic, reasoning, and creativity, to draw conclusions and generally understand things better.

This may sound like a pretty broad definition, and that's because critical thinking is a broad skill that can be applied to so many different situations. You can use it to prepare for a job interview, manage your time better, make decisions about purchasing things, and so much more.

The process

As humans, we are constantly thinking . It's something we can't turn off. But not all of it is critical thinking. No one thinks critically 100% of the time... that would be pretty exhausting! Instead, it's an intentional process , something that we consciously use when we're presented with difficult problems or important decisions.

Improving your critical thinking

In order to become a better critical thinker, it's important to ask questions when you're presented with a problem or decision, before jumping to any conclusions. You can start with simple ones like What do I currently know? and How do I know this? These can help to give you a better idea of what you're working with and, in some cases, simplify more complex issues.  

Real-world applications

Let's take a look at how we can use critical thinking to evaluate online information . Say a friend of yours posts a news article on social media and you're drawn to its headline. If you were to use your everyday automatic thinking, you might accept it as fact and move on. But if you were thinking critically, you would first analyze the available information and ask some questions :

• What's the source of this article?
• Is the headline potentially misleading?
• What are my friend's general beliefs?
• Do their beliefs inform why they might have shared this?

After analyzing all of this information, you can draw a conclusion about whether or not you think the article is trustworthy.

Critical thinking has a wide range of real-world applications . It can help you to make better decisions, become more hireable, and generally better understand the world around you.

/en/problem-solving-and-decision-making/why-is-it-so-hard-to-make-decisions/content/

Why and How to Use Critical Thinking in Everyday Life

Written by Argumentful

Critical thinking is a helpful skill that allows you to analyze information and make informed decisions. It’s all about taking a step back and evaluating information objectively, considering multiple perspectives, and making sound judgments based on evidence. With critical thinking, you can tackle problems with confidence, communicate your thoughts and ideas clearly, and reduce the influence of emotions, biases, and misinformation. Plus, by using critical thinking, you can continue to grow and develop as a person by questioning your own beliefs and perspectives.

Elder and Paul’s article “ Critical Thinking: The Nature of Critical and Creative Thought ” argues that critical thinking is essential for success in everyday life. They explain that critical thinking involves analyzing and evaluating information, as well as generating new ideas and perspectives.

Overall, critical thinking is a valuable tool for all of us to navigate the complex and ever-changing world we live in.

Here are some examples of using critical thinking in our daily lives.

EXAMPLES OF CRITICAL THINKING IN EVERYDAY LIFE

Using critical thinking in making smart health choices.

When it comes to taking care of yourself, using critical thinking to check the reliability of your sources and weigh the strength of the evidence can help you make better decisions for your health. If your doctor recommends a certain treatment or you come across a new health trend online, how can you be sure it’s the right choice for you? By using critical thinking, you can evaluate the credibility of sources, consider the evidence behind health claims, and make informed decisions that promote your well-being. Whether it’s choosing a fitness plan, exploring alternative therapies, or making dietary changes, critical thinking can help you take control of your health and make choices that are truly right for you. Don’t just blindly follow health advice, use critical thinking to help you make informed decisions for a healthier you!

Smart budgeting for a stable future

By taking a closer look at your income and expenses, you can use critical thinking to make informed decisions about your finances that will set you up for long-term stability. Should you invest now or should you save for a rainy day? What expenses can you cut back on to reach your financial goals? By using critical thinking, you can assess your financial situation, weigh the risks and benefits of different options, and make smart decisions that improve your financial stability.

Diane Halpern, award-winning educator and past president of the American Psychological Association, explains that critical thinking involves skills such as analyzing arguments, evaluating evidence, and making informed decisions.

Whether it’s creating a budget, setting savings goals, or making investments, critical thinking can help you make informed decisions that put you on a path towards financial security.

Problem solving at work

When you’re facing a problem on the job, using critical thinking can help you get to the bottom of it, weigh your options, and make a well-informed decision. Sometimes the solution may be simple, but other times, it can be complex and involve multiple factors. By using critical thinking, you can objectively analyze the problem, consider different perspectives, and determine the best course of action. This can lead to more effective problem-solving and decision-making in the workplace, helping you to tackle challenges and reach your goals with confidence.

Joe Lau, associate Professor at the University of Hong Kong explains how to identify and avoid common thinking errors, as well as how to use critical thinking to solve problems and make decisions.

So, when a problem arises on the job, don’t just react impulsively, take a step back and use critical thinking to find the best solution.

Fighting propaganda and misinformation with critical thinking

In today’s world with so much information at our fingertips, it’s important to use critical thinking skills to sort out credible sources from misinformation and propaganda. What if instead of relying on hearsay or biased sources, you could make informed decisions based on accurate information? That’s where critical thinking comes in handy. By evaluating the evidence and reasoning behind information, you can separate facts from fiction and make well-informed choices in all areas of your life. Whether it’s evaluating news articles, scientific studies, or even advertisements, critical thinking can help you navigate the maze of information and make informed decisions.

Making decisions about relationships

This might sound like we’re overthinking it, but even in the area of personal relationship you should use clear thinking. When making decisions about relationships, critical thinking can help you evaluate the strengths and weaknesses of your relationships, and make informed choices about the future. Should you get married? Should you end the relationship with a friend that is not supportive of your life choices and goals? By using critical thinking, you can weigh the pros and cons of these important decisions, and make choices that align with your values and aspirations. You can work out the decisions to these challenges methodically when you think critically.

Shopping and consumer decisions

By critically evaluating product claims, advertisements, and customer reviews, you can make informed purchasing decisions that meet your needs and budget. No longer will you be swayed by flashy advertising or a single glowing review. With critical thinking skills, you can objectively assess the validity of product claims, compare prices and features, and determine what truly matches your needs and budget. This can lead to more informed and confident purchasing decisions, saving you time and money in the long run. So, before you click “add to cart,” take a moment to critically evaluate the information available and make an informed choice!

Planning for the future

When making decisions about education, career, and retirement, critical thinking skills will help you evaluate options and make informed choices about the future. Will you continue living driven by others or will you make choices that align with your own goals and values? Weigh the pros and cons of different options, consider long-term consequences, and make decisions that are truly right for you!

Evaluating political information

In a politically charged world, you need critical thinking skills to evaluate political information, identify biases and propaganda, and make informed decisions about political issues. Who will you vote for in the next election? What political issues matter most to you? By using critical thinking, you can examine political information with a skeptical eye, consider multiple perspectives, and make justified choices based on facts and evidence. This can help you navigate the complex world of politics. So, don’t just take political information at face value, use your critical thinking skills to help you make informed and impactful decisions.

Making decisions about personal safety

If you are faced with safety concerns, critical thinking skills can also help you evaluate potential risks, make informed decisions, and take action to protect yourself and your loved ones. It’s always better to be prepared and proactive when it comes to safety. By using critical thinking, you can assess potential dangers, weigh your options, and take steps to ensure the well-being of yourself and those around you. Whether it’s preparing for natural disasters, navigating unfamiliar territory, or making decisions about personal safety, critical thinking can help you make choices that promote peace of mind and security.

Managing stress and emotions by thinking critically

By critically evaluating the root causes of stress and emotions, individuals can make informed decisions about how to manage their mental health and well-being. When was the last time you took a step back and evaluated what’s causing your stress and emotions? By using critical thinking, you can dig deeper into the root causes of your feelings and identify patterns or triggers. For example, maybe you notice that you feel stressed every time you have a big project due at work. By recognizing this pattern, you can take proactive steps to manage your stress, such as breaking down the project into smaller tasks or seeking support from a colleague. Similarly, if you’re feeling overwhelmed with negative emotions, critical thinking can help you evaluate what might be contributing to those feelings and determine steps you can take to improve your emotional well-being. For example, perhaps you’re feeling down because you’re not spending enough time with friends and family.

By recognizing this, you can make an effort to reach out and connect with loved ones, which can help boost your mood and emotional health.

By now you can probably guess the benefits of thinking critically. Here are some of them.

BENEFITS OF THINKING CRITICALLY

• Better decision making : By using critical thinking skills, you can evaluate information objectively, consider multiple perspectives, and make informed decisions that are based on evidence.
• Improved problem solving : When faced with a challenge, critical thinking can help you identify the root cause, evaluate potential solutions, and make an informed decision.
• Increased creativity : Critical thinking encourages you to challenge assumptions and consider new ideas, leading to increased creativity and innovation.
• Better communication : By using critical thinking, you can organize your thoughts, clarify your ideas, and communicate effectively with others.
• Reduced influence of emotions and biases : By using critical thinking, you can reduce the influence of emotions, biases, and misinformation and make decisions based on rational analysis and evidence.
• Personal growth and development : By questioning your own beliefs and perspectives, critical thinking can lead to personal growth and self-discovery.
• Enhanced analytical skills : By regularly practicing critical thinking, you can improve your ability to analyze information, evaluate arguments, and make sound judgments.
• Increased confidence : By making informed decisions based on rational analysis and evidence, critical thinking can increase your confidence in your own abilities.
• Improved critical evaluation skills : Critical thinking can help you evaluate information and arguments from multiple perspectives, leading to improved critical evaluation skills.
• Better understanding of complex issues : By using critical thinking skills, you can gain a better understanding of complex issues and make informed decisions about important topics.

So what are some techniques that can help in building critical thinking?

TECHNIQUES FOR IMPROVING CRITICAL THINKING

• Asking questions : Asking questions helps to clarify understanding, gather information, and challenge assumptions.
• Examining evidence : Evaluate the evidence supporting a claim, and determine its relevance, reliability, and sufficiency.
• Analyzing arguments : Evaluate the structure of arguments, including the premises, conclusions, and any underlying assumptions.
• Considering multiple perspectives : Try to consider multiple viewpoints and understand the reasoning behind each perspective.
• Practicing skepticism : Don’t accept information or arguments at face value, instead question their validity and seek additional evidence.
• Checking for biases : Recognize your own biases and try to avoid them when evaluating information and arguments.
• Seeking diverse sources of information : Look for information from a variety of sources, including those that challenge your beliefs.
• Reflecting on your thought process : Regularly reflect on your own thought processes, and try to identify areas where you may be able to improve your critical thinking skills.
• Engaging in discussion and debate : Engage in discussions and debates with others, and actively listen to their perspectives and arguments.
• Continuously learning : Stay curious and actively seek out new information and knowledge, as this can help you to expand your understanding and improve your critical thinking skills.

It’s important to also be aware of the many challenges that can divert us from thinking critically.

CHALLENGES TO CRITICAL THINKING

Challenges to critical thinking can arise from a variety of sources, such as emotions, biases, lack of information, and cognitive biases. However, these challenges can be overcome with practice and a few helpful tips.

• Emotional involvement : Emotions can cloud your judgment and make it difficult to think critically. To overcome this challenge, try to recognize when you are feeling emotional and take a step back to assess the situation objectively.
• Confirmation bias : Confirmation bias is the tendency to search for and interpret information in a way that confirms your existing beliefs. To overcome this, seek out diverse sources of information and try to consider multiple perspectives.
• Lack of information : When making decisions or evaluating arguments, it can be challenging to think critically when you don’t have all the necessary information. To overcome this challenge, gather information from credible sources and be transparent about what you don’t know.
• Cognitive biases : Cognitive biases refer to systematic errors in thinking that can impact our decision making and critical thinking skills. To overcome this, try to recognize and avoid common cognitive biases, such as the sunk cost fallacy or the availability heuristic.
• Fear of being wrong : Sometimes, fear of being wrong can prevent you from thinking critically. To overcome this challenge, try to approach situations with an open mind and embrace the opportunity to learn and grow.

Final words

In conclusion, critical thinking is a valuable skill that can be improved with practice and by being aware of the challenges that can impact our ability to think critically.

Richard Paul, an expert in critical thinking and co-founder of the Foundation for Critical Thinking, emphasized the importance of critical thinking in everyday life and provided several insights on how to apply it effectively.

One of the key things that Paul said about critical thinking for everyday life is that it involves actively and skillfully analyzing information and ideas, rather than simply accepting them at face value. He stressed the importance of questioning assumptions, considering different perspectives, and evaluating evidence in order to arrive at well-reasoned conclusions.

Paul also emphasized the need to be aware of our own biases and assumptions, as well as the influence of external factors such as media and advertising. He encouraged us to develop a habit of reflection and self-assessment, constantly questioning our own thought processes and seeking out new information and perspectives.

By recognizing these challenges and taking steps to overcome them, you can become a more effective critical thinker and make better decisions in your everyday life.

References :

• “Critical Thinking: The Nature of Critical and Creative Thought” by Richard Paul and Linda Elder
• “Thought and Knowledge: An Introduction to Critical Thinking” by Diane Halpern
• “An Introduction to Critical Thinking and Creativity: Think More, Think Better” by Joe Lau
• “Critical Thinking: An Introduction” by Alec Fisher
• “Thinking Critically” by John Chaffee
• “A Rulebook for Arguments” by Anthony Weston
• “How to Read a Book” by Mortimer Adler and Charles Van Doren
• “The Art of Reasoning” by David Kelley
• “Thinking, Fast and Slow” by Daniel Kahneman
• “Thinking About Thinking: A Guide to Metacognition” by John Dunlosky and Katherine Rawson

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Critical Thinking and Decision-Making Skills

Chapter 4 Critical Thinking and Decision-Making Skills Betsy Frank http://evolve.elsevier.com/Huber/leadership/ In an era of changing reimbursements, value based purchasing, and expanded roles for nursing in the health care delivery system, critical thinking and decision making are important skills for nurses caring for patients and for nurse leaders and managers. Both the American Nurses Association’s (2009) and American Association of Nurse Executives’ (2005) standards for practice for nurse administrators and executives support the fact that in a fast-paced health care delivery environment, staff nurses, leaders, and managers must be able to analyze and synthesize a large array of information, use critical thinking and decision making skills to deliver effective day to day patient care, and solve complex problems that occur in complex health care delivery systems (see Figure 4-1 ). Furthermore, the Magnet Hospital initiative and the Institute of Medicine’s ( Committee on the Robert Wood Johnson Foundation, 2011 ) Future of Nursing report highlight the need for nurses to be able to be fully involved and even take the lead in decision making from the unit level to the larger health care delivery system. FIGURE 4-1 Differences and interactions among critical thinking, problem solving, and decision making. Nurses are a cadre of knowledge workers within the health care system. As such, they need information, resources, and support from their environment. In fact, the nurse manager’s expertise in critical thinking and shared decision making are essential for creating healthy work environments where quality and effective care can be delivered ( Kramer et al., 2010 ; Zori et al., 2010 ). Critical thinking and decision-making competences include analytical skills as well as intuition. Just as intuition is part of expert clinical practice ( Benner, 1984 ), intuition plays an important role in developing managerial and leadership expertise (Shirey, 2007). DEFINITIONS Critical thinking can be defined as a set of cognitive skills including “interpretation, analysis, evaluation, inference, explanation, and self-regulation” ( Facione, 2007 , p. 1). Using these skills, nurses in direct patient care and leaders and managers can reflect analytically, reconceptualize events, and avoid the tendency to make decisions and problem solve hastily or on the basis of inadequate information. Facione also pointed out that critical thinking is not only a skill but also a disposition that is grounded in a strong ethical component. Critical thinking in nursing can be defined as “purposeful, informed, outcomes focused thinking…[that] applies logic, intuition, creativity and is grounded in specific knowledge, skills, and experience” ( Alfaro-LeFevre, 2009 , p. 7). Alfaro-LeFevre noted that outcomes-focused thinking helps to prevent, control, and solve problems. Tanner (2000) noted that critical thinking is much more than just the five steps of the nursing process. Problem solving involves moving from an undesirable to a desirable state ( Chambers, 2009 ). Problem solving occurs in a variety of nursing contexts, including direct client care, team-level leadership, and systems-level leadership. Nurses and nurse managers are challenged to move from step-by-step problem-solving techniques to incorporating creative thinking, which involves considering the context when meeting current and future challenges in health care delivery ( Chambers, 2009 ; Rubenfeld & Scheffer, 2006 ). Decision making is the process of making choices that will provide maximum benefit ( Drummond, 2001 ). Decision making can also be defined as a behavior exhibited in selecting and implementing a course of action from alternative courses of action for dealing with a situation or problem. It may or may not be the result of an immediate problem. Critical thinking and effective decision making are the foundation of effective problem solving. If problems require urgent action, then decisions must be made rapidly; if solutions do not need to be identified immediately, decision making can occur in a more deliberative way. Because problems change over time, decisions made at one point in time may need to be changed ( Choo, 2006 ). For example, decisions about how to staff a unit when a nurse calls in sick have to be made immediately. However, if a unit is chronically short-staffed, a decision regarding long-term solutions will have to be made. The process of selecting one course of action from alternatives forms the basic core of the definition of decision making. Choo (2006) noted that all decisions are bounded by cognitive and mental limits, how much information is processed, and values and assumptions. In other words, no matter the decision-making process, all decisions are limited by a variety of known and unknown factors. In a chaotic health care delivery environment, where regulations and standards of care are always changing, any decision may cause an unanticipated future problem. BACKGROUND Critical Thinking Critical thinking is both an attitude toward handling issues and a reasoning process. Critical thinking is not synonymous with problem solving and decision making ( Figure 4-1 ), but it is the foundation for effective decision making that helps to solve problems ( Fioratou et al., 2011 ). Figure 4-2 illustrates the way obstacles such as poor judgment or biased thinking create detours to good judgment and effective decision making. Critical thinking helps overcome these obstacles. Critical thinking skills may not come naturally. The nurse who is a critical thinker has to be open-minded and have the ability to reflect on present and past actions and to analyze complex information. Nurses who are critical thinkers also have a keen awareness of their surroundings ( Fioratou et al., 2011 ). FIGURE 4-2 Decision-making maze. Critical thinking is a skill that is developed for clarity of thought and improvement in decision-making effectiveness. The roots of the concept of critical thinking can be traced to Socrates, who developed a method of questioning as a way of thinking more clearly and with greater logical consistency. He demonstrated that people often cannot rationally justify confident claims to knowledge. Confused meanings, inadequate evidence, or self-contradictory beliefs may lie below the surface of rhetoric. Therefore it is important to ask deep questions and probe into thinking sequences, seek evidence, closely examine reasoning and assumptions, analyze basic concepts, and trace out implications. Other thinkers, such as Plato, Aristotle, Thomas Aquinas, Francis Bacon, and Descartes, emphasized the importance of systematic critical thinking and the need for a systematic disciplining of the mind to guide it in clarity and precision of thinking. In the early 1900s, Dewey equated critical thinking with reflective thought ( The Critical Thinking Community, 2008 ). Critical thinking, then, is characterized by thinking that has a purpose, is systematic, considers alternative viewpoints, occurs within a frame of reference, and is grounded in information ( The Critical Thinking Community, 2008 ). Questioning is implicit in the critical thinking process. The following are some of the questions to be asked when thinking critically about a problem or issue ( Elder & Paul, n.d. ): •  What is the question being asked? •  Is this the right question? •  Is there another question that must be answered first? •  What information is needed? •  Given the information, what conclusions are justified? •  Are there alternative viewpoints? No matter what questions are asked, critical thinkers need to know the “why” of the thinking, the mode of reasoning (inductive or deductive), what the source and accuracy of the information is, what the underlying assumptions and concepts are, and what might be the outcome of the thinking ( The Critical Thinking Community, 2008 ). Critical Thinking in Nursing Nurses in clinical practice continually make judgments and decisions based on the assessment and diagnosis of client needs and practice problems or situations. Clinical judgment is a complex skill grounded in critical thinking. Clinical judgment results in nursing actions directed toward achieving health outcomes ( Alfaro-LeFevre, 2009 ). Scheffer and Rubenfeld (2000) have stated that habits of the mind that are characteristic of critical thinking by nurses include confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, open-mindedness, perseverance, and reflection. Emphasizing the value of expert experience and holistic judgment ability, Benner (2003) cautioned that clinical judgments must not rely too heavily on technology and that the economic incentives to use technology must not come at the expense of human critical thinking and reasoning in individual cases. Critical thinkers have been distinguished from traditional thinkers in nursing. A traditional thinker, thought to be the norm in nursing, preserves status quo. Critical thinkers go beyond the step-by-step processes outlined in the nursing process and traditional problem solving. A critical thinker challenges and questions the norm and considers in the context of decision making potential unintended consequences. Unlike traditional thinkers, critical thinkers are creative in their thinking and anticipate the consequences of their thinking ( Rubenfeld & Scheffer, 2006 ). Creativity is necessary to deal with the complex twenty-first century health care delivery environment. Nurse leaders and managers have an obligation to create care delivery climates that promote critical thinking, which leads to innovative solutions to problems within the system of care ( Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine; Institute of Medicine, 2011 ; Porter-O’Grady, 2011 ). Such a climate encourages deep reflection, especially so that nurses feel safe to learn from mistakes, and encourages nurses to ask questions and consider a variety of viewpoints and alternative solutions to problems. What specific strategies can be used to promote a climate in which critical thinking is fostered? First and foremost, the nurse manager/leader, in the role of mentor, coach, or preceptor, should encourage questions such as “Is what you are doing or proposing based on sound evidence?” ( Ignatavicius, 2008 ). However, Snowden and Boone (2007) cautioned that “best practice, by definition is past practice” (p. 71). Therefore use of best practices needs to be examined carefully in order to use them appropriately. Staff nurses and managers must use critical thinking skills in order to determine the appropriateness of implementing recommended practice protocols. As managers, allowing staff and self “think time” is essential for reflection and is a key component of critical thinking ( Zori & Morrison, 2009 ). Nurse managers’ critical thinking abilities promotes a positive practice environment which can lead to better patient outcomes ( Zori, Nosek, & Musil, 2010 ). Coaching new and experienced nurses to develop expertise in clinical judgment is critically important. Many new nurses, in particular, need to further develop their critical thinking skills ( Fero et al., 2008 ; Forneris & Peden-McAlpine, 2009 ). In addition to having preceptors and others ask questions of new nurses, nurse managers and leaders can use other strategies to enhance critical thinking in nursing staff. Developing concept maps is another useful strategy to promote critical thinking. Although typically used in prelicensure programs ( Ellermann et al., 2006 ), nurse managers can encourage their preceptors to use concept maps with orientees ( Toofany, 2008 ). Developing concept maps in concert with others further develops a nurse’s critical thinking through the process of dialogue. Simulations also promote critical thinking or “thinking like a nurse” ( Tanner, 2006 ). According to Tanner, simulations can promote clinical reasoning, which leads to making conclusions in the form of clinical judgments and, thus, effective problem solving. The use of human patient simulators is well known in educational settings. Simulators may also be useful in orienting new graduates to the acute care setting ( Leigh, 2011 ). Pulman and colleagues (2009) have reported on the use of simulators to promote critical thinking role development in inter-professional environments. Decision Making Decision making is the essence of leadership and management. It is what leaders and managers are expected to do ( Keynes, 2008 ). Thus decisions are visible outcomes of the leadership and management process. The effectiveness of decision making is one criterion for evaluating a leader or manager. Yet staff nurses and nurse managers and leaders must make decisions in uncertain and complex environments ( Clancy & Delaney, 2005 ). Within a climate of uncertainty and complexity, nurse managers and leaders must also understand that all decision making involves high-stakes risk taking ( Clancy & Delaney, 2005 ; Keynes, 2008 ). If poor decisions are made, progress can be impeded, resources wasted, harm caused, and a career adversely affected. The results of poor decisions may be subtle and not appear until years later. Take, for instance, a decision to reduce expenses by decreasing the ratio of registered nurses to nurses’ aides. There may be a short-term cost savings, but if not implemented appropriately, this tactic may result in the gradual erosion of patient care over time (Kane et al., 2007). Unintended effects may include higher turnover of experienced nurses, increased adverse events such as medication errors, decreased staff morale, and lower patient satisfaction scores. The long-term outcome of this decision may actually result in increased expenses not reduced expenses. Thus it is vital for nurses to understand decision making and explore styles and strategies to enhance decision-making skills. Decision making, like traditional problem solving, has been traditionally thought of as a process with identifiable steps yet influenced by the context and by whether there is an intuitive grasp of the situation. However, Effken and colleagues (2010) stated that decision making is much more. Expert decision making is a constructive process in which the outcomes are not preplanned or simply pulled out of a memory bank. Instead, expert decision-making activities are creative, innovative, and adapted to uncertainty and the context of the current problem, using learning from prior experience (p. 189). Nurses make decisions in personal, clinical, and organizational situations and under conditions of certainty, uncertainty, and risk. Various decision-making models and strategies exist. Nurses’ control over decision making may vary as to amount of control and where in the process they can influence decisions. Although decision-making is more than a step-by-step process as noted by Effken and colleagues (2010) , awareness of the components, process, and strategies of decision making contributes to effectiveness in nursing leadership and management decision making. The basic elements of decision making, which enhances day to day activities, contributes to strategic planning and solves problems can be summarized into the following two parts: (1) identifying the goal for decision-making, and (2) making the decision. According to Guo (2008, p. 120) , the steps of the decision-making process can be illustrated as follows, using DECIDE: •  D efine the problem and determine why anything should be done about it and explore what could be happening. •  E stablish desirable criteria for what you want to accomplish. What should stay the same and what can be done to avoid future problems? •  C onsider all possible alternative choices that will accomplish the desired goal or criteria for problem solution. •  I dentify the best choice or alternative based on experience, intuition, experimentation. •  D evelop and implement an action plan for problem solution. •  E valuate decision through monitoring, troubleshooting, and feedback. Notice how these steps are analogous to the traditional problem-solving process or nursing process well-known by nurses and nurse managers. Thus decision making is used to solve problems. However, decision making is more than just problem solving. Decision making may also be the result of opportunities, challenges, or more long-term leadership initiatives as opposed to being triggered by an immediate problem. In any case, the processes are virtually the same, but their purposes may be slightly different. Nurse managers use decision making in managing resources and the environment of care delivery. Decision making involves an evaluation of the effectiveness of the outcomes that result from the decision-making process itself. Whether nurse managers are the sole decision makers or facilitate group decision making, all the factors that influence the problem-solving process also impact how decisions are made: who owns the problem that will result in a decision, what is the context of the decision to be made, and what lenses or perspectives influence the decision to be made? For example, the chief executive officer may frame issues as a competitive struggle not unlike a sports event. The marketing staff may interpret problems as military battles that need to be won. Nurse executives may view concerns from a care or family frame that emphasizes collaboration and working together. Learning and understanding which analogies and perspectives offer the best view of a problem or issue are vital to effective decision making. It may be necessary for nurse managers to expand their frame of reference and be willing to consider even the most outlandish ideas. Obviously, it is important to begin the goal definition phase with staff members who are closest to the issue. That includes staff nurses in concert with their managers. Often, decisions can originate within the confines of the shared governance system that may be in place within an organization ( Dunbar et al., 2007 ). It is wise, also, to consider adding individuals who have no connection with the issue whatsoever. Often it is these “unconnected” staff members who bring new decision frames to the meeting and have the most unbiased view of the problem. One of the core competencies for all health professionals is working in interprofessional teams ( Interprofessional Education Collaborative Expert Panel, 2011 ). Therefore using interprofessional teams for problem solving and decision making can be assumed to be more effective than working in disciplinary silos. No matter who is involved in the decision-making process, the basic steps to arrive at a decision to resolve problems remain the same. One critical aspect to note, however, is that in making decisions, nurse managers must have situational awareness ( Sharma & Ivancevic, 2010 ). That is, decision makers must always consider the context in which the outcome of the decision is to occur. A decision that leads to a desired outcome on one patient care unit may lead to undesirable outcomes on another unit because the patient care environment and personnel are different. DECISION OUTCOMES When looking at outcomes, one critical aspect of decision making is to determine the desired outcome. The desired outcome may vary, according to Guo (2008) , from an ideal or short-term resolution to covering up a situation. What is desired may be (1) for a problem to go away forever, (2) to make sure that all involved in this problem are satisfied with the solution and gain some benefit from it, or (3) to obtain an ideal solution. Sometimes a quick decision is desired, and researching different aspects of the problem or allowing for participation in decision making is not appropriate. For example, in disaster management, the nurse leader will use predetermined procedures for determining roles of the various personnel involved (Coyle et al., 2007). Desired decisions can be categorized into two end points: minimal and optimal. A minimal decision results in an outcome that is sufficient, satisfies basic requirements, and minimally meets desired objectives. This is sometimes called a “satisficing” decision . An optimizing decision includes comparing all possible solutions with desired objectives and then selecting the optimal solution that best meets objectives ( Choo, 2006 ; Guo, 2008 ). In addition to these two strategies, Layman (2011) drawing from Etzioni (1986) , discussed two other strategies: mixed scanning and incrementalism. Incrementalism is slow progress toward an optimal course of action. Mixed scanning combines the stringent rationalism of optimizing with the “muddling through” approach of incrementalism to form substrategies. Optimizing has the goal of selecting the course of action with the highest payoff (maximization). Limitations of time, money, or people may prevent the decision maker from selecting the more deliberative and slower process of optimizing. Still, the decision maker needs to focus on techniques that will enhance effectiveness in decision-making situations. Barriers to effective decision making exist and, once identified, can lead to going back through the decision-making process. Flaws in thinking can create hidden traps in decision making. These are common psychological tendencies that create barriers or biases in cognitive reflection and appraisal. Six common distortions are as follows ( Hammond et al., 1998 ; 2006 ): 1.  Anchoring trap: When a decision is being considered, the mind gives a disproportionate weight to the first information it receives. Past events, trends, and numbers outweigh current and future realities. All individuals have preconceived notions and biases that influence decisions in a variety of ways. For instance the Institute of Medicine (IOM, 2001) endorsed the use of c omputerized p hysician o rder e ntry (CPOE) as one solution to reduce medication errors. Furthermore, The Centers for Medicare and Medicaid Services has set forth meaningful use criteria for implementation of CPOE as well as electronic health records (EHR). Despite incentive payments for implementing EHR ( HFMA P & P Board, 2012 ), the financial costs involved, human-factor errors and work-flow issues can hamper successful implementation ( Campbell et al., 2006 ). 2.  Status-quo trap: Decision makers display a strong bias toward alternatives that perpetuate the status quo. In the face or rapid change in the environment, past practices that exhibit any sense of permanence provide managers with a feeling of security. 3.  Sunk-cost trap: Past decisions become sunk costs, and new choices are often made in a way that justifies past choices. This may result in becoming trapped by an escalation of commitment. Because of rapid, ongoing advances in medical technology, managers are frequently pressured to replace existing equipment before it is fully depreciated. If the new equipment provides a higher level of quality at a lower cost, the sunk cost of the existing equipment is irrelevant to the decision-making process. However, managers may delay purchasing new equipment and forgo subsequent savings because the equipment has yet to reach the end of its useful life. 4.  Confirming-evidence trap: Kahneman and colleagues (2011) noted that decision makers also fall into the trap of confirmation bias where contradictory data are ignored. This bias leads people to seek out information that supports an existing instinct or point of view while avoiding contradictory evidence. A typical example is favoring new technology over less glamorous alternatives. A decision maker may become so enamored by technological solutions (and slick vendor demonstrations) that he or she may unconsciously decide in favor of these systems even though strong evidence supports implementing less costly solutions first. 5.  Framing trap: The way a problem is initially framed profoundly influences the choices made. Different framing of the same problem can lead to different decision responses. A decision frame can be viewed as a window into the varied reasons a problem exists. As implied by the word frame , individuals may perceive problems only within the boundaries of their own frame. The human resources director may perceive a staffing shortage as a compensation problem, the chief financial officer as an insurance reimbursement issue, the director of education as a training issue, and the chief nursing officer as a work environment problem. Obviously all these issues may contribute, in part, to the problem; however, each person, in looking through his or her individual frame, sees only that portion with which he or she is most familiar ( Layman, 2011 ). 6.  Estimating and forecasting traps: People make estimates or forecasts about uncertain events, but their minds are not calibrated for making estimates in the face of uncertainty. The notion that experience is the parent of wisdom suggests that mature managers, over the course of their careers, learn from their mistakes. It is reasonable to assume that the knowledge gained from a manager’s failed projects would be applied to future decisions. Whether right or wrong, humans tend to take credit for successful projects and find ways to blame external factors on failed ones. Unfortunately, this form of overconfidence often results in overly optimistic projections in project planning. This optimism is usually buried in the analysis done before ranking alternatives and recommendations. Conversely, excessive cautiousness or prudence may also result in faulty decisions. This is called aversion bias ( Kahneman et al., 2011 ). Dramatic events may overly influence decisions because of recall and memory, exaggerating the probability of rare but catastrophic occurrences. It is important that managers objectively examine project planning assumptions in the decision-making process to ensure accurate projections. Because misperceptions, biases, and flaws in thinking can influence choices, actions related to awareness, testing, and mental discipline can be employed to ferret out errors in thinking before the stage of decision making ( Hammond et al., 1998 ). Data-driven decision making is important ( Dexter et al., 2011 ; Lamont, 2010 ; Mick, 2011 ). The electronic health record can be mined for valuable data, upon which fiscal, human resource, and patient care decisions can be made. However, the data derived can be overwhelming and cause decision makers to make less than optimal decisions. Shared decision making can help ameliorate decision traps ( Kahneman et al., 2011 ) because dissent within the group may help those accountable for the decision to prevent errors that are “motivated by self-interest” (p. 54). More alternatives can be generated by a group and more data can be gathered upon which to base the decision, rather than just using data that is more readily apparent. DECISION-MAKING SITUATIONS The situations in which decisions are made may be personal, clinical, or organizational ( Figure 4-3 ). Personal decision making is a familiar part of everyday life. Personal decisions range from multiple small daily choices to time management and career or life choices. FIGURE 4-3 Decision-making situations. Clinical decision making in nursing relates to quality of care and competency issues. According to Tanner (2006) , decision making in the clinical arena is called clinical judgment . In nursing, as with all health professions, clinical judgments should be patient-centered, use available evidence from research and other sources, and use available informatics tools (IOM, 2003). These crucial judgments should take place within the context of interprofessional collaboration. Within a hospital or other health care agency, a social network forms that is interprofessional ( Tan et al., 2005 ). This social network has to collaborate for positive change within the organization and to make clinical decisions of the highest quality. Nurses manage care and make decisions under conditions of certainty, uncertainty, and risk. For example, if research has shown that, under prescribed conditions, the selection of a specific nursing intervention is highly likely to produce a certain outcome, then the nurse in that situation faces a condition of relative certainty. An example would be the prevention of decubitus ulcers by frequent repositioning. If little knowledge is available or if the specific situation is more complex or variant from the usual, then the nurse faces uncertainty. Risk situations occur when a threat of harm to patients exists. Conditions of risk occur commonly relative to the administration of medications, crisis events, infection control, invasive procedures, and the use of technology in nursing practice. Furthermore, these conditions also apply to the administration of nursing care delivery, in which decision making is a critical function. Conditions of uncertainty and complexity are common in nursing care management. Over time, the complexity of health care processes has increased as a natural outgrowth of innovation and new technology. With computerized integration of billing, physician ordering, results of diagnostic tests, information about medications and their actions and side effects, and critical pathways and computerized charting, complexity increases more. Trying to integrate so many data points in care delivery can overwhelm the care provider who is making clinical judgments. As a result, subtle failures in any part of the information system can go unnoticed and have catastrophic outcomes. For example, if the computer system in the emergency room cannot “talk” to the system in the operating room, then errors in care management, such as giving cephalexin to patient who has an allergy can occur. If a provider fails to input critical information, such as a medication that a patient is taking, a fatal drug interaction could occur when another provider prescribes a new medication. Ready access to the Internet and online library sources can further create complexity in the decision-making process as care providers have access to more information upon which to make decisions. Readily accessible information related to evidence-based practice and information gleaned from human resources records and clinical systems can overwhelm nurse managers and leaders. Nurse leaders are coming to understand that innovation and new technology are the driving forces behind the discovery of new knowledge and improvements in patient care. Overlapping, unclear, and changing roles for nurses as a result of new technology and services create complex decision-making situations and impact the quality of care delivered (IOM, 2003). In addition, workflow interruptions can inhibit critical thinking, particularly in a chaotic environment ( Cornell et al., 2011 ; Sitterding et al., 2012 ). ADMINISTRATIVE AND ORGANIZATIONAL DECISION MAKING According to Choo (2006) , organizations use information to “make decisions that commit resources and capabilities to purposeful action” (p. 1). Nurse managers, for example, make staffing decisions and thus commit financial resources for the purpose of delivering patient care. Hospital administrators may decide to add additional services to keep up with external forces. These decisions subsequently have financial implications related to reimbursement, staffing, and the like. Etzioni (1989) noted that the traditional model for business decisions was rationalism. However, he further asserted that as information flow became more complex and faster-paced, a new decision-making model based on the use of partial information that has not been fully analyzed had begun to evolve. He called this model “humble decision making.” This approach arises in response to the need to make a decision when the amount of data exceeds the time available to analyze it. For instance, predicting the outcome of clinical and administrative decisions in health care is problematic because such processes are collectively defined as c omplex a daptive s ystems (CASs). A CAS is characterized by groups of individuals who act in unpredictable, nonlinear (not cause and effect) ways, such that one person’s actions affect all the others ( Holden, 2005 ). In CASs, humans do behave in unpredictable ways ( Tan et al., 2005 ). Critical thinking can help all health care personnel to examine these complex systems, wherein groups solve problems through complex, continually altering interactions between the environment and all involved in the decision making ( Fioratou et al., 2011 ). Situations within the environment constantly change and decision makers need to reframe their thinking as they broaden their awareness of the context of their decisions ( Sharma & Ivancevic, 2010 ). Having situation awareness is a must ( Fioratou et al., 2011 ; Sitterding et al., 2012 ). Decision makers need to make every effort to forecast unanticipated consequences of their decisions. For example if staffing is cut, what adverse events might occur (Kane et al., 2007)? Decision making is also influenced by the manager’s leadership style. A democratic/collaborative style of leadership and decision making works best in a complex adaptive system, such as a hospital, which is characterized by a large array of social relationships that can have an economic impact on an organization. Staff nurses who are not engaged in shared decision making may experience less job satisfaction and subsequently may leave an organization, leading to loss of expertise in patient care ( Gromley, 2011 ). However, the full array of leadership styles may at some time be used in the decision-making process. Vroom and Yetton (1973) proposed a classic managerial decision-making model that identified five managerial decision styles on a continuum from minimal subordinate involvement to delegation. Their model uses a contingency approach, which assumes that situational variables and personal attributes of the leader influence leader behavior and thus can affect organizational effectiveness. To diagnose the situation, the decision maker examines the following seven problem attributes: 1.  The importance of the quality of the decision 2.  Whether there is sufficient information/expertise 3.  The amount of structure to the problem 4.  The extent to which acceptance/commitment of followers is critical to implementation 5.  The probability that an autocratic decision will be accepted 6.  The motivation of followers to achieve organizational goals 7.  The extent to which conflict over preferred solutions is likely

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Critical thinking in healthcare and education

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• Peer review
• Jonathan M Sharples , professor 1 ,
• Andrew D Oxman , research director 2 ,
• Kamal R Mahtani , clinical lecturer 3 ,
• Iain Chalmers , coordinator 4 ,
• Sandy Oliver , professor 1 ,
• Kevan Collins , chief executive 5 ,
• Astrid Austvoll-Dahlgren , senior researcher 2 ,
• Tammy Hoffmann , professor 6
• 1 EPPI-Centre, UCL Department of Social Science, London, UK
• 2 Global Health Unit, Norwegian Institute of Public Health, Oslo, Norway
• 3 Centre for Evidence-Based Medicine, Oxford University, Oxford, UK
• 4 James Lind Initiative, Oxford, UK
• 5 Education Endowment Foundation, London, UK
• 6 Centre for Research in Evidence-Based Practice, Bond University, Gold Coast, Australia
• Correspondence to: J M Sharples Jonathan.Sharples{at}eefoundation.org.uk

Critical thinking is just one skill crucial to evidence based practice in healthcare and education, write Jonathan Sharples and colleagues , who see exciting opportunities for cross sector collaboration

Imagine you are a primary care doctor. A patient comes into your office with acute, atypical chest pain. Immediately you consider the patient’s sex and age, and you begin to think about what questions to ask and what diagnoses and diagnostic tests to consider. You will also need to think about what treatments to consider and how to communicate with the patient and potentially with the patient’s family and other healthcare providers. Some of what you do will be done reflexively, with little explicit thought, but caring for most patients also requires you to think critically about what you are going to do.

Critical thinking, the ability to think clearly and rationally about what to do or what to believe, is essential for the practice of medicine. Few doctors are likely to argue with this. Yet, until recently, the UK regulator the General Medical Council and similar bodies in North America did not mention “critical thinking” anywhere in their standards for licensing and accreditation, 1 and critical thinking is not explicitly taught or assessed in most education programmes for health professionals. 2

Moreover, although more than 2800 articles indexed by PubMed have “critical thinking” in the title or abstract, most are about nursing. We argue that it is important for clinicians and patients to learn to think critically and that the teaching and learning of these skills should be considered explicitly. Given the shared interest in critical thinking with broader education, we also highlight why healthcare and education professionals and researchers need to work together to enable people to think critically about the health choices they make throughout life.

Essential skills for doctors and patients

Critical thinking is not a new concept in education: at the beginning of the last century the US educational reformer John Dewey identified the need to help students “to think well.” 3 Critical thinking encompasses a broad set of skills and dispositions, including cognitive skills (such as analysis, inference, and self regulation); approaches to specific questions or problems (orderliness, diligence, and reasonableness); and approaches to life in general (inquisitiveness, concern with being well informed, and open mindedness). 4

An increasing body of evidence highlights that developing critical thinking skills can benefit academic outcomes as well as wider reasoning and problem solving capabilities. 5 For example, the Thinking, Doing, Talking Science programme trains teachers in a repertoire of strategies that encourage pupils to use critical thinking skills in primary school science lessons. An independently conducted randomised trial of this approach found that it had a positive impact on pupils’ science attainment, with signs that it was particularly beneficial for pupils from poorer families. 6

In medicine, increasing attention has been paid to “critical appraisal” in the past 40 years. Critical appraisal is a subset of critical thinking that focuses on how to use research evidence to inform health decisions. 7 8 9 The need for critical appraisal in medicine was recognised at least 75 years ago, 10 and critical appraisal has been recognised for some decades as an essential competency for healthcare professionals. 11 The General Medical Council’s Good Medical Practice guidance includes the need for doctors to be able to “provide effective treatments based on the best available evidence.” 12

If patients and the public are to make well informed health choices, they must also be able to assess the reliability of health claims and information. This is something that most people struggle to do, and it is becoming increasingly important because patients are taking on a bigger role in managing their health and making healthcare decisions, 13 while needing to cope with more and more health information, much of which is not reliable. 14 15 16 17

Teaching critical thinking

Although critical thinking skills are given limited explicit attention in standards for medical education, they are included as a key competency in most frameworks for national curriculums for primary and secondary schools in many countries. 18 Nonetheless, much health and science education, and education generally, still tends towards rote learning rather than the promotion of critical thinking. 19 20 This matters because the ability to think critically is an essential life skill relevant to decision making in many circumstances. The capacity to think critically is, like a lot of learning, developed in school and the home: parental influence creates advantage for pupils who live in homes where they are encouraged to think and talk about what they are doing. This, importantly, goes beyond simply completing tasks to creating deeper understanding of learning processes. As such, the “critical thinking gap” between children from disadvantaged communities and their more advantaged peers requires attention as early as possible.

Although it is possible to teach critical thinking to adults, it is likely to be more productive if the grounds for this have been laid down in an educational environment early in life, starting in primary school. Erroneous beliefs, attitudes, and behaviours developed during childhood may be difficult to change later. 21 22 This also applies to medical education and to health professionals. It becomes increasingly difficult to teach these skills without a foundation to build on and adequate time to learn them.

Strategies for teaching students to think critically have been evaluated in health and medical education; in science, technology, engineering, and maths; and in other subjects. 23 These studies suggest that critical thinking skills can be taught and that in the absence of explicit teaching of critical thinking, important deficiencies emerge in the abilities of students to make sound judgments. In healthcare studies, many medical students score poorly on tests that measure the ability to think critically , and the ability to think critically is correlated with academic success. 24 25

Evaluations of strategies for teaching critical thinking in medicine have focused primarily on critical appraisal skills as part of evidence based healthcare. An overview of systematic reviews of these studies suggests that improving evidence based healthcare competencies is likely to require multifaceted, clinically integrated approaches that include assessment. 26

Cross sector collaboration

Informed Health Choices, an international project aiming to improve decision making, shows the opportunities and benefits of cross sector collaboration between education and health. 27 This project has brought together people working in education and healthcare to develop a curriculum and learning resources for critical thinking about any action that is claimed to improve health. It aims to develop, identify, and promote the use of effective learning resources, beginning at primary school, to help people to make well informed choices as patients and health professionals, and well informed decisions as citizens and policy makers.

The project has drawn on several approaches used in education, including the development of a “spiral curriculum,” measurement tools, and the design of learning resources. A spiral curriculum begins with determining what people should know and be able to do, and outlines where they should begin and how they should progress to reach these goals. The basic ideas are revisited repeatedly, building on them until the student has grasped a deep understanding of the concepts. 28 29 The project has also drawn on educational research and methods to develop reliable and valid tools for measuring the extent to which those goals have been achieved. 30 31 32 The development of learning resources to teach these skills has been informed by educational research, including educational psychology, motivational psychology, and research and methods for developing learning games. 33 34 35 It has also built on the traditions of clinical epidemiology and evidence based medicine to identify the key concepts required to assess health claims. 29

It is difficult to teach critical thinking abstractly, so focusing on health may have advantages beyond the public health benefits of increasing health literacy. 36 Nearly everyone is interested in health, including children, making it easy to engage learners. It is also immediately relevant to students. As reported by one 10 year old in a school that piloted primary school resources, this is about “things we might actually use instead of things we might use when we are all grown up and by then we’ll forget.” Although the current evaluation of the project is focusing on outcomes relating to appraisal of treatment claims, if the intervention shows promise the next step could be to explore how these skills translate to wider educational contexts and outcomes.

Beyond critical thinking

Exciting opportunities for cross sector collaboration are emerging between healthcare and education. Although critical thinking is a useful example of this, other themes cross the education and healthcare domains, including nutrition, exercise, educational neuroscience, learning disabilities and special education needs, and mental health.

In addition to shared topics, several common methodological and conceptual issues also provide opportunities for sharing ideas and innovations and learning from mistakes and successes. For example, the Education Endowment Foundation is the UK government’s What Works Centre for education, aiming to improve evidence based decision making. Discussions hosted by the foundation are exploring how methods to develop guidelines in healthcare can be adapted and applied in education and other sectors.

Similarly, the foundation’s universal use of independent evaluation for teaching and learning interventions is an approach that should be explored, adapted, and applied in healthcare. Since the development and evaluation of educational interventions are separated, evaluators have no vested interested in the results of the assessment, all results are published, and bias and spin in how results are analysed and presented are reduced. By contrast, industry sponsorship of drug and device studies consistently produces results that favour the manufacturer. 37

Another example of joint working between educators and health is the Best Evidence Medical Education Collaboration, an international collaboration focused on improving education of health professionals. 38 And in the UK, the Centre for Evidence Based Medicine coordinates Evidence in School Teaching (Einstein), a project that supports introducing evidence based medicine as part of wider science activities in schools. 39 It aims to engage students, teachers, and the public in evidence based medicine and develop critical thinking to assess health claims and make better choices.

Collaboration has also been important in the development of the Critical Thinking and Appraisal Resource Library (CARL), 40 a set of resources designed to help people understand fair comparisons of treatments. An important aim of CARL is to promote evaluation of these critical thinking resources and interventions, some of which are currently under way at the Education Endowment Foundation. On 22 May 2017, the foundation is also cohosting an event with the Royal College of Paediatrics and Child Health that will focus on their shared interest in critical thinking and appraisal skills.

Education and healthcare have overlapping interests. Doctors, teachers, researchers, patients, learners, and the public can all benefit from working together to help people to think critically about the choices they make. Events such as the global evidence summit in September 2017 ( https://globalevidencesummit.org ) can help bring people together and build on current international experience.

Contributors and sources: This article reflects conclusions from discussions during 2016 among education and health service researchers exploring opportunities for cross sector collaboration and learning. This group includes people with a longstanding interest in evidence informed policy and practice, with expertise in evaluation design, reviewing methodology, knowledge mobilisation, and critical thinking and appraisal.

Competing interests: We have read and understood BMJ policy on declaration of interests and declare that we have no competing interests.

Provenance and peer review: Not commissioned; externally peer reviewed.

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Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr.

Patient Safety and Quality: An Evidence-Based Handbook for Nurses.

Chapter 6 clinical reasoning, decisionmaking, and action: thinking critically and clinically.

Patricia Benner ; Ronda G. Hughes ; Molly Sutphen .

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This chapter examines multiple thinking strategies that are needed for high-quality clinical practice. Clinical reasoning and judgment are examined in relation to other modes of thinking used by clinical nurses in providing quality health care to patients that avoids adverse events and patient harm. The clinician’s ability to provide safe, high-quality care can be dependent upon their ability to reason, think, and judge, which can be limited by lack of experience. The expert performance of nurses is dependent upon continual learning and evaluation of performance.

• Critical Thinking

Nursing education has emphasized critical thinking as an essential nursing skill for more than 50 years. 1 The definitions of critical thinking have evolved over the years. There are several key definitions for critical thinking to consider. The American Philosophical Association (APA) defined critical thinking as purposeful, self-regulatory judgment that uses cognitive tools such as interpretation, analysis, evaluation, inference, and explanation of the evidential, conceptual, methodological, criteriological, or contextual considerations on which judgment is based. 2 A more expansive general definition of critical thinking is

. . . in short, self-directed, self-disciplined, self-monitored, and self-corrective thinking. It presupposes assent to rigorous standards of excellence and mindful command of their use. It entails effective communication and problem solving abilities and a commitment to overcome our native egocentrism and sociocentrism. Every clinician must develop rigorous habits of critical thinking, but they cannot escape completely the situatedness and structures of the clinical traditions and practices in which they must make decisions and act quickly in specific clinical situations. 3

There are three key definitions for nursing, which differ slightly. Bittner and Tobin defined critical thinking as being “influenced by knowledge and experience, using strategies such as reflective thinking as a part of learning to identify the issues and opportunities, and holistically synthesize the information in nursing practice” 4 (p. 268). Scheffer and Rubenfeld 5 expanded on the APA definition for nurses through a consensus process, resulting in the following definition:

Critical thinking in nursing is an essential component of professional accountability and quality nursing care. Critical thinkers in nursing exhibit these habits of the mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, openmindedness, perseverance, and reflection. Critical thinkers in nursing practice the cognitive skills of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting, and transforming knowledge 6 (Scheffer & Rubenfeld, p. 357).

The National League for Nursing Accreditation Commission (NLNAC) defined critical thinking as:

the deliberate nonlinear process of collecting, interpreting, analyzing, drawing conclusions about, presenting, and evaluating information that is both factually and belief based. This is demonstrated in nursing by clinical judgment, which includes ethical, diagnostic, and therapeutic dimensions and research 7 (p. 8).

These concepts are furthered by the American Association of Colleges of Nurses’ definition of critical thinking in their Essentials of Baccalaureate Nursing :

Critical thinking underlies independent and interdependent decision making. Critical thinking includes questioning, analysis, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application, and creativity 8 (p. 9).

Course work or ethical experiences should provide the graduate with the knowledge and skills to:

• Use nursing and other appropriate theories and models, and an appropriate ethical framework;
• Apply research-based knowledge from nursing and the sciences as the basis for practice;
• Use clinical judgment and decision-making skills;
• Engage in self-reflective and collegial dialogue about professional practice;
• Evaluate nursing care outcomes through the acquisition of data and the questioning of inconsistencies, allowing for the revision of actions and goals;
• Engage in creative problem solving 8 (p. 10).

Taken together, these definitions of critical thinking set forth the scope and key elements of thought processes involved in providing clinical care. Exactly how critical thinking is defined will influence how it is taught and to what standard of care nurses will be held accountable.

Professional and regulatory bodies in nursing education have required that critical thinking be central to all nursing curricula, but they have not adequately distinguished critical reflection from ethical, clinical, or even creative thinking for decisionmaking or actions required by the clinician. Other essential modes of thought such as clinical reasoning, evaluation of evidence, creative thinking, or the application of well-established standards of practice—all distinct from critical reflection—have been subsumed under the rubric of critical thinking. In the nursing education literature, clinical reasoning and judgment are often conflated with critical thinking. The accrediting bodies and nursing scholars have included decisionmaking and action-oriented, practical, ethical, and clinical reasoning in the rubric of critical reflection and thinking. One might say that this harmless semantic confusion is corrected by actual practices, except that students need to understand the distinctions between critical reflection and clinical reasoning, and they need to learn to discern when each is better suited, just as students need to also engage in applying standards, evidence-based practices, and creative thinking.

The growing body of research, patient acuity, and complexity of care demand higher-order thinking skills. Critical thinking involves the application of knowledge and experience to identify patient problems and to direct clinical judgments and actions that result in positive patient outcomes. These skills can be cultivated by educators who display the virtues of critical thinking, including independence of thought, intellectual curiosity, courage, humility, empathy, integrity, perseverance, and fair-mindedness. 9

The process of critical thinking is stimulated by integrating the essential knowledge, experiences, and clinical reasoning that support professional practice. The emerging paradigm for clinical thinking and cognition is that it is social and dialogical rather than monological and individual. 10–12 Clinicians pool their wisdom and multiple perspectives, yet some clinical knowledge can be demonstrated only in the situation (e.g., how to suction an extremely fragile patient whose oxygen saturations sink too low). Early warnings of problematic situations are made possible by clinicians comparing their observations to that of other providers. Clinicians form practice communities that create styles of practice, including ways of doing things, communication styles and mechanisms, and shared expectations about performance and expertise of team members.

By holding up critical thinking as a large umbrella for different modes of thinking, students can easily misconstrue the logic and purposes of different modes of thinking. Clinicians and scientists alike need multiple thinking strategies, such as critical thinking, clinical judgment, diagnostic reasoning, deliberative rationality, scientific reasoning, dialogue, argument, creative thinking, and so on. In particular, clinicians need forethought and an ongoing grasp of a patient’s health status and care needs trajectory, which requires an assessment of their own clarity and understanding of the situation at hand, critical reflection, critical reasoning, and clinical judgment.

Critical Reflection, Critical Reasoning, and Judgment

Critical reflection requires that the thinker examine the underlying assumptions and radically question or doubt the validity of arguments, assertions, and even facts of the case. Critical reflective skills are essential for clinicians; however, these skills are not sufficient for the clinician who must decide how to act in particular situations and avoid patient injury. For example, in everyday practice, clinicians cannot afford to critically reflect on the well-established tenets of “normal” or “typical” human circulatory systems when trying to figure out a particular patient’s alterations from that typical, well-grounded understanding that has existed since Harvey’s work in 1628. 13 Yet critical reflection can generate new scientifically based ideas. For example, there is a lack of adequate research on the differences between women’s and men’s circulatory systems and the typical pathophysiology related to heart attacks. Available research is based upon multiple, taken-for-granted starting points about the general nature of the circulatory system. As such, critical reflection may not provide what is needed for a clinician to act in a situation. This idea can be considered reasonable since critical reflective thinking is not sufficient for good clinical reasoning and judgment. The clinician’s development of skillful critical reflection depends upon being taught what to pay attention to, and thus gaining a sense of salience that informs the powers of perceptual grasp. The powers of noticing or perceptual grasp depend upon noticing what is salient and the capacity to respond to the situation.

Critical reflection is a crucial professional skill, but it is not the only reasoning skill or logic clinicians require. The ability to think critically uses reflection, induction, deduction, analysis, challenging assumptions, and evaluation of data and information to guide decisionmaking. 9 , 14 , 15 Critical reasoning is a process whereby knowledge and experience are applied in considering multiple possibilities to achieve the desired goals, 16 while considering the patient’s situation. 14 It is a process where both inductive and deductive cognitive skills are used. 17 Sometimes clinical reasoning is presented as a form of evaluating scientific knowledge, sometimes even as a form of scientific reasoning. Critical thinking is inherent in making sound clinical reasoning. 18

An essential point of tension and confusion exists in practice traditions such as nursing and medicine when clinical reasoning and critical reflection become entangled, because the clinician must have some established bases that are not questioned when engaging in clinical decisions and actions, such as standing orders. The clinician must act in the particular situation and time with the best clinical and scientific knowledge available. The clinician cannot afford to indulge in either ritualistic unexamined knowledge or diagnostic or therapeutic nihilism caused by radical doubt, as in critical reflection, because they must find an intelligent and effective way to think and act in particular clinical situations. Critical reflection skills are essential to assist practitioners to rethink outmoded or even wrong-headed approaches to health care, health promotion, and prevention of illness and complications, especially when new evidence is available. Breakdowns in practice, high failure rates in particular therapies, new diseases, new scientific discoveries, and societal changes call for critical reflection about past assumptions and no-longer-tenable beliefs.

Clinical reasoning stands out as a situated, practice-based form of reasoning that requires a background of scientific and technological research-based knowledge about general cases, more so than any particular instance. It also requires practical ability to discern the relevance of the evidence behind general scientific and technical knowledge and how it applies to a particular patient. In dong so, the clinician considers the patient’s particular clinical trajectory, their concerns and preferences, and their particular vulnerabilities (e.g., having multiple comorbidities) and sensitivities to care interventions (e.g., known drug allergies, other conflicting comorbid conditions, incompatible therapies, and past responses to therapies) when forming clinical decisions or conclusions.

Situated in a practice setting, clinical reasoning occurs within social relationships or situations involving patient, family, community, and a team of health care providers. The expert clinician situates themselves within a nexus of relationships, with concerns that are bounded by the situation. Expert clinical reasoning is socially engaged with the relationships and concerns of those who are affected by the caregiving situation, and when certain circumstances are present, the adverse event. Halpern 19 has called excellent clinical ethical reasoning “emotional reasoning” in that the clinicians have emotional access to the patient/family concerns and their understanding of the particular care needs. Expert clinicians also seek an optimal perceptual grasp, one based on understanding and as undistorted as possible, based on an attuned emotional engagement and expert clinical knowledge. 19 , 20

Clergy educators 21 and nursing and medical educators have begun to recognize the wisdom of broadening their narrow vision of rationality beyond simple rational calculation (exemplified by cost-benefit analysis) to reconsider the need for character development—including emotional engagement, perception, habits of thought, and skill acquisition—as essential to the development of expert clinical reasoning, judgment, and action. 10 , 22–24 Practitioners of engineering, law, medicine, and nursing, like the clergy, have to develop a place to stand in their discipline’s tradition of knowledge and science in order to recognize and evaluate salient evidence in the moment. Diagnostic confusion and disciplinary nihilism are both threats to the clinician’s ability to act in particular situations. However, the practice and practitioners will not be self-improving and vital if they cannot engage in critical reflection on what is not of value, what is outmoded, and what does not work. As evidence evolves and expands, so too must clinical thought.

Clinical judgment requires clinical reasoning across time about the particular, and because of the relevance of this immediate historical unfolding, clinical reasoning can be very different from the scientific reasoning used to formulate, conduct, and assess clinical experiments. While scientific reasoning is also socially embedded in a nexus of social relationships and concerns, the goal of detached, critical objectivity used to conduct scientific experiments minimizes the interactive influence of the research on the experiment once it has begun. Scientific research in the natural and clinical sciences typically uses formal criteria to develop “yes” and “no” judgments at prespecified times. The scientist is always situated in past and immediate scientific history, preferring to evaluate static and predetermined points in time (e.g., snapshot reasoning), in contrast to a clinician who must always reason about transitions over time. 25 , 26

Techne and Phronesis

Distinctions between the mere scientific making of things and practice was first explored by Aristotle as distinctions between techne and phronesis. 27 Learning to be a good practitioner requires developing the requisite moral imagination for good practice. If, for example, patients exercise their rights and refuse treatments, practitioners are required to have the moral imagination to understand the probable basis for the patient’s refusal. For example, was the refusal based upon catastrophic thinking, unrealistic fears, misunderstanding, or even clinical depression?

Techne, as defined by Aristotle, encompasses the notion of formation of character and habitus 28 as embodied beings. In Aristotle’s terms, techne refers to the making of things or producing outcomes. 11 Joseph Dunne defines techne as “the activity of producing outcomes,” and it “is governed by a means-ends rationality where the maker or producer governs the thing or outcomes produced or made through gaining mastery over the means of producing the outcomes, to the point of being able to separate means and ends” 11 (p. 54). While some aspects of medical and nursing practice fall into the category of techne, much of nursing and medical practice falls outside means-ends rationality and must be governed by concern for doing good or what is best for the patient in particular circumstances, where being in a relationship and discerning particular human concerns at stake guide action.

Phronesis, in contrast to techne, includes reasoning about the particular, across time, through changes or transitions in the patient’s and/or the clinician’s understanding. As noted by Dunne, phronesis is “characterized at least as much by a perceptiveness with regard to concrete particulars as by a knowledge of universal principles” 11 (p. 273). This type of practical reasoning often takes the form of puzzle solving or the evaluation of immediate past “hot” history of the patient’s situation. Such a particular clinical situation is necessarily particular, even though many commonalities and similarities with other disease syndromes can be recognized through signs and symptoms and laboratory tests. 11 , 29 , 30 Pointing to knowledge embedded in a practice makes no claim for infallibility or “correctness.” Individual practitioners can be mistaken in their judgments because practices such as medicine and nursing are inherently underdetermined. 31

While phronetic knowledge must remain open to correction and improvement, real events, and consequences, it cannot consistently transcend the institutional setting’s capacities and supports for good practice. Phronesis is also dependent on ongoing experiential learning of the practitioner, where knowledge is refined, corrected, or refuted. The Western tradition, with the notable exception of Aristotle, valued knowledge that could be made universal and devalued practical know-how and experiential learning. Descartes codified this preference for formal logic and rational calculation.

Aristotle recognized that when knowledge is underdetermined, changeable, and particular, it cannot be turned into the universal or standardized. It must be perceived, discerned, and judged, all of which require experiential learning. In nursing and medicine, perceptual acuity in physical assessment and clinical judgment (i.e., reasoning across time about changes in the particular patient or the clinician’s understanding of the patient’s condition) fall into the Greek Aristotelian category of phronesis. Dewey 32 sought to rescue knowledge gained by practical activity in the world. He identified three flaws in the understanding of experience in Greek philosophy: (1) empirical knowing is the opposite of experience with science; (2) practice is reduced to techne or the application of rational thought or technique; and (3) action and skilled know-how are considered temporary and capricious as compared to reason, which the Greeks considered as ultimate reality.

In practice, nursing and medicine require both techne and phronesis. The clinician standardizes and routinizes what can be standardized and routinized, as exemplified by standardized blood pressure measurements, diagnoses, and even charting about the patient’s condition and treatment. 27 Procedural and scientific knowledge can often be formalized and standardized (e.g., practice guidelines), or at least made explicit and certain in practice, except for the necessary timing and adjustments made for particular patients. 11 , 22

Rational calculations available to techne—population trends and statistics, algorithms—are created as decision support structures and can improve accuracy when used as a stance of inquiry in making clinical judgments about particular patients. Aggregated evidence from clinical trials and ongoing working knowledge of pathophysiology, biochemistry, and genomics are essential. In addition, the skills of phronesis (clinical judgment that reasons across time, taking into account the transitions of the particular patient/family/community and transitions in the clinician’s understanding of the clinical situation) will be required for nursing, medicine, or any helping profession.

Thinking Critically

Being able to think critically enables nurses to meet the needs of patients within their context and considering their preferences; meet the needs of patients within the context of uncertainty; consider alternatives, resulting in higher-quality care; 33 and think reflectively, rather than simply accepting statements and performing tasks without significant understanding and evaluation. 34 Skillful practitioners can think critically because they have the following cognitive skills: information seeking, discriminating, analyzing, transforming knowledge, predicating, applying standards, and logical reasoning. 5 One’s ability to think critically can be affected by age, length of education (e.g., an associate vs. a baccalaureate decree in nursing), and completion of philosophy or logic subjects. 35–37 The skillful practitioner can think critically because of having the following characteristics: motivation, perseverance, fair-mindedness, and deliberate and careful attention to thinking. 5 , 9

Thinking critically implies that one has a knowledge base from which to reason and the ability to analyze and evaluate evidence. 38 Knowledge can be manifest by the logic and rational implications of decisionmaking. Clinical decisionmaking is particularly influenced by interpersonal relationships with colleagues, 39 patient conditions, availability of resources, 40 knowledge, and experience. 41 Of these, experience has been shown to enhance nurses’ abilities to make quick decisions 42 and fewer decision errors, 43 support the identification of salient cues, and foster the recognition and action on patterns of information. 44 , 45

Clinicians must develop the character and relational skills that enable them to perceive and understand their patient’s needs and concerns. This requires accurate interpretation of patient data that is relevant to the specific patient and situation. In nursing, this formation of moral agency focuses on learning to be responsible in particular ways demanded by the practice, and to pay attention and intelligently discern changes in patients’ concerns and/or clinical condition that require action on the part of the nurse or other health care workers to avert potential compromises to quality care.

Formation of the clinician’s character, skills, and habits are developed in schools and particular practice communities within a larger practice tradition. As Dunne notes,

A practice is not just a surface on which one can display instant virtuosity. It grounds one in a tradition that has been formed through an elaborate development and that exists at any juncture only in the dispositions (slowly and perhaps painfully acquired) of its recognized practitioners. The question may of course be asked whether there are any such practices in the contemporary world, whether the wholesale encroachment of Technique has not obliterated them—and whether this is not the whole point of MacIntyre’s recipe of withdrawal, as well as of the post-modern story of dispossession 11 (p. 378).

Clearly Dunne is engaging in critical reflection about the conditions for developing character, skills, and habits for skillful and ethical comportment of practitioners, as well as to act as moral agents for patients so that they and their families receive safe, effective, and compassionate care.

Professional socialization or professional values, while necessary, do not adequately address character and skill formation that transform the way the practitioner exists in his or her world, what the practitioner is capable of noticing and responding to, based upon well-established patterns of emotional responses, skills, dispositions to act, and the skills to respond, decide, and act. 46 The need for character and skill formation of the clinician is what makes a practice stand out from a mere technical, repetitious manufacturing process. 11 , 30 , 47

In nursing and medicine, many have questioned whether current health care institutions are designed to promote or hinder enlightened, compassionate practice, or whether they have deteriorated into commercial institutional models that focus primarily on efficiency and profit. MacIntyre points out the links between the ongoing development and improvement of practice traditions and the institutions that house them:

Lack of justice, lack of truthfulness, lack of courage, lack of the relevant intellectual virtues—these corrupt traditions, just as they do those institutions and practices which derive their life from the traditions of which they are the contemporary embodiments. To recognize this is of course also to recognize the existence of an additional virtue, one whose importance is perhaps most obvious when it is least present, the virtue of having an adequate sense of the traditions to which one belongs or which confront one. This virtue is not to be confused with any form of conservative antiquarianism; I am not praising those who choose the conventional conservative role of laudator temporis acti. It is rather the case that an adequate sense of tradition manifests itself in a grasp of those future possibilities which the past has made available to the present. Living traditions, just because they continue a not-yet-completed narrative, confront a future whose determinate and determinable character, so far as it possesses any, derives from the past 30 (p. 207).

It would be impossible to capture all the situated and distributed knowledge outside of actual practice situations and particular patients. Simulations are powerful as teaching tools to enable nurses’ ability to think critically because they give students the opportunity to practice in a simplified environment. However, students can be limited in their inability to convey underdetermined situations where much of the information is based on perceptions of many aspects of the patient and changes that have occurred over time. Simulations cannot have the sub-cultures formed in practice settings that set the social mood of trust, distrust, competency, limited resources, or other forms of situated possibilities.

One of the hallmark studies in nursing providing keen insight into understanding the influence of experience was a qualitative study of adult, pediatric, and neonatal intensive care unit (ICU) nurses, where the nurses were clustered into advanced beginner, intermediate, and expert level of practice categories. The advanced beginner (having up to 6 months of work experience) used procedures and protocols to determine which clinical actions were needed. When confronted with a complex patient situation, the advanced beginner felt their practice was unsafe because of a knowledge deficit or because of a knowledge application confusion. The transition from advanced beginners to competent practitioners began when they first had experience with actual clinical situations and could benefit from the knowledge gained from the mistakes of their colleagues. Competent nurses continuously questioned what they saw and heard, feeling an obligation to know more about clinical situations. In doing do, they moved from only using care plans and following the physicians’ orders to analyzing and interpreting patient situations. Beyond that, the proficient nurse acknowledged the changing relevance of clinical situations requiring action beyond what was planned or anticipated. The proficient nurse learned to acknowledge the changing needs of patient care and situation, and could organize interventions “by the situation as it unfolds rather than by preset goals 48 (p. 24). Both competent and proficient nurses (that is, intermediate level of practice) had at least two years of ICU experience. 48 Finally, the expert nurse had a more fully developed grasp of a clinical situation, a sense of confidence in what is known about the situation, and could differentiate the precise clinical problem in little time. 48

Expertise is acquired through professional experience and is indicative of a nurse who has moved beyond mere proficiency. As Gadamer 29 points out, experience involves a turning around of preconceived notions, preunderstandings, and extends or adds nuances to understanding. Dewey 49 notes that experience requires a prepared “creature” and an enriched environment. The opportunity to reflect and narrate one’s experiential learning can clarify, extend, or even refute experiential learning.

Experiential learning requires time and nurturing, but time alone does not ensure experiential learning. Aristotle linked experiential learning to the development of character and moral sensitivities of a person learning a practice. 50 New nurses/new graduates have limited work experience and must experience continuing learning until they have reached an acceptable level of performance. 51 After that, further improvements are not predictable, and years of experience are an inadequate predictor of expertise. 52

The most effective knower and developer of practical knowledge creates an ongoing dialogue and connection between lessons of the day and experiential learning over time. Gadamer, in a late life interview, highlighted the open-endedness and ongoing nature of experiential learning in the following interview response:

Being experienced does not mean that one now knows something once and for all and becomes rigid in this knowledge; rather, one becomes more open to new experiences. A person who is experienced is undogmatic. Experience has the effect of freeing one to be open to new experience … In our experience we bring nothing to a close; we are constantly learning new things from our experience … this I call the interminability of all experience 32 (p. 403).

Practical endeavor, supported by scientific knowledge, requires experiential learning, the development of skilled know-how, and perceptual acuity in order to make the scientific knowledge relevant to the situation. Clinical perceptual and skilled know-how helps the practitioner discern when particular scientific findings might be relevant. 53

Often experience and knowledge, confirmed by experimentation, are treated as oppositions, an either-or choice. However, in practice it is readily acknowledged that experiential knowledge fuels scientific investigation, and scientific investigation fuels further experiential learning. Experiential learning from particular clinical cases can help the clinician recognize future similar cases and fuel new scientific questions and study. For example, less experienced nurses—and it could be argued experienced as well—can use nursing diagnoses practice guidelines as part of their professional advancement. Guidelines are used to reflect their interpretation of patients’ needs, responses, and situation, 54 a process that requires critical thinking and decisionmaking. 55 , 56 Using guidelines also reflects one’s problem identification and problem-solving abilities. 56 Conversely, the ability to proficiently conduct a series of tasks without nursing diagnoses is the hallmark of expertise. 39 , 57

Experience precedes expertise. As expertise develops from experience and gaining knowledge and transitions to the proficiency stage, the nurses’ thinking moves from steps and procedures (i.e., task-oriented care) toward “chunks” or patterns 39 (i.e., patient-specific care). In doing so, the nurse thinks reflectively, rather than merely accepting statements and performing procedures without significant understanding and evaluation. 34 Expert nurses do not rely on rules and logical thought processes in problem-solving and decisionmaking. 39 Instead, they use abstract principles, can see the situation as a complex whole, perceive situations comprehensively, and can be fully involved in the situation. 48 Expert nurses can perform high-level care without conscious awareness of the knowledge they are using, 39 , 58 and they are able to provide that care with flexibility and speed. Through a combination of knowledge and skills gained from a range of theoretical and experiential sources, expert nurses also provide holistic care. 39 Thus, the best care comes from the combination of theoretical, tacit, and experiential knowledge. 59 , 60

Experts are thought to eventually develop the ability to intuitively know what to do and to quickly recognize critical aspects of the situation. 22 Some have proposed that expert nurses provide high-quality patient care, 61 , 62 but that is not consistently documented—particularly in consideration of patient outcomes—and a full understanding between the differential impact of care rendered by an “expert” nurse is not fully understood. In fact, several studies have found that length of professional experience is often unrelated and even negatively related to performance measures and outcomes. 63 , 64

In a review of the literature on expertise in nursing, Ericsson and colleagues 65 found that focusing on challenging, less-frequent situations would reveal individual performance differences on tasks that require speed and flexibility, such as that experienced during a code or an adverse event. Superior performance was associated with extensive training and immediate feedback about outcomes, which can be obtained through continual training, simulation, and processes such as root-cause analysis following an adverse event. Therefore, efforts to improve performance benefited from continual monitoring, planning, and retrospective evaluation. Even then, the nurse’s ability to perform as an expert is dependent upon their ability to use intuition or insights gained through interactions with patients. 39

Intuition and Perception

Intuition is the instant understanding of knowledge without evidence of sensible thought. 66 According to Young, 67 intuition in clinical practice is a process whereby the nurse recognizes something about a patient that is difficult to verbalize. Intuition is characterized by factual knowledge, “immediate possession of knowledge, and knowledge independent of the linear reasoning process” 68 (p. 23). When intuition is used, one filters information initially triggered by the imagination, leading to the integration of all knowledge and information to problem solve. 69 Clinicians use their interactions with patients and intuition, drawing on tacit or experiential knowledge, 70 , 71 to apply the correct knowledge to make the correct decisions to address patient needs. Yet there is a “conflated belief in the nurses’ ability to know what is best for the patient” 72 (p. 251) because the nurses’ and patients’ identification of the patients’ needs can vary. 73

A review of research and rhetoric involving intuition by King and Appleton 62 found that all nurses, including students, used intuition (i.e., gut feelings). They found evidence, predominately in critical care units, that intuition was triggered in response to knowledge and as a trigger for action and/or reflection with a direct bearing on the analytical process involved in patient care. The challenge for nurses was that rigid adherence to checklists, guidelines, and standardized documentation, 62 ignored the benefits of intuition. This view was furthered by Rew and Barrow 68 , 74 in their reviews of the literature, where they found that intuition was imperative to complex decisionmaking, 68 difficult to measure and assess in a quantitative manner, and was not linked to physiologic measures. 74

Intuition is a way of explaining professional expertise. 75 Expert nurses rely on their intuitive judgment that has been developed over time. 39 , 76 Intuition is an informal, nonanalytically based, unstructured, deliberate calculation that facilitates problem solving, 77 a process of arriving at salient conclusions based on relatively small amounts of knowledge and/or information. 78 Experts can have rapid insight into a situation by using intuition to recognize patterns and similarities, achieve commonsense understanding, and sense the salient information combined with deliberative rationality. 10 Intuitive recognition of similarities and commonalities between patients are often the first diagnostic clue or early warning, which must then be followed up with critical evaluation of evidence among the competing conditions. This situation calls for intuitive judgment that can distinguish “expert human judgment from the decisions” made by a novice 79 (p. 23).

Shaw 80 equates intuition with direct perception. Direct perception is dependent upon being able to detect complex patterns and relationships that one has learned through experience are important. Recognizing these patterns and relationships generally occurs rapidly and is complex, making it difficult to articulate or describe. Perceptual skills, like those of the expert nurse, are essential to recognizing current and changing clinical conditions. Perception requires attentiveness and the development of a sense of what is salient. Often in nursing and medicine, means and ends are fused, as is the case for a “good enough” birth experience and a peaceful death.

• Applying Practice Evidence

Research continues to find that using evidence-based guidelines in practice, informed through research evidence, improves patients’ outcomes. 81–83 Research-based guidelines are intended to provide guidance for specific areas of health care delivery. 84 The clinician—both the novice and expert—is expected to use the best available evidence for the most efficacious therapies and interventions in particular instances, to ensure the highest-quality care, especially when deviations from the evidence-based norm may heighten risks to patient safety. Otherwise, if nursing and medicine were exact sciences, or consisted only of techne, then a 1:1 relationship could be established between results of aggregated evidence-based research and the best path for all patients.

Evaluating Evidence

Before research should be used in practice, it must be evaluated. There are many complexities and nuances in evaluating the research evidence for clinical practice. Evaluation of research behind evidence-based medicine requires critical thinking and good clinical judgment. Sometimes the research findings are mixed or even conflicting. As such, the validity, reliability, and generalizability of available research are fundamental to evaluating whether evidence can be applied in practice. To do so, clinicians must select the best scientific evidence relevant to particular patients—a complex process that involves intuition to apply the evidence. Critical thinking is required for evaluating the best available scientific evidence for the treatment and care of a particular patient.

Good clinical judgment is required to select the most relevant research evidence. The best clinical judgment, that is, reasoning across time about the particular patient through changes in the patient’s concerns and condition and/or the clinician’s understanding, are also required. This type of judgment requires clinicians to make careful observations and evaluations of the patient over time, as well as know the patient’s concerns and social circumstances. To evolve to this level of judgment, additional education beyond clinical preparation if often required.

Sources of Evidence

Evidence that can be used in clinical practice has different sources and can be derived from research, patient’s preferences, and work-related experience. 85 , 86 Nurses have been found to obtain evidence from experienced colleagues believed to have clinical expertise and research-based knowledge 87 as well as other sources.

For many years now, randomized controlled trials (RCTs) have often been considered the best standard for evaluating clinical practice. Yet, unless the common threats to the validity (e.g., representativeness of the study population) and reliability (e.g., consistency in interventions and responses of study participants) of RCTs are addressed, the meaningfulness and generalizability of the study outcomes are very limited. Relevant patient populations may be excluded, such as women, children, minorities, the elderly, and patients with multiple chronic illnesses. The dropout rate of the trial may confound the results. And it is easier to get positive results published than it is to get negative results published. Thus, RCTs are generalizable (i.e., applicable) only to the population studied—which may not reflect the needs of the patient under the clinicians care. In instances such as these, clinicians need to also consider applied research using prospective or retrospective populations with case control to guide decisionmaking, yet this too requires critical thinking and good clinical judgment.

Another source of available evidence may come from the gold standard of aggregated systematic evaluation of clinical trial outcomes for the therapy and clinical condition in question, be generated by basic and clinical science relevant to the patient’s particular pathophysiology or care need situation, or stem from personal clinical experience. The clinician then takes all of the available evidence and considers the particular patient’s known clinical responses to past therapies, their clinical condition and history, the progression or stages of the patient’s illness and recovery, and available resources.

In clinical practice, the particular is examined in relation to the established generalizations of science. With readily available summaries of scientific evidence (e.g., systematic reviews and practice guidelines) available to nurses and physicians, one might wonder whether deep background understanding is still advantageous. Might it not be expendable, since it is likely to be out of date given the current scientific evidence? But this assumption is a false opposition and false choice because without a deep background understanding, the clinician does not know how to best find and evaluate scientific evidence for the particular case in hand. The clinician’s sense of salience in any given situation depends on past clinical experience and current scientific evidence.

Evidence-Based Practice

The concept of evidence-based practice is dependent upon synthesizing evidence from the variety of sources and applying it appropriately to the care needs of populations and individuals. This implies that evidence-based practice, indicative of expertise in practice, appropriately applies evidence to the specific situations and unique needs of patients. 88 , 89 Unfortunately, even though providing evidence-based care is an essential component of health care quality, it is well known that evidence-based practices are not used consistently.

Conceptually, evidence used in practice advances clinical knowledge, and that knowledge supports independent clinical decisions in the best interest of the patient. 90 , 91 Decisions must prudently consider the factors not necessarily addressed in the guideline, such as the patient’s lifestyle, drug sensitivities and allergies, and comorbidities. Nurses who want to improve the quality and safety of care can do so though improving the consistency of data and information interpretation inherent in evidence-based practice.

Initially, before evidence-based practice can begin, there needs to be an accurate clinical judgment of patient responses and needs. In the course of providing care, with careful consideration of patient safety and quality care, clinicians must give attention to the patient’s condition, their responses to health care interventions, and potential adverse reactions or events that could harm the patient. Nonetheless, there is wide variation in the ability of nurses to accurately interpret patient responses 92 and their risks. 93 Even though variance in interpretation is expected, nurses are obligated to continually improve their skills to ensure that patients receive quality care safely. 94 Patients are vulnerable to the actions and experience of their clinicians, which are inextricably linked to the quality of care patients have access to and subsequently receive.

The judgment of the patient’s condition determines subsequent interventions and patient outcomes. Attaining accurate and consistent interpretations of patient data and information is difficult because each piece can have different meanings, and interpretations are influenced by previous experiences. 95 Nurses use knowledge from clinical experience 96 , 97 and—although infrequently—research. 98–100

Once a problem has been identified, using a process that utilizes critical thinking to recognize the problem, the clinician then searches for and evaluates the research evidence 101 and evaluates potential discrepancies. The process of using evidence in practice involves “a problem-solving approach that incorporates the best available scientific evidence, clinicians’ expertise, and patient’s preferences and values” 102 (p. 28). Yet many nurses do not perceive that they have the education, tools, or resources to use evidence appropriately in practice. 103

Reported barriers to using research in practice have included difficulty in understanding the applicability and the complexity of research findings, failure of researchers to put findings into the clinical context, lack of skills in how to use research in practice, 104 , 105 amount of time required to access information and determine practice implications, 105–107 lack of organizational support to make changes and/or use in practice, 104 , 97 , 105 , 107 and lack of confidence in one’s ability to critically evaluate clinical evidence. 108

When Evidence Is Missing

In many clinical situations, there may be no clear guidelines and few or even no relevant clinical trials to guide decisionmaking. In these cases, the latest basic science about cellular and genomic functioning may be the most relevant science, or by default, guestimation. Consequently, good patient care requires more than a straightforward, unequivocal application of scientific evidence. The clinician must be able to draw on a good understanding of basic sciences, as well as guidelines derived from aggregated data and information from research investigations.

Practical knowledge is shaped by one’s practice discipline and the science and technology relevant to the situation at hand. But scientific, formal, discipline-specific knowledge are not sufficient for good clinical practice, whether the discipline be law, medicine, nursing, teaching, or social work. Practitioners still have to learn how to discern generalizable scientific knowledge, know how to use scientific knowledge in practical situations, discern what scientific evidence/knowledge is relevant, assess how the particular patient’s situation differs from the general scientific understanding, and recognize the complexity of care delivery—a process that is complex, ongoing, and changing, as new evidence can overturn old.

Practice communities like individual practitioners may also be mistaken, as is illustrated by variability in practice styles and practice outcomes across hospitals and regions in the United States. This variability in practice is why practitioners must learn to critically evaluate their practice and continually improve their practice over time. The goal is to create a living self-improving tradition.

Within health care, students, scientists, and practitioners are challenged to learn and use different modes of thinking when they are conflated under one term or rubric, using the best-suited thinking strategies for taking into consideration the purposes and the ends of the reasoning. Learning to be an effective, safe nurse or physician requires not only technical expertise, but also the ability to form helping relationships and engage in practical ethical and clinical reasoning. 50 Good ethical comportment requires that both the clinician and the scientist take into account the notions of good inherent in clinical and scientific practices. The notions of good clinical practice must include the relevant significance and the human concerns involved in decisionmaking in particular situations, centered on clinical grasp and clinical forethought.

The Three Apprenticeships of Professional Education

We have much to learn in comparing the pedagogies of formation across the professions, such as is being done currently by the Carnegie Foundation for the Advancement of Teaching. The Carnegie Foundation’s broad research program on the educational preparation of the profession focuses on three essential apprenticeships:

To capture the full range of crucial dimensions in professional education, we developed the idea of a three-fold apprenticeship: (1) intellectual training to learn the academic knowledge base and the capacity to think in ways important to the profession; (2) a skill-based apprenticeship of practice; and (3) an apprenticeship to the ethical standards, social roles, and responsibilities of the profession, through which the novice is introduced to the meaning of an integrated practice of all dimensions of the profession, grounded in the profession’s fundamental purposes. 109

This framework has allowed the investigators to describe tensions and shortfalls as well as strengths of widespread teaching practices, especially at articulation points among these dimensions of professional training.

Research has demonstrated that these three apprenticeships are taught best when they are integrated so that the intellectual training includes skilled know-how, clinical judgment, and ethical comportment. In the study of nursing, exemplary classroom and clinical teachers were found who do integrate the three apprenticeships in all of their teaching, as exemplified by the following anonymous student’s comments:

With that as well, I enjoyed the class just because I do have clinical experience in my background and I enjoyed it because it took those practical applications and the knowledge from pathophysiology and pharmacology, and all the other classes, and it tied it into the actual aspects of like what is going to happen at work. For example, I work in the emergency room and question: Why am I doing this procedure for this particular patient? Beforehand, when I was just a tech and I wasn’t going to school, I’d be doing it because I was told to be doing it—or I’d be doing CPR because, you know, the doc said, start CPR. I really enjoy the Care and Illness because now I know the process, the pathophysiological process of why I’m doing it and the clinical reasons of why they’re making the decisions, and the prioritization that goes on behind it. I think that’s the biggest point. Clinical experience is good, but not everybody has it. Yet when these students transition from school and clinicals to their job as a nurse, they will understand what’s going on and why.

The three apprenticeships are equally relevant and intertwined. In the Carnegie National Study of Nursing Education and the companion study on medical education as well as in cross-professional comparisons, teaching that gives an integrated access to professional practice is being examined. Once the three apprenticeships are separated, it is difficult to reintegrate them. The investigators are encouraged by teaching strategies that integrate the latest scientific knowledge and relevant clinical evidence with clinical reasoning about particular patients in unfolding rather than static cases, while keeping the patient and family experience and concerns relevant to clinical concerns and reasoning.

Clinical judgment or phronesis is required to evaluate and integrate techne and scientific evidence.

Within nursing, professional practice is wise and effective usually to the extent that the professional creates relational and communication contexts where clients/patients can be open and trusting. Effectiveness depends upon mutual influence between patient and practitioner, student and learner. This is another way in which clinical knowledge is dialogical and socially distributed. The following articulation of practical reasoning in nursing illustrates the social, dialogical nature of clinical reasoning and addresses the centrality of perception and understanding to good clinical reasoning, judgment and intervention.

Clinical Grasp *

Clinical grasp describes clinical inquiry in action. Clinical grasp begins with perception and includes problem identification and clinical judgment across time about the particular transitions of particular patients. Garrett Chan 20 described the clinician’s attempt at finding an “optimal grasp” or vantage point of understanding. Four aspects of clinical grasp, which are described in the following paragraphs, include (1) making qualitative distinctions, (2) engaging in detective work, (3) recognizing changing relevance, and (4) developing clinical knowledge in specific patient populations.

Making Qualitative Distinctions

Qualitative distinctions refer to those distinctions that can be made only in a particular contextual or historical situation. The context and sequence of events are essential for making qualitative distinctions; therefore, the clinician must pay attention to transitions in the situation and judgment. Many qualitative distinctions can be made only by observing differences through touch, sound, or sight, such as the qualities of a wound, skin turgor, color, capillary refill, or the engagement and energy level of the patient. Another example is assessing whether the patient was more fatigued after ambulating to the bathroom or from lack of sleep. Likewise the quality of the clinician’s touch is distinct as in offering reassurance, putting pressure on a bleeding wound, and so on. 110

Engaging in Detective Work, Modus Operandi Thinking, and Clinical Puzzle Solving

Clinical situations are open ended and underdetermined. Modus operandi thinking keeps track of the particular patient, the way the illness unfolds, the meanings of the patient’s responses as they have occurred in the particular time sequence. Modus operandi thinking requires keeping track of what has been tried and what has or has not worked with the patient. In this kind of reasoning-in-transition, gains and losses of understanding are noticed and adjustments in the problem approach are made.

We found that teachers in a medical surgical unit at the University of Washington deliberately teach their students to engage in “detective work.” Students are given the daily clinical assignment of “sleuthing” for undetected drug incompatibilities, questionable drug dosages, and unnoticed signs and symptoms. For example, one student noted that an unusual dosage of a heart medication was being given to a patient who did not have heart disease. The student first asked her teacher about the unusually high dosage. The teacher, in turn, asked the student whether she had asked the nurse or the patient about the dosage. Upon the student’s questioning, the nurse did not know why the patient was receiving the high dosage and assumed the drug was for heart disease. The patient’s staff nurse had not questioned the order. When the student asked the patient, the student found that the medication was being given for tremors and that the patient and the doctor had titrated the dosage for control of the tremors. This deliberate approach to teaching detective work, or modus operandi thinking, has characteristics of “critical reflection,” but stays situated and engaged, ferreting out the immediate history and unfolding of events.

Recognizing Changing Clinical Relevance

The meanings of signs and symptoms are changed by sequencing and history. The patient’s mental status, color, or pain level may continue to deteriorate or get better. The direction, implication, and consequences for the changes alter the relevance of the particular facts in the situation. The changing relevance entailed in a patient transitioning from primarily curative care to primarily palliative care is a dramatic example, where symptoms literally take on new meanings and require new treatments.

Developing Clinical Knowledge in Specific Patient Populations

Extensive experience with a specific patient population or patients with particular injuries or diseases allows the clinician to develop comparisons, distinctions, and nuanced differences within the population. The comparisons between many specific patients create a matrix of comparisons for clinicians, as well as a tacit, background set of expectations that create population- and patient-specific detective work if a patient does not meet the usual, predictable transitions in recovery. What is in the background and foreground of the clinician’s attention shifts as predictable changes in the patient’s condition occurs, such as is seen in recovering from heart surgery or progressing through the predictable stages of labor and delivery. Over time, the clinician develops a deep background understanding that allows for expert diagnostic and interventions skills.

Clinical Forethought

Clinical forethought is intertwined with clinical grasp, but it is much more deliberate and even routinized than clinical grasp. Clinical forethought is a pervasive habit of thought and action in nursing practice, and also in medicine, as clinicians think about disease and recovery trajectories and the implications of these changes for treatment. Clinical forethought plays a role in clinical grasp because it structures the practical logic of clinicians. At least four habits of thought and action are evident in what we are calling clinical forethought: (1) future think, (2) clinical forethought about specific patient populations, (3) anticipation of risks for particular patients, and (4) seeing the unexpected.

Future think

Future think is the broadest category of this logic of practice. Anticipating likely immediate futures helps the clinician make good plans and decisions about preparing the environment so that responding rapidly to changes in the patient is possible. Without a sense of salience about anticipated signs and symptoms and preparing the environment, essential clinical judgments and timely interventions would be impossible in the typically fast pace of acute and intensive patient care. Future think governs the style and content of the nurse’s attentiveness to the patient. Whether in a fast-paced care environment or a slower-paced rehabilitation setting, thinking and acting with anticipated futures guide clinical thinking and judgment. Future think captures the way judgment is suspended in a predictive net of anticipation and preparing oneself and the environment for a range of potential events.

Clinical forethought about specific diagnoses and injuries

This habit of thought and action is so second nature to the experienced nurse that the new or inexperienced nurse may have difficulty finding out about what seems to other colleagues as “obvious” preparation for particular patients and situations. Clinical forethought involves much local specific knowledge about who is a good resource and how to marshal support services and equipment for particular patients.

Examples of preparing for specific patient populations are pervasive, such as anticipating the need for a pacemaker during surgery and having the equipment assembled ready for use to save essential time. Another example includes forecasting an accident victim’s potential injuries, and recognizing that intubation might be needed.

Anticipation of crises, risks, and vulnerabilities for particular patients

This aspect of clinical forethought is central to knowing the particular patient, family, or community. Nurses situate the patient’s problems almost like a topography of possibilities. This vital clinical knowledge needs to be communicated to other caregivers and across care borders. Clinical teaching could be improved by enriching curricula with narrative examples from actual practice, and by helping students recognize commonly occurring clinical situations in the simulation and clinical setting. For example, if a patient is hemodynamically unstable, then managing life-sustaining physiologic functions will be a main orienting goal. If the patient is agitated and uncomfortable, then attending to comfort needs in relation to hemodynamics will be a priority. Providing comfort measures turns out to be a central background practice for making clinical judgments and contains within it much judgment and experiential learning.

When clinical teaching is too removed from typical contingencies and strong clinical situations in practice, students will lack practice in active thinking-in-action in ambiguous clinical situations. In the following example, an anonymous student recounted her experiences of meeting a patient:

I was used to different equipment and didn’t know how things went, didn’t know their routine, really. You can explain all you want in class, this is how it’s going to be, but when you get there … . Kim was my first instructor and my patient that she assigned me to—I walked into the room and he had every tube imaginable. And so I was a little overwhelmed. It’s not necessarily even that he was that critical … . She asked what tubes here have you seen? Well, I know peripheral lines. You taught me PICC [peripherally inserted central catheter] lines, and we just had that, but I don’t really feel comfortable doing it by myself, without you watching to make sure that I’m flushing it right and how to assess it. He had a chest tube and I had seen chest tubes, but never really knew the depth of what you had to assess and how you make sure that it’s all kosher and whatever. So she went through the chest tube and explained, it’s just bubbling a little bit and that’s okay. The site, check the site. The site looked okay and that she’d say if it wasn’t okay, this is what it might look like … . He had a feeding tube. I had done feeding tubes but that was like a long time ago in my LPN experiences schooling. So I hadn’t really done too much with the feeding stuff either … . He had a [nasogastric] tube, and knew pretty much about that and I think at the time it was clamped. So there were no issues with the suction or whatever. He had a Foley catheter. He had a feeding tube, a chest tube. I can’t even remember but there were a lot.

As noted earlier, a central characteristic of a practice discipline is that a self-improving practice requires ongoing experiential learning. One way nurse educators can enhance clinical inquiry is by increasing pedagogies of experiential learning. Current pedagogies for experiential learning in nursing include extensive preclinical study, care planning, and shared postclinical debriefings where students share their experiential learning with their classmates. Experiential learning requires open learning climates where students can discuss and examine transitions in understanding, including their false starts, or their misconceptions in actual clinical situations. Nursing educators typically develop open and interactive clinical learning communities, so that students seem committed to helping their classmates learn from their experiences that may have been difficult or even unsafe. One anonymous nurse educator described how students extend their experiential learning to their classmates during a postclinical conference:

So for example, the patient had difficulty breathing and the student wanted to give the meds instead of addressing the difficulty of breathing. Well, while we were sharing information about their patients, what they did that day, I didn’t tell the student to say this, but she said, ‘I just want to tell you what I did today in clinical so you don’t do the same thing, and here’s what happened.’ Everybody’s listening very attentively and they were asking her some questions. But she shared that. She didn’t have to. I didn’t tell her, you must share that in postconference or anything like that, but she just went ahead and shared that, I guess, to reinforce what she had learned that day but also to benefit her fellow students in case that thing comes up with them.

The teacher’s response to this student’s honesty and generosity exemplifies her own approach to developing an open community of learning. Focusing only on performance and on “being correct” prevents learning from breakdown or error and can dampen students’ curiosity and courage to learn experientially.

Seeing the unexpected

One of the keys to becoming an expert practitioner lies in how the person holds past experiential learning and background habitual skills and practices. This is a skill of foregrounding attention accurately and effectively in response to the nature of situational demands. Bourdieu 29 calls the recognition of the situation central to practical reasoning. If nothing is routinized as a habitual response pattern, then practitioners will not function effectively in emergencies. Unexpected occurrences may be overlooked. However, if expectations are held rigidly, then subtle changes from the usual will be missed, and habitual, rote responses will inappropriately rule. The clinician must be flexible in shifting between what is in background and foreground. This is accomplished by staying curious and open. The clinical “certainty” associated with perceptual grasp is distinct from the kind of “certainty” achievable in scientific experiments and through measurements. Recognition of similar or paradigmatic clinical situations is similar to “face recognition” or recognition of “family resemblances.” This concept is subject to faulty memory, false associative memories, and mistaken identities; therefore, such perceptual grasp is the beginning of curiosity and inquiry and not the end. Assessment and validation are required. In rapidly moving clinical situations, perceptual grasp is the starting point for clarification, confirmation, and action. Having the clinician say out loud how he or she is understanding the situation gives an opportunity for confirmation and disconfirmation from other clinicians present. 111 The relationship between foreground and background of attention needs to be fluid, so that missed expectations allow the nurse to see the unexpected. For example, when the background rhythm of a cardiac monitor changes, the nurse notices, and what had been background tacit awareness becomes the foreground of attention. A hallmark of expertise is the ability to notice the unexpected. 20 Background expectations of usual patient trajectories form with experience. Tacit expectations for patient trajectories form that enable the nurse to notice subtle failed expectations and pay attention to early signs of unexpected changes in the patient's condition. Clinical expectations gained from caring for similar patient populations form a tacit clinical forethought that enable the experienced clinician to notice missed expectations. Alterations from implicit or explicit expectations set the stage for experiential learning, depending on the openness of the learner.

Learning to provide safe and quality health care requires technical expertise, the ability to think critically, experience, and clinical judgment. The high-performance expectation of nurses is dependent upon the nurses’ continual learning, professional accountability, independent and interdependent decisionmaking, and creative problem-solving abilities.

This section of the paper was condensed and paraphrased from Benner, Hooper-Kyriakidis, and Stannard. 23 Patricia Hooper-Kyriakidis wrote the section on clinical grasp, and Patricia Benner wrote the section on clinical forethought.

• Cite this Page Benner P, Hughes RG, Sutphen M. Clinical Reasoning, Decisionmaking, and Action: Thinking Critically and Clinically. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 6.
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5.3: Using Critical Thinking Skills- Decision Making and Problem Solving

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Introduction

In previous lessons, you learned about characteristics of critical thinkers and information literacy. In this module, you will learn how to put those skills into action through the important processes of decision making and problem solving.

As with the process of developing information literacy, asking questions is an important part of decision making and problem solving. Thinking is born of questions. Questions wake us up. Questions alert us to hidden assumptions. Questions promote curiosity and create new distinctions. Questions open up options that otherwise go unexplored. Besides, teachers love questions.

We make decisions all the time, whether we realize it or not. Even avoiding decisions is a form of decision making. The student who puts off studying for a test until the last minute, for example, might really be saying, “I’ve decided this course is not important” or “I’ve decided not to give this course much time.”

Decisions are specific and lead to focused action. When we decide, we narrow down. We give up actions that are inconsistent with our decision.

In addition to decision making, critical thinking skills are important to solving problems. We encounter problems every single day, and having a solid process in place is important to solving them.

At the end of the lesson, you will learn how to put your critical thinking skills to use by reviewing an example of how critical thinking skills can help with making those everyday decisions.

Using Critical Thinking Skills: Asking Questions

Questions have practical power. Asking for directions can shave hours off a trip. Asking a librarian for help can save hours of research time. Asking how to address an instructor—by first name or formal title—can change your relationship with that person. Asking your academic advisor a question can alter your entire education. Asking people about their career plans can alter your career plans.

You can use the following strategies to develop questions for problem solving and decision making:

Ask questions that create possibilities. At any moment, you can ask a question that opens up a new possibility for someone.

• Suppose a friend walks up to you and says, “People just never listen to me.” You listen carefully. Then you say, “Let me make sure I understand. Who, specifically, doesn’t listen to you? And how do you know they’re not listening?”
• Another friend tells you, “I just lost my job to someone who has less experience. That should never happen.” You respond, “Wow, that’s hard. I’m sorry you lost your job. Who can help you find another job?”
• A relative seeks your advice. “My mother-in-law makes me mad,” she says. “You’re having a hard time with this person,” you say. “What does she say and do when you feel mad at her? And are there times when you don’t get mad at her?”

These kinds of questions—asked with compassion and a sense of timing—can help people move from complaining about problems to solving them.

Discover new questions. Students sometimes say, “I don’t know what questions to ask.” Consider the following ways to create questions about any subject you want to study or about any

area of your life that you want to change:

• Let your pen start moving. Sometimes you can access a deeper level of knowledge by taking out your pen, putting it on a piece of paper, and writing down questions—even before you know what to write. Don’t think. Just watch the pen move across the paper. Notice what appears. The results might be surprising.
• Ask about what’s missing . Another way to invent useful questions is to notice what’s missing from your life and then ask how to supply it. For example, if you want to take better notes, you can write, “What’s missing is skill in note taking. How can I gain more skill in taking notes?” If you always feel rushed, you can write, “What’s missing is time. How do I create enough time in my day to actually do the things that I say I want to do?”
• Pretend to be someone else. Another way to invent questions is first to think of someone you greatly respect. Then pretend you’re that person. Ask the questions you think she would ask.
• What can I do when ... an instructor calls on me in class and I have no idea what to say? When a teacher doesn’t show up for class on time? When I feel overwhelmed with assignments?
• How can I ... take the kind of courses that I want? Expand my career options? Become much more effective as a student, starting today?
• When do I ... decide on a major? Transfer to another school? Meet with an instructor to discuss an upcoming term paper?
• What else do I want to know about ... my academic plan? My career plan? My options for job hunting? My friends? My relatives? My spouse?
• Who can I ask about ... my career options? My major? My love life? My values and purpose in life?

Many times you can quickly generate questions by simply asking yourself, “What else do I want to know?” Ask this question immediately after you read a paragraph in a book or listen to someone speak.

Start from the assumption that you are brilliant. Then ask questions to unlock your brilliance.

Using Critical Thinking Skills in Decision Making

As you develop your critical thinking skills, you can apply them as you make decisions. The following suggestions can help in your decision-making process:

Recognize decisions. Decisions are more than wishes or desires. There’s a world of difference between “I wish I could be a better student” and “I will take more powerful notes, read with greater retention, and review my class notes daily.” Deciding to eat fruit for dessert instead of ice cream rules out the next trip to the ice cream store.

Establish priorities. Some decisions are trivial. No matter what the outcome, your life is not affected much. Other decisions can shape your circumstances for years. Devote more time and energy to the decisions with big outcomes.

Base decisions on a life plan. The benefit of having long-term goals for our lives is that they provide a basis for many of our daily decisions. Being certain about what we want to accomplish this year and this month makes today’s choices more clear.

Balance learning styles in decision making. To make decisions more effectively, use all four modes of learning explained in a previous lesson. The key is to balance reflection with action, and thinking with experience. First, take the time to think creatively, and generate many options. Then think critically about the possible consequences of each option before choosing one. Remember, however, that thinking is no substitute for experience. Act on your chosen option, and notice what happens. If you’re not getting the results you want, then quickly return to creative thinking to invent new options.

Choose an overall strategy. Every time you make a decision, you choose a strategy—even when you’re not aware of it. Effective decision makers can articulate and choose from among several strategies. For example:

• Find all of the available options, and choose one deliberately. Save this strategy for times when you have a relatively small number of options, each of which leads to noticeably different results.
• Find all of the available options, and choose one randomly. This strategy can be risky. Save it for times when your options are basically similar and fairness is the main issue.
• Limit the options, and then choose. When deciding which search engine to use, visit many search sites and then narrow the list down to two or three from which to choose.

Use time as an ally. Sometimes we face dilemmas—situations in which any course of action leads to undesirable consequences. In such cases, consider putting a decision on hold. Wait it out. Do nothing until the circumstances change, making one alternative clearly preferable to another.

Use intuition. Some decisions seem to make themselves. A solution pops into your mind, and you gain newfound clarity. Using intuition is not the same as forgetting about the decision or refusing to make it. Intuitive decisions usually arrive after we’ve gathered the relevant facts and faced a problem for some time.

Evaluate your decision. Hindsight is a source of insight. After you act on a decision, observe the consequences over time. Reflect on how well your decision worked and what you might have done differently.

Think of choices. This final suggestion involves some creative thinking. Consider that the word decide derives from the same roots as suicide and homicide . In the spirit of those words, a decision forever “kills” all other options. That’s kind of heavy. Instead, use the word choice , and see whether it frees up your thinking. When you choose , you express a preference for one option over others. However, those options remain live possibilities for the future. Choose for today, knowing that as you gain more wisdom and experience, you can choose again.

Using Critical Thinking Skills in Problem Solving

Think of problem solving as a process with four Ps : Define the problem , generate possibilities ,

create a plan , and perform your plan.

Step 1: Define the problem. To define a problem effectively, understand what a problem is—a mismatch between what you want and what you have. Problem solving is all about reducing the gap between these two factors.

Tell the truth about what’s present in your life right now, without shame or blame. For example: “I often get sleepy while reading my physics assignments, and after closing the book I cannot remember what I just read.”

Next, describe in detail what you want. Go for specifics: “I want to remain alert as I read about physics. I also want to accurately summarize each chapter I read.”

Remember that when we define a problem in limiting ways, our solutions merely generate new problems. As Albert Einstein said, “The world we have made is a result of the level of thinking we have done thus far. We cannot solve problems at the same level at which we created them” (Calaprice 2000).

This idea has many applications for success in school. An example is the student who struggles with note taking. The problem, she thinks, is that her notes are too sketchy. The logical solution, she decides, is to take more notes; her new goal is to write down almost everything her instructors say. No matter how fast and furiously she writes, she cannot capture all of the instructors’ comments.

Consider what happens when this student defines the problem in a new way. After more thought, she decides that her dilemma is not the quantity of her notes but their quality . She adopts a new format for taking notes, dividing her notepaper into two columns. In the right-hand column, she writes down only the main points of each lecture. In the left-hand column, she notes two or three supporting details for each point.

Over time, this student makes the joyous discovery that there are usually just three or four core ideas to remember from each lecture. She originally thought the solution was to take more notes. What really worked was taking notes in a new way.

Step 2: Generate possibilities. Now put on your creative thinking hat. Open up. Brainstorm as many possible solutions to the problem as you can. At this stage, quantity counts. As you generate possibilities, gather relevant facts. For example, when you’re faced with a dilemma about what courses to take next semester, get information on class times, locations, and instructors. If you haven’t decided which summer job offer to accept, gather information on salary, benefits, and working conditions.

Step 3: Create a plan. After rereading your problem definition and list of possible solutions, choose the solution that seems most workable. Think about specific actions that will reduce the gap between what you have and what you want. Visualize the steps you will take to make this solution a reality, and arrange them in chronological order. To make your plan even more powerful, put it in writing.

Step 4: Perform your plan. This step gets you off your chair and out into the world. Now you actually do what you have planned.

Ultimately, your skill in solving problems lies in how well you perform your plan. Through the quality of your actions, you become the architect of your own success.

When facing problems, experiment with these four Ps, and remember that the order of steps is not absolute. Also remember that any solution has the potential to create new problems. If that happens, cycle through the four Ps of problem solving again.

Critical Thinking Skills in Action: Thinking About Your Major, Part 1

One decision that troubles many students in higher education is the choice of a major. Weighing the benefits, costs, and outcomes of a possible major is an intellectual challenge. This choice is an opportunity to apply your critical thinking, decision-making, and problem-solving skills. The following suggestions will guide you through this seemingly overwhelming process.

The first step is to discover options. You can use the following suggestions to discover options for choosing your major:

Follow the fun. Perhaps you look forward to attending one of your classes and even like completing the assignments. This is a clue to your choice of major.

See whether you can find lasting patterns in the subjects and extracurricular activities that you’ve enjoyed over the years. Look for a major that allows you to continue and expand on these experiences.

Also, sit down with a stack of 3 × 5 cards and brainstorm answers to the following questions:

• What do you enjoy doing most with your unscheduled time?
• Imagine that you’re at a party and having a fascinating conversation. What is this conversation about?
• What kind of problems do you enjoy solving—those that involve people? Products? Ideas?
• What interests are revealed by your choices of reading material, television shows, and other entertainment?
• What would an ideal day look like for you? Describe where you would live, who would be with you, and what you would do throughout the day. Do any of these visions suggest a possible major?

Questions like these can uncover a “fun factor” that energizes you to finish the work of completing a major.

Consider your abilities. In choosing a major, ability counts as much as interest. In addition to considering what you enjoy, think about times and places when you excelled. List the courses that you aced, the work assignments that you mastered, and the hobbies that led to rewards or recognition. Let your choice of a major reflect a discovery of your passions and potentials.

Use formal techniques for self-discovery. Explore questionnaires and inventories that are designed to correlate your interests with specific majors. Examples include the Strong Interest Inventory and the Self-Directed Search. Your academic advisor or someone in your school’s career planning office can give you more details about these and related assessments. For some fun, take several of them and meet with an advisor to interpret the results. Remember inventories can help you gain self-knowledge, and other people can offer valuable perspectives. However, what you do with all this input is entirely up to you.

Critical Thinking Skills in Action: Thinking About Your Major, Part 2

As you review the following additional suggestions of discovering options, think about what strategies you already use in your own decision-making process. Also think about what new strategies you might try in the future.

Link to long-term goals. Your choice of a major can fall into place once you determine what you want in life. Before you choose a major, back up to a bigger picture. List your core values, such as contributing to society, achieving financial security and professional recognition, enjoying good health, or making time for fun. Also write down specific goals that you want to accomplish 5 years, 10 years, or even 50 years from today.

Many students find that the prospect of getting what they want in life justifies all of the time, money, and day-to-day effort invested in going to school. Having a major gives you a powerful incentive for attending classes, taking part in discussions, reading textbooks, writing papers, and completing other assignments. When you see a clear connection between finishing school and creating the life of your dreams, the daily tasks of higher education become charged with meaning.

Ask other people. Key people in your life might have valuable suggestions about your choice of major. Ask for their ideas, and listen with an open mind. At the same time, distance yourself from any pressure to choose a major or career that fails to interest you. If you make a choice solely on the basis of the expectations of other people, you could end up with a major or even a career you don’t enjoy.

Gather information. Check your school’s catalog or website for a list of available majors. Here is a gold mine of information. Take a quick glance, and highlight all the majors that interest you. Then talk to students who have declared these majors. Also read the descriptions of courses required for these majors. Do you get excited about the chance to enroll in them? Pay attention to your gut feelings.

Also chat with instructors who teach courses in a specific major. Ask for copies of their class syllabi. Go to the bookstore and browse the required texts. Based on all of this information, write a list of prospective majors. Discuss them with an academic advisor and someone at your school’s career-planning center.

Invent a major. When choosing a major, you might not need to limit yourself to those listed in your school catalog. Many schools now have flexible programs that allow for independent study. Through such programs, you might be able to combine two existing majors or invent an entirely new one of your own.

Consider a complementary minor. You can add flexibility to your academic program by choosing a minor to complement or contrast with your major. The student who wants to be a minister could opt for a minor in English; all of those courses in composition can help in writing sermons. Or the student with a major in psychology might choose a minor in business administration, with the idea of managing a counseling service some day. An effective choice of a minor can expand your skills and career options.

Think critically about the link between your major and your career. Your career goals might have a significant impact on your choice of major.

You could pursue a rewarding career by choosing among several different majors. Even students planning to apply for law school or medical school have flexibility in their choice of majors. In addition, after graduation, many people tend to be employed in jobs that have little relationship to their major. And you might choose a career in the future that is unrelated to any currently available major.

Critical Thinking Skills in Action: Thinking About Your Major, Part 3

Once you have discovered all of your options, you can move on to the next step in the process— making a trial choice.

Make a Trial Choice

Pretend that you have to choose a major today. Based on the options for a major that you’ve already discovered, write down the first three ideas that come to mind. Review the list for a few minutes, and then choose one.

Evaluate Your Trial Choice

When you’ve made a trial choice of major, take on the role of a scientist. Treat your choice as a hypothesis, and then design a series of experiments to evaluate and test it. For example:

• Schedule office meetings with instructors who teach courses in the major. Ask about required course work and career options in the field.
• Discuss your trial choice with an academic advisor or career counselor.
• Enroll in a course related to your possible major. Remember that introductory courses might not give you a realistic picture of the workload involved in advanced courses. Also, you might not be able to register for certain courses until you’ve actually declared a related major.
• Find a volunteer experience, internship, part-time job, or service-learning experience related to the major.
• Interview students who have declared the same major. Ask them in detail about their experiences and suggestions for success.
• Interview people who work in a field related to the major and “shadow” them—that is, spend time with those people during their workday.
• Think about whether you can complete your major given the amount of time and money that you plan to invest in higher education.
• Consider whether declaring this major would require a transfer to another program or even another school.

If your “experiments” confirm your choice of major, celebrate that fact. If they result in choosing a new major, celebrate that outcome as well.

Also remember that higher education represents a safe place to test your choice of major—and to change your mind. As you sort through your options, help is always available from administrators, instructors, advisors, and peers.

Choose Again

Keep your choice of a major in perspective. There is probably no single “correct” choice. Your unique collection of skills is likely to provide the basis for majoring in several fields.

Odds are that you’ll change your major at least once—and that you’ll change careers several times during your life. One benefit of higher education is mobility. You gain the general skills and knowledge that can help you move into a new major or career field at any time.

Viewing a major as a one-time choice that determines your entire future can raise your stress levels. Instead, look at choosing a major as the start of a continuing path that involves discovery, choice, and passionate action.

As you review this example of how you can use critical thinking to make a decision about choosing your major, think about how you will use your critical thinking to make decisions and solve problems in the future.

• Critical Thinking and Decision Making

In this Critical Thinking module delegates discover that, with increased responsibility in an ever-changing world, they will need a toolkit to become more naturally empowered to form a sound judgement and make good decisions.

The key to this module is taking the most complex of subjects and making them simple. In just a few moves delegates will be able to cut through the fog and clearly see the problem, ask the right questions and make informed decisions from a simple trilogy of answers, helping you to form better judgements and decisions, both individually and collectively.

Who is it for?

Managers and any individual who is part of the decision-making process.

Course Objectives:

By the end of this programme, participants will be able to:

• Understand how individual and organisational character drive our reasoning and
• Improve ‘Judgement & Decision Making’ to drive the organization forward
• Learn how to influence others effectively and make good team decisions

Course Content:

• The Chemistry of Change
• The change curve – organizational and personal effects
• Problem and critical analysis
• Judgement and decision-making criteria – priorities and preferences
• Power of influence – taking people with you
• Actions, Summary & Close

Indicative Duration:

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