medical term of critical thinking

Medical Student Guide For Critical Thinking

Critical thinking is an essential cognitive skill for every individual but is a crucial component for healthcare professionals such as doctors, nurses and dentists. It is a skill that should be developed and trained, not just during your career as a doctor, but before that when you are still a medical student.

To be more effective in their studies, students must think their way through abstract problems, work in teams and separate high quality from low quality information. These are the same qualities that today's medical students are supposed to possess regardless of whether they graduate in the UK or study medicine in Europe .

In both well-defined and ill-defined medical emergencies, doctors are expected to make competent decisions. Critical thinking can help medical students and doctors achieve improved productivity, better clinical decision making, higher grades and much more.

This article will explain why critical thinking is a must for people in the medical field.

Definition of Critical Thinking

You can find a variety of definitions of Critical Thinking (CT). It is a term that goes back to the Ancient Greek philosopher Socrates and his teaching practice and vision. Critical thinking and its meaning have changed over the years, but at its core always will be the pursuit of proper judgment.

We can agree on one thing. Critical thinkers question every idea, assumption, and possibility rather than accepting them at once.

The most basic definition of CT is provided by Beyer (1995):

"Critical thinking means making reasoned judgements."

In other words, it is the ability to think logically about what to do and/or believe. It also includes the ability to think critically and independently. CT is the process of identifying, analysing, and then making decisions about a particular topic, advice, opinion or challenge that we are facing.

Steps to critical thinking

There is no universal standard for becoming a critical thinker. It is more like a unique journey for each individual. But as a medical student, you have already so much going on in your academic and personal life. This is why we created a list with 6 steps that will help you develop the necessary skills for critical thinking.

1. Determine the issue or question

The first step is to answer the following questions:

What is the problem?
Why is it important?
Why do we need to find a solution?
Who is involved?

By answering them, you will define the situation and acquire a deeper understanding of the problem and of any factors that may impact it.

Only after you have a clear picture of the issue and people involved can you start to dive deeper into the problem and search for a solution.

2. Research

Nowadays, we are flooded with information. We have an unlimited source of knowledge – the Internet.

Before choosing which medical schools to apply to, most applicants researched their desired schools online. Some of the areas you might have researched include:

If the degree is recognised worldwide
Tuition fees
Living costs
Entry requirements
Competition for entry
Number of exams
Programme style

Having done the research, you were able to make an informed decision about your medical future based on the gathered information. Our list may be a little different to yours but that's okay. You know what factors are most important and relevant to you as a person.

The process you followed when choosing which medical school to apply to also applies to step 2 of critical thinking. As a medical student and doctor, you will face situations when you have to compare different arguments and opinions about an issue. Independent research is the key to the right clinical decisions. Medical and dentistry students have to be especially careful when learning from online sources. You shouldn't believe everything you read and take it as the absolute truth. So, here is what you need to do when facing a medical/study argument:

Gather relevant information from all available reputable sources
Pay attention to the salient points
Evaluate the quality of the information and the level of evidence (is it just an opinion, or is it based upon a clinical trial?)

Once you have all the information needed, you can start the process of analysing it. It’s helpful to write down the strong and weak points of the various recommendations and identify the most evidence-based approach.

Here is an example of a comparison between two online course platforms , which shows their respective strengths and weaknesses.

When recommendations or conclusions are contradictory, you will need to make a judgement call on which point of view has the strongest level of evidence to back it up. You should leave aside your feelings and analyse the problem from every angle possible. In the end, you should aim to make your decision based on the available evidence, not assumptions or bias.

4. Be careful about confirmation bias

It is in our nature to want to confirm our existing ideas rather than challenge them. You should try your best to strive for objectivity while evaluating information.

Often, you may find yourself reading articles that support your ideas, but why not broaden your horizons by learning about the other viewpoint?

By doing so, you will have the opportunity to get closer to the truth and may even find unexpected support and evidence for your conclusion.

Curiosity will keep you on the right path. However, if you find yourself searching for information or confirmation that aligns only with your opinion, then it’s important to take a step back. Take a short break, acknowledge your bias, clear your mind and start researching all over.

5. Synthesis

As we have already mentioned a couple of times, medical students are preoccupied with their studies. Therefore, you have to learn how to synthesise information. This is where you take information from multiple sources and bring the information together. Learning how to do this effectively will save you time and help you make better decisions faster.

You will have already located and evaluated your sources in the previous steps. You now have to organise the data into a logical argument that backs up your position on the problem under consideration.

6. Make a decision

Once you have gathered and evaluated all the available evidence, your last step is to make a logical and well-reasoned conclusion.

By following this process you will ensure that whatever decision you make can be backed up if challenged

Why is critical thinking so important for medical students?

The first and most important reason for mastering critical thinking is that it will help you to avoid medical and clinical errors during your studies and future medical career.

Another good reason is that you will be able to identify better alternative options for diagnoses and treatments. You will be able to find the best solution for the patient as a whole which may be different to generic advice specific to the disease.

Furthermore, thinking critically as a medical student will boost your confidence and improve your knowledge and understanding of subjects.

In conclusion, critical thinking is a skill that can be learned and improved. It will encourage you to be the best version of yourself and teach you to take responsibility for your actions.

Critical thinking has become an essential for future health care professionals and you will find it an invaluable skill throughout your career.

We’ll keep you updated

Science-Based Medicine

Exploring issues and controversies in the relationship between science and medicine

Critical Thinking in Medicine

Cognitive Errors and Diagnostic Mistakes is a superb new guide to critical thinking in medicine written by Jonathan Howard. It explains how our psychological foibles regularly bias and betray us, leading to diagnostic mistakes. Learning critical thinking skills is essential but difficult. Every known cognitive error is illustrated with memorable patient stories.

Rodin’s Thinker is doing his best to think but if he hasn’t learned critical thinking skills, he is likely to make mistakes. The human brain is prone to a multitude of cognitive errors.

Critical thinking in medicine is what the Science-Based Medicine ( SBM ) blog is all about. Jonathan Howard has written a superb book, Cognitive Errors and Diagnostic Mistakes: A Case-Based Guide to Critical Thinking in Medicine , that epitomizes the message of SBM . In fact, in the Acknowledgements, he credits the entire team at SBM for teaching him “an enormous amount about skepticism and critical thinking”, and he specifically thanks Steven Novella, Harriet Hall (moi!), and David Gorski.

Dr. Howard is a neurologist and psychiatrist at NYU and Bellevue Hospital. The book is a passionate defense of science and a devastating critique of Complementary and Alternative Medicine ( CAM ) and pseudoscience. Its case-based approach is a stroke of genius. We humans are story-tellers; we are far more impressed by stories than by studies or by textbook definitions of a disease. Dr. Howard points out that “Anecdotes are part of the very cognition that allows us to derive meaning from experience and turn noise into signal.” They are incredibly powerful from an emotional standpoint. That’s why he chose to begin every discussion of a cognitive error with a patient’s case, an anecdote.

CAM knows how effective this can be; that’s why it relies so heavily on anecdotes. When doctors think of a disease, they are likely to think of a memorable patient they treated with that disease, and that patient’s case is likely to bias their thinking about other patients with the same disease. If there is a bad outcome with a treatment, they will remember that and may reject that treatment for the next patient even if it is the most appropriate one. Dr. Howard uses patient stories to great advantage, first providing the bare facts of the case and then letting the patient’s doctors explain their thought processes so we can understand exactly where and why they went wrong. Then he goes on to explain the psychology behind the cognitive error, with study findings, other examples, and plentiful references. If readers remember these cases, they might avoid similar mishaps.

An encyclopedia of cognitive errors

The book is encyclopedic, running to 30 chapters and 588 pages. I can’t think of anything he failed to mention, and whenever an example or a quotation occurred to me, he had thought of it first and included it in the text. I couldn’t begin to list all the cognitive errors he covers, but they fall roughly into these six categories:

Errors of overattachment to a particular diagnosis
Errors due to failure to consider alternative diagnoses.
Errors due to inheriting someone else’s thinking.
Errors in prevalence perception or estimation.
Errors involving patient characteristics or presentation context.
Errors associated with physician affect, personality, or decision style.

A smattering of examples

There is so much information and wisdom in this book! I’ll try to whet your appetite with a few excerpts that particularly struck me.

Discussing an issue with others who disagree can help us avoid confirmation bias and groupthink.
Negative panic: when a group of people witness an emergency and fail to respond, thinking someone else will.
Reactance bias: doctors who object to conventional practices and want to feel independent may reject science and embrace pseudoscience.
Cyberchondria: using the Internet to interpret mundane symptoms as dire diagnoses.
Motivated reasoning: People who “know” they have chronic Lyme disease will fail to believe 10 negative Lyme tests in a row and then believe the 11 th test if it is positive.
The backfire effect: “encountering contradictory information can have the paradoxical effect of strengthening our initial belief rather than causing us to question it.”
Biases are easy to see in others but nearly impossible to detect in oneself.
Checklists for fake diseases take advantage of the Forer effect . As with horoscopes and cold readings, vague, nonspecific statements convince people that a specific truth about them is being revealed. Fake diseases are unfalsifiable: there is no way to rule them out.
When presenting risk/benefit data to patients, don’t present risk data first; it will act as an “anchor” to make them fixate on risk.
The doctor’s opinion of the patient will affect the quality of care.
Randomness is difficult to grasp. The hot hand and the gambler’s fallacy can both fool doctors. If the last two patients had disease X and this patient has similar symptoms, the doctor will think he probably has disease X too. Or if the doctor has just seen two cases of a rare disease, it will seem unlikely that the next patient with similar symptoms will have it too.
Apophenia : the tendency to perceive meaningful patterns with random information, like seeing the face on Mars.
Information bias: doctors tend to think the more information, the better. But tests are indicated only if they will help establish a diagnosis or alter management. They should not be ordered out of curiosity or to make the clinician feel better. Sometimes doctors don’t know what to do with the information from a test. This should be a lesson for doctors who practice so-called functional medicine : they order all kinds of nonstandard tests whose questionable results give no evidence-based guidance for treating the patient. Doctors should ask “How will this test alter my management?” and if they can’t answer, they shouldn’t order the test.
Once a treatment is started, it can be exceedingly difficult to stop. A study showed that 58% of medications could be stopped in elderly patients and only 2% had to be re-started.
Doctors feel obligated to “do something” for the patient, but sometimes the best course is to do nothing. “Just don’t do something, stand there.” At the end of their own life, 90% of doctors would refuse the treatments they routinely give to patients with terminal illnesses.
Incidentalomas: when a test reveals an unsuspected finding, it’s important to remember that abnormality doesn’t necessarily mean pathology or require treatment.
Fear of possible unknown long-term consequences may lead doctors to reject a treatment, but that should be weighed carefully against the well-known consequences of the disease itself.
It’s good for doctors to inform patients and let them participate in decisions, but too much information can overwhelm patients. He gives the example of a patient with multiple sclerosis whose doctor describes the effectiveness and risks of 8 injectables, 3 pills, and 4 infusions. The patient can’t choose; she misses the follow-up appointment and returns a year later with visual loss that might have been prevented.
Most patients don’t benefit from drugs; the NNT tells us the Number of patients who will Need to be Treated for one person to benefit.
Overconfidence bias: in the Dunning-Kruger effect, people think they know more than the experts about things like climate change, vaccines and evolution. Yet somehow these same people never question that experts know how to predict eclipses.
Patient satisfaction does not measure effectiveness of treatment. A study showed that the most satisfied patients were 12% more likely to be admitted to the hospital, had 9% higher prescription costs, and were 26% more likely to die.
The availability heuristic and the frequency illusion: “Clinicians should be aware that their experience is distorted by recent or memorable [cases], the experiences of their colleagues, and the news.” He repeats Mark Crislip’s aphorism that the three most dangerous words in medicine are “in my experience”.
Illusory truth: people are likely to believe a statement simply because they have heard it many times.
What makes an effective screening test? He covers concepts like lead time bias, length bias, and selection bias. Screening tests may do more harm than good. The PSA test is hardly better than a coin toss.
Blind spot bias: Everyone has blind spots; we recognize them in others but can’t see our own. Most doctors believe they won’t be influenced by gifts from drug companies, but they believe others are unconsciously biased by such gifts. Books like this can make things worse: they give us false confidence. “Being inclined to think that you can avoid a bias because you [are] aware of it is a bias in itself.”
He quotes from Contrived Platitudes: “Everything happens for a reason except when it doesn’t. But even then you can in hindsight fabricate a reason that will satisfy your belief system.” This is the essence of what CAM does, especially the versions that attribute all diseases to a single cause.

Some juicy quotes

Knowledge of bias should contribute to your humility, not your confidence.

Only by studying treatments in large, randomized, blinded, controlled trials can the efficacy of a treatment truly be measured.

When beliefs are based in emotion, facts alone stand little chance.

CAM , when not outright fraudulent, is nothing more than the triumph of cognitive biases over rationality and science.

Reason evolved primarily to win arguments, not to solve problems.

He includes a thorough discussion of the pros and cons of limiting doctors’ work hours, with factors most people have never considered, and a thorough discussion of financial motivations.

The book is profusely illustrated with pictures, diagrams, posters, and images from the Internet like “The Red Flags of Quackery” from sci-ence.org. Many famous quotations are presented with pictures of the person quoted, like Christopher Hitchens and his “What can be asserted without evidence can be dismissed without evidence”.

He never goes beyond the evidence. Rather than just giving study results, he tells the reader when other researchers have failed to replicate the findings.

We rely on scientific evidence, but researchers are not immune from bias. He describes the many ways research can go astray: 235 biases have been identified that can lead to erroneous results. As Ioannidis said, most published research findings are wrong. But all is not lost: people who understand statistics and the methodologies of science can usually distinguish a good study from a bad one.

He tells the infamous N-ray story. He covers the file drawer effect, publication bias, conflicts of interest, predatory journals, ghostwriting, citation plagiarism, retractions, measuring poor surrogates instead of meaningful clinical outcomes, and outright fraud. Andrew Wakefield features prominently. Dr. Howard’s discussions of p-hacking, multiple variables, random chance, and effect size are particularly valuable. HARKing is Hypothesizing After the Results are Known. It can be exploited to create erroneous results.

He tells a funny story that was new to me. Two scientists wrote a paper consisting entirely of the repeated sentence “Get me off your fucking mailing list” complete with diagrams of that sentence. It was rated as excellent and was accepted for publication!

Conclusion: Well worth reading for doctors and for everyone else

As the book explains, “The brain is a self-affirming spin-doctor with a bottomless bag of tricks…” Our brains are “pattern-seeking machines that fill in the gaps in our perception and knowledge consistent with our expectations, beliefs, and wishes”. This book is a textbook explaining our cognitive errors. Its theme is medicine but the same errors occur everywhere. We all need to understand our psychological foibles in order to think clearly about every aspect of our lives and to make the best decisions. Every doctor would benefit from reading this book, and I wish it could be required reading in medical schools. I wish everyone who considers trying CAM would read it first. I wish patients would ask doctors to explain why they ordered a test.

The book is not inexpensive. The price on Amazon is $56.99 for both softcover and Kindle versions. But it might be a good investment: you might save much more money that that by applying the principles it teaches, and critical thinking skills might even save your life. Well-written, important, timely, easy, and entertaining to read, lots of illustrations, packed with good stuff. Highly recommended.

Harriet Hall, MD also known as The SkepDoc, is a retired family physician who writes about pseudoscience and questionable medical practices. She received her BA and MD from the University of Washington, did her internship in the Air Force (the second female ever to do so), and was the first female graduate of the Air Force family practice residency at Eglin Air Force Base. During a long career as an Air Force physician, she held various positions from flight surgeon to DBMS (Director of Base Medical Services) and did everything from delivering babies to taking the controls of a B-52. She retired with the rank of Colonel. In 2008 she published her memoirs, Women Aren't Supposed to Fly .

Posted in: Book & movie reviews , Critical Thinking , Neuroscience/Mental Health , Science and Medicine
Tagged in: bias , CAM , cognitive errors , diagnostic mistakes , Jonathan Howard

Posted by Harriet Hall

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Critical Thinking in medical education: When and How?

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Critical thinking in healthcare and education

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Critical thinking is an essential cognitive skill for the individuals involved in various healthcare domains such as doctors, nurses, lab assistants, patients and so on, as is emphasized by the Authors. Recent evidence suggests that critical thinking is being perceived/evaluated as a domain-general construct and it is less distinguishable from that of general cognitive abilities [1].

People cannot think critically about topics for which they have little knowledge. Critical thinking should be viewed as a domain-specific construct that evolves as an individual acquires domain-specific knowledge [1]. For instance, most common people have no basis for prioritizing patients in the emergency department to be shifted to the only bed available in the intensive care unit. Medical professionals who could thinking critically in their own discipline would have difficulty thinking critically about problems in other fields. Therefore, ‘domain-general’ critical thinking training and evaluation could be non-specific and might not benefit the targeted domain i.e. medical profession.

Moreover, the literature does not demonstrate that it is possible to train universally effective critical thinking skills [1]. As medical teachers, we can start building up student’s critical thinking skill by contingent teaching-learning environment wherein one should encourage reasoning and analytics, problem solving abilities and welcome new ideas and opinions [2]. But at the same time, one should continue rather tapering the critical skills as one ascends towards a specialty, thereby targeting ‘domain-specific’ critical thinking.

For the benefit of healthcare, tools for training and evaluating ‘domain-specific’ critical thinking should be developed for each of the professional knowledge domains such as doctors, nurses, lab technicians and so on. As the Authors rightly pointed out, this humongous task can be accomplished only with cross border collaboration among cognitive neuroscientists, psychologists, medical education experts and medical professionals.

References 1. National Research Council. (2011). Assessing 21st Century Skills: Summary of a Workshop. J.A. Koenig, Rapporteur. Committee on the Assessment of 21st Century Skills. Board on Testing and Assessment, Division of Behavioral and Social Sciences and Education. Washington, DC: The National Academies Press. 2. Mafakheri Laleh M, Mohammadimehr M, Zargar Balaye Jame S. Designing a model for critical thinking development in AJA University of Medical Sciences. J Adv Med Educ Prof. 2016 Oct;4(4):179–87.

Competing interests: No competing interests

Critical Thinking in Medicine: All You Wanted To Know

by [email protected] | Jan 15, 2020 | critical thinking | 0 comments

Critical Thinking in Medicine: All You Wanted To Know

We’ve often come across the importance of possessing critical thinking into our lives. From being trained at coaching institutes to getting listed as one of the requisites in job descriptions, the quality of critical thinking is regarded as important everywhere. It can be an art, science, and a miracle, all at the same time! Let’s dig deeper and discover more about this art, science, and miracle of the human brain.

What is critical thinking?

Starting with its meaning and definition, over time, the clarity of critical thinking has evolved with multiple understandings about the subject. Most definitions of it can be fairly complex and best taught and understood by philosophy majors or psychologists.

Beyer (1995), provides the most basic definition of Critical Thinking as “making reasoned judgments”.

In another understanding, it is the ability to think clearly and rationally about what to do and/or what to believe. It also includes the ability to engage in reflective and independent thinking. A person with critical thinking skills is capable of the following:

Having an understanding of logical connections between multiple ideas
Identify, construct, and evaluate arguments
Detect loopholes and common mistakes in reasoning
Reflect on the justification of one’s own values and beliefs
Identify the relevance and importance of ideas

What are its characteristics?

According to experts, to think critically involves asking questions, defining a problem, analyzing evidence, examining assumptions and biases, overlooking emotional reasoning, avoiding oversimplification, and tolerating ambiguity.

Besides, considering other interpretations and dealing with ambiguity also constitute critical thinking. Other characteristics include:

Disposition – People who think critically are skeptical, open-minded, respect clarity and precision, look at different points of view, and respect evidence and reasoning.
Criteria – An individual must apply specific criteria along with conditions that must be met for something to be reasoned as believable.
Reasoning – The ability to arrive at a conclusion from one or more premises, using logical relationships among statements or data.

What are the steps involved in critical thinking?

It is a common misconception that it limits creativity as it involves the rules of rationality and logic, however, creativity requires breaking rules, unlike to think critically. Cognitive steps in thinking critically include:

Gathering information from all sources i.e. verbal and/or written expressions, reflections, experience, and observation
Gathering and assessing relevant information
Deriving well-reasoned conclusions and solutions
Testing outcomes against relevant criteria
Evaluating all assumptions, implications, and practical consequences

How critical thinking is helpful to medical students?

In the healthcare industry, medical professionals are known to use critical thinking, especially when they derive knowledge from other interdisciplinary subject areas to provide a holistic approach to their patients. Medical students can utilize their ability to think critically for the following:

Avoiding medical/clinical errors
Identifying better alternatives for diagnosis and treatment
Better ability to make clinical decisions
Working in a resource-limited environment
Quality thinking, quality work output, and increased productivity

Can it be taught?

To an extent, critical thinking can not only be taught but also developed and enhanced by experts through technology. As massive information is available in the present times, students only need a befitting trainer to guide them through the information and inculcate it the right way.

Students need to develop and apply critical thinking skills effectively to complex problems and to critical choices they are forced to face, as a result of the information explosion and other dynamic technological changes. Since questioning is one of the important aspects of critical thinking, it is essential to teach students how to ask good, relevant, and logical questions to think critically and succeed.

The Takeaway

Every new or established medical professional should understand their psychological foibles so as to be much clearer about every aspect of their lives and to make the best decisions. Some worthwhile quotes for every medical practitioner:

“Knowledge of bias should contribute to your humility, not your confidence”
“When beliefs are based on emotions, facts alone stand little chance”
“Reason evolved primarily to win arguments, not to solve problems”

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Int J Appl Basic Med Res
v.13(2); Apr-Jun 2023
PMC10443455

Inculcating Critical Thinking Skills in Medical Students: Ways and Means

Mandeep kaur.

Department of Pharmacology, Adesh Institute of Medical Sciences and Research, Bathinda, Punjab, India

Rajiv Mahajan

Critical thinking is one of the most important skills required to be possessed by any medical student for providing quality health care. With the introduction of a new competency-based medical education curriculum that focuses on the desired and observable ability of Indian medical graduates in real-life situations, inculcating critical thinking skills in the medical graduate is the need of the hour. With the changing expectations of society from the doctor, there is a need to focus more on this higher-order thinking skill which can serve as an essential attribute of any medical professional. It may serve as an important avenue for medical students to deal with any ill-defined medical emergencies and evolve with the best judgment for the clinical situation and solve the clinical problem. It is considered to be key competency to be cultivated and assessed in any medical school.

What is Critical Thinking and why it is Needed?

Critical thinking is a high-level thinking process that can be used in conceptual learning for students.[ 1 ] It is defined as the ability to identify and analyze problems as well as seek and evaluate relevant information to reach an appropriate conclusion.[ 2 ] Thus, critical thinking enables medical students to assess their needs for learning and comprehend their perspectives. This may aid in enhancing their problem-solving ability and making effective clinical decisions during their routine clinical encounter in the future.

In a medical college, during the budding years of medical students, they need to identify their own learning needs and take control of them as self-directed learners. This approach inculcates problem-solving ability and critical thinking skills in the students, which is considered to be the strong determinant for any good medical practitioner.

Strategies and Tools to Promote and Assess the Critical Thinking Skills of Medical Students

The various strategies and tools to promote and assess the critical thinking skills of medical students include:

Problem-based learning

It is an innovative teaching methodology that provides students with real-life scenarios to motivate them to seek out a deeper understanding of the given topic. In this, students learn to monitor their own learning process directing them toward building up on existing conceptual knowledge frameworks.[ 3 ] It is a student-centered learning method, in which the students work collaboratively as a team to find a solution to the given problem by digging deeper into the concepts. Different questions pertaining to the given problem and exploration of the topic occur during the session itself. This strategy of teaching inculcates a wide range of skills like problem-solving abilities and communication in addition to critical thinking skills.

Case-based learning

It is an effective tool that promotes active learning by linking theory to practice. It utilizes the clinical case scenario which is reflective of real-life experiences. Advanced study is required by the students before the discussion of the cases with their peers.[ 4 ] It encourages critical thinking by directing the learners toward the pavement of lifelong learner.[ 5 ]

Think, pair, and share strategy

It is one of the forms of cooperative learning strategy, where students are actively involved in group discussions.[ 6 ] They critically analyze the given question at an individual level and then practice sharing with their peers to achieve a pertinent solution to the given question and to further share that with a larger group.

Flipped classroom teaching

With an aim to address the higher-order skills and active involvement of students inside the classroom, this model of teaching was introduced in 2007.[ 7 ] The term “flipping” refers to providing the students with the resource material in advance before the classroom and utilizing the classroom time for active learning, fostering problem-solving skills, and enhancing their critical thinking skills.[ 8 ] It is considered a reverse of traditional teaching methodology which promotes the passive learning rather than active learning of the students.

Reflective writing

It is the process of creating a new insight in which experiences are recollected, critically analyzed, and then transformed into words in the form of writing.[ 9 ] It may strengthen and promote the development of critical thinking skills of medical students.[ 10 ]

Script concordance test

The script concordance test (SCT) is an innovative tool to assess the clinical and critical reasoning skills of medical students. It is based on the script theory which assumes that the clinician has a network of knowledge called scripts to make judgments for the clinical encounter they have in their routine practice. These scripts are imbibed by any medical student during their evolving stage from novice to expert in a medical college. As the career advances, these are further refined depending on their exposure to the clinical practice. In this test, trainees are exposed to ill-defined case vignettes which are pertaining to diagnostic, therapeutic, or investigative problems, for which there is no definitive answer. This serves as a very effective tool in probing into the critical thinking skills of medical students. The answers given by the trainees are then compared with the answers given by the panel of experts, and the final scoring is done.[ 11 ] Thus, this tool compares the judgment skills of the trainees with the reference panel and measures the degree of concordance between both.

An original study about the use of SCT in medical training is being published in this issue, and the article will give more insights to the readers.

In this era of the 21 st century, with an effort to tackle the recent trends and challenges in the medical field, there needs to be more emphasis on drifting the students from lower-order thinking skills to higher-order thinking skills. This helps the medical students to analyze the information critically and then apply that to the existing information. Critical thinking skill is considered a cornerstone for teaching and training medical students so as to maintain clinical competence and medical professionalism.

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Defining Critical Thinking




Everyone thinks; it is our nature to do so. But much of our thinking, left to itself, is biased, distorted, partial, uninformed or down-right prejudiced. Yet the quality of our life and that of what we produce, make, or build depends precisely on the quality of our thought. Shoddy thinking is costly, both in money and in quality of life. Excellence in thought, however, must be systematically cultivated. Critical thinking is that mode of thinking - about any subject, content, or problem - in which the thinker improves the quality of his or her thinking by skillfully taking charge of the structures inherent in thinking and imposing intellectual standards upon them. Foundation for Critical Thinking Press, 2008) Teacher’s College, Columbia University, 1941)

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Thinking critically about critical thinking: ability, disposition or both?

Affiliation.

1 Center for Evaluation, Harvard Medical School, Boston, Massachusetts 02115, USA. [email protected]
PMID: 21564200
DOI: 10.1111/j.1365-2923.2010.03910.x

Objectives: The objectives of this study were to determine the extent to which clinician-educators agree on definitions of critical thinking and to determine whether their descriptions of critical thinking in clinical practice are consistent with these definitions.

Methods: Ninety-seven medical educators at five medical schools were surveyed. Respondents were asked to define critical thinking, to describe a clinical scenario in which critical thinking would be important, and to state the actions of a clinician in that situation who was thinking critically and those of another who was not. Qualitative content analysis was conducted to identify patterns and themes.

Results: The definitions mostly described critical thinking as a process or an ability; a minority of respondents described it as a personal disposition. In the scenarios, however, the majority of the actions manifesting an absence of critical thinking resulted from heuristic thinking and a lack of cognitive effort, consistent with a dispositional approach, rather than a lack of ability to analyse or synthesise.

Conclusions: If we are to foster critical thinking among medical students, we must reconcile the way it is defined with the manner in which clinician-educators describe critical thinking--and its absence--in action. Such a reconciliation would include consideration of clinicians' sensitivity to complexity and their inclination to exert cognitive effort, in addition to their ability to master material and process information.

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LingYing Wang 1 ,
WenLing Chang 2 ,
http://orcid.org/0000-0002-1507-7890 HaiTao Tang 3 ,
WenBo He 4 ,
http://orcid.org/0000-0002-6682-8279 Yan Wu 3 , 5
1 Critical Care Medicine Department, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University , Chengdu , China
2 School of Population Health & Environmental Sciences , King’s College London , London SE1 1UL , UK
3 Department of Postgraduate Students, West China School of Medicine/West China Hospital, Sichuan University , Chengdu , China
4 Institute of Hospital Management, West China Hospital, Sichuan University , Chengdu , Sichuan , China
5 College of Marxism, Sichuan University , Chengdu , China
Correspondence to Yan Wu; wuyan{at}wchscu.cn

Objectives This study aimed to investigate the associations between critical thinking (CT) disposition and personal characteristics and tutors’ guidance among medical graduate students, which may provide a theoretical basis for cultivating CT.

Design A cross-sectional study was conducted.

Setting This study was conducted in Sichuan and Chongqing from November to December 2021.

Participants A total of 1488 graduate students from clinical medical schools were included in this study.

Data analysis The distribution of the study participants’ underlying characteristics and CT was described and tested. The Spearman rank correlation coefficient was used to evaluate the correlation between each factor and the CT score. The independent risk factors for CT were assessed using a logistic regression model.

Results The average total CT score was 81.79±11.42 points, and the proportion of CT (score ≥72 points) was 78.9% (1174/1488). Female sex (OR 1.405, 95% CI 1.042 to 1.895), curiosity (OR 1.847, 95% CI 1.459 to 2.338), completion of scientific research design with reference (OR 1.779, 95% CI 1.460 to 2.167), asking ‘why’ (OR 1.942, 95% CI 1.508 to 2.501) and team members’ logical thinking ability (OR 1.373, 95% CI 1.122 to 1.681) were positively associated with CT while exhaustion and burn-out (OR 0.721, 95% CI 0.526 to 0.989), inattention (OR 0.572, 95% CI 0.431 to 0.759), Following others’ opinions in decision-making (OR 0.425, 95% CI 0.337 to 0.534) and no allow of doubt to tutors (OR 0.674, 95% CI 0.561 to 0.809) had negative associations with the formation of CT disposition in the fully adjusted model.

Conclusions Factors associated with motivation and internal drive are more important in the educational practice of cultivating CT. Educators should change the reward mechanism from result-oriented to motivation-maintaining to cultivate students’ CT awareness.

risk factors
public health

Data availability statement

Data are available on reasonable request.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2023-082461

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STRENGTHS AND LIMITATIONS OF THIS STUDY

Our study focused on postgraduate medical students, and the sample size was relatively large.

Previous research on critical thinking has focused primarily on Europe, the USA and Japan. Hence, researching critical thinking in Chinese populations is a valuable addition to this area.

Given the traditional limitations of cross-sectional studies, the findings of this study cannot be used as direct evidence of a causal relationship between potential influences and outcomes. Nevertheless, they can provide clues to reveal causal relationships.

Introduction

Critical thinking (CT) is reasoned, reflective thinking that decides what to believe or do. The emphasis is on reasonableness, reflection and decision-making. 1 CT is even more important in the medical field, where a lack of CT can lead to delayed or missed diagnoses, incorrect cognition and mismanagement. The centrality of CT is reflected in the competency framework of health professions and is a core skill of healthcare professionals. 2–6 Six crucial skills have been proposed to operationalise the definition of CT: interpretation, analysis, evaluation, inference, explanation and self-regulation. Specifically, interpretation involves comprehending the significance of information and conveying it effectively to others. Analysis requires piecing together fragmented data to decipher their intended purpose. Inference entails identifying and leveraging relevant information to formulate logical conclusions or hypotheses. Evaluation necessitates assessing the trustworthiness of a statement or information. Explanation aims to clarify shared information to ensure its comprehensibility to others. Finally, self-regulation pertains to regulating one’s thoughts, behaviours and emotions. 7–9

The role of CT in assisting medical students in navigating complex health scenarios and resolving clinical issues through sound decision-making is paramount. Extensive research has established positive correlations between CT and clinical proficiency, 10 11 academic excellence 12 and research capabilities. 13 Consequently, the Institute for International Medical Education has emphasised ‘CT and research’ as one of the seven crucial competencies that medical graduates must possess, as outlined in the Global Minimum Essential Requirements. 14 Similarly, the Ministry of Education in the People’s Republic of China has underscored the importance of ‘scientific attitude, innovation and CT’ as essential requirements for Chinese medical graduates. 15

Research on CT in medical students has been carried out to varying degrees in Western countries and many Asian countries. 16 17 Some scholars have pointed out that Western methods, including CT and clinical reasoning, are used in thinking skills education worldwide. However, there are significant differences between Chinese and Western culture, especially educational culture while cultural differences affect ways of thinking 17 18 ; therefore, previous research may not be able to reflect the actual situation of Chinese students and teaching methods may not apply to them. Most Western students tend to possess assimilating learning styles, enabling them to excel in student-centred learning environments. Conversely, Eastern students often exhibit accommodating learning styles that align more with teacher-centred instruction. 19 The discipline-based curriculum in China may not adequately foster the development of CT dispositions among Chinese medical students. This curriculum typically comprises isolated phases (theory, clerkship and internship), limited faculty–student interaction and a knowledge-focused evaluation system. 20

Previous research has suggested that a range of personal characteristics, including gender, major, blended learning methods, increased self-study hours, heightened self-efficacy in learning and performance, exposure to supportive environments and active participation in research activities, contribute to varying degrees of CT dispositions and skills. 21–24 A study conducted in Vietnam revealed that age, gender, ethnicity, educational level, health status, nursing experience, tenure at the current hospital, familiarity with ‘CT’ and job position all influence CT ability. 25 Furthermore, teacher support is paramount to learners’ mental and psychological development. This support encompasses educators’ empathy, compassion, commitment, reliability and warmth towards their students. 26 According to Tardy’s social support paradigm, 27 teacher support is defined as providing informational, instrumental, emotional or appraisal assistance to students, irrespective of their learning setting. Supportive teachers prioritise fostering personal relationships with their students and offering aid, assistance and guidance to those in need. 28 Practical teacher assistance can make students feel comfortable and inspired, motivating them to invest more effort in their studies, engage more actively in educational pursuits and achieve superior educational outcomes. 29

Current CT research on mainland Chinese medical students focuses on the impact of undergraduates’ experiences and classroom instruction. However, for postgraduates, their tutors play a more critical role in education and cultivation. According to Wosinski’s study, 30 tutors should be trained to effectively guide the teamwork of undergraduate nursing students during the problem-based learning (PBL) process to achieve their goals. There is no analysis of the influencing factors of CT focused on medical postgraduates.

Therefore, assessing the tutor’s effect on postgraduates’ CT disposition. This study investigated the associations between CT disposition and personal characteristics and tutors’ guidance among medical graduate students, which may provide a theoretical basis for cultivating CT.

Study design and participants

Study design.

This was a cross-sectional observational study. The project team sent 1525 electronic questionnaire links to WeChat groups of full-time medical graduate students in higher medical institutions in Sichuan and Chongqing between November and December 2021. After removing incomplete and duplicate questionnaires, a total of 1488 valid questionnaires were returned for an effective rate of 97.57%.

Sampling procedure

We employed a random sampling method to select medical graduate students carefully and used PASS V.15.0 software to calculate the sample size for different analyses and outcome scenarios. In the estimation of the sample size with the proportion of CT disposition as the primary outcome, we considered p=0.5, adopted the two-sided Z value under the significance level of a=0.05, and the sample size was the largest when the sampling error was 3%, which was 1067. Moreover, estimating of sample size with the correlation coefficient as the primary outcome, we considered r=0.1 according to the results from the prestudy, and the test power was 0.9; thus, we obtained n=1048. The sample size should be at least 1334 considering a 20% non-response rate.

The inclusion criteria were as follows: (1) full-time medical graduate students (clinical medicine, medicine technology, integrative Chinese and Western medicine, medical laboratory, nursing and so on) in higher medical institutions in Sichuan and Chongqing and (2) after reading the introduction to the research, participants voluntarily agreed to participate and electronically signed the study’s informed consent form. The exclusion criterion was a refusal to participate in the study.

Procedure and data collection

The electronic questionnaire we used consisted of a condensed version of the Critical Thinking Measurement Scale, which was used to evaluate participants’ scores on CT disposition and a Potential Influencing Factors Questionnaire, which investigated participants’ underlying information, personal factors and education-related factors. To increase the response rate, we told the students how long it might take to fill out this questionnaire when we sent the questionnaire link to WeChat groups. Moreover, our participants all had master’s degrees or above whose understanding ability and compliance were better. We also sent reminders to all invited participants three times, and the survey lasted approximately 1 month.

Critical Thinking Measurement Scale

We used the Chinese version of the short-form critical thinking disposition inventory (SF-CTDI-CV), which is based on the CTDI-CV reported by Huang. 31 The CTDI-CV includes seven subscales, namely Truth Seeking, Open-mindedness, Analyticity, Systematicity, Critical Thinking Self-confidence, Inquisitiveness and Cognitive Maturity, which have good reliability and validity (0.90 for the overall Cronbach’s alpha and 0.89 for the overall Content Validity Index). 32 Huang removed ineffective questions based on the CTDI-CV and obtained a simplified scale with 18 items of three factors, which increased the proportion of total explained variation and had better reliability and validity than the original version. Huang selected items according to important indicators in factor analysis, including factor loading and communality. Specifically, Huang removed items whose factor loading was less than 0.4 or whose commonality was less than 0.3. Each item of the SF-CTDI-CV has six options (Likert scale) from 1 to 6 (1 means complete agreement and 6 means disagree entirely); the higher the score is, the stronger the CT tendency. 31 The Kaiser-Meyer-Olkin (KMO) value for SF-CTDI-CV is 0.90 while the p value of Bartlett’s test is less than 0.05, indicating that this short-form inventory has ideal structural validity. A total score of 72 or more indicates a CT disposition, and all participants were divided into two groups according to whether they possessed essential characteristics of thinking.

Potential Influencing Factors Questionnaire

The Potential Influencing Factors Questionnaire was based on previous research and interviews. The interviewees including senior education practitioners and invited medical postgraduate students, focused on their experiences and feelings regarding medical education in China. We compiled an interview outline and invited a total of 22 professionals, including 9 doctoral candidates, 5 doctoral supervisors, 2 counsellors and 6 young backbone teachers, to participate in the interviews. The interview schedule is flexible, but to ensure efficiency, we controlled the interview duration for each participant to within 40 min. After the interviews, we used professional NVivo V.11.0 software to analyse the collected interview data thoroughly.

The Potential Influencing Factors Questionnaire consists of 10 questions in the essential information section, 35 questions in the influencing factors section and 3 flexible questions, for 48 valid entries. The essential information section includes gender, age, secondary education background, higher education major, level of education, type of degree, full-time work experience, type of household registration, the highest level of parental education and whether the respondent was from an only child family. The influencing factors section can be grouped into two main areas: ‘personal factors’ and ‘educational factors’, with personal factors including the individual characteristics section. The educational factors include the practice and training, tutor and team, and educational environment section. This study defines every potential factor as an ordinal variable, with greater rank, depth and frequency of the corresponding factors. For reliability, Cronbach’s alpha=0.795 indicates that the questionnaire’s reliability is good enough for investigation. The content validity of the questionnaire was tested to determine whether the content met the objectives and requirements of the study. Most of the items of the influencing factors questionnaire were selected from previous literature, and the content validity was good. The KMO values and p values for the Bartlett’s test of sphericity for every aspect indicate that the structural validity of the questionnaire is good (see more details in online supplemental table S1 ).

Supplemental material

In the questionnaire design process, we first formed a preliminary framework concerning previous qualitative and quantitative research. Then we conducted interviews with educators, doctoral supervisors and representatives of medical postgraduate students according to the initial framework to understand their work experience in the practice of medical postgraduate education in China. Then, the questionnaire was supplemented according to the frequently mentioned items in the interviews. Finally, a questionnaire focusing on whether personal and educational pathways influence the formation of CT disposition was developed, as well as the key points of CT cultivation.

Data collection and organisation

The project team designed the electronic questionnaire based on the Influencing Factors Questionnaire and Critical Thinking Measurement Scale. Excel 2019 collated the raw data exported from the electronic questionnaire platform. Using the electronic questionnaire platform, answer completion settings rule out the possibility of logical anomalies. Samples with missing answers on the Critical Thinking Inventory were eliminated. Participants who were missing other information were asked to fill in as much as possible through the telephone number they had left. Those who were unable to do so were eliminated. Each factor in the influencing factors section was assigned a value in steps of 1 from lowest to highest (eg, the four categorical variables were assigned values of 1, 2, 3, and 4; 1 for never and 4 for always).

Students and public involvement

Former students were involved in the preparatory phase of this study. They reviewed the informed consent form and provided feedback.

Statistical analysis

The data were analysed by using SPSS V.24.0 software. The distribution of the study participants’ underlying characteristics and CT were described and tested. Continuous variables are described as the mean±SD, and t-tests or one-way analysis of variance (ANOVA) were used for hypothesis tests. Categorical variables are expressed as composition ratios and χ 2 tests are used for hypothesis tests. Correlation analysis: The Spearman rank correlation coefficient was used to evaluate the correlation between each factor and the CT score. Difference analysis: Trend ANOVA was used to test whether there was a trend change in CT scores at different levels of each potential influencing factor. A t-test was used to compare the differences in the levels of influencing factors between different CT trait groups. Factors with differences between groups were included in a multivariate unconditional logistic regression model. We fitted several multivariate logistic regression models to evaluate potential confounding variables. By comparing the χ 2 value, the −2-likelihood ratio, the Akaike information criterion, and the practical meanings of this study’s interesting factors, the final model in which X variables could explain most of the Y variables (CT scores) was chosen. The above tests were performed at 0.05, and a p<0.05 was considered statistically significant.

Essential characteristics

A total of 1488 medical graduate students were included in this study, with an average age of 26.63±3.72 years. Most of the participants had a science background in high school (96.84%), a higher education major in clinical medicine (78.43%) and had never participated in full-time work (71.91%). Most of the participants were female (65.93%), lived in urban areas (61.69%), had parents with junior school education or below (39.18%), were not the only child in the family (51.48%), scientific graduate students (51.61%) and had a master’s degree (55.51%). Among all the research subjects, the average total CT score was 81.79±11.42 points, and the proportion of CT (score ≥72 points) was 78.9% (1174/1488). The essential characteristics of the included subjects are shown in table 1 .

View inline

Participants’ essential characteristics and the distribution of critical thinking dispositions

Distribution of CT disposition

Table 1 demonstrates the distribution of CT disposition among the study participants. For the essential CT scores, participants with urban residence, higher parental education, only-child families, a science background before admission, science-based graduates, longer full-time employment and higher education levels had significantly greater CT scores (p<0.05). According to the CT questionnaire used in this project, subjects with a score more excellent than 72 points were considered to have an apparent CT disposition. The results showed that among our participants, women (80.80% vs 75.10%), science students (79.50% vs 61.70%) and PhD students (81.60% vs 76.80%) had a more significant proportion of CT disposition (p<0.05).

CT scores are linearly correlated with impact factor scores

Table 2 shows the correlation between each factor and the CT scores. The Spearman correlation coefficients suggested that most terms related to personal factors were correlated with CT scores (p<0.001). Sense of achievement (r=0.324), curiosity (r=0.480) and following others’ opinions in decision-making (r=−0.292) were strongly correlated with CT scores. Regarding educational factors, all factors in the practice and training section, all factors in the tutor and team section, and most factors in the educational environment impacted CT scores (p<0.001). Factors in the tutor and team section were more strongly related to CT scores, such as teaching students according to their aptitude (r=0.247) and tutors asking heuristic questions (r=0.242). Only no allow of doubt to tutors hurt the CT scores (r=−0.179, p<0.001).

The correlation between the potential influencing factors and the score of critical thinking

Factors influencing CT disposition

Univariate analysis.

The influencing factors associated with CT disposition are presented in table 3 . Univariate analysis revealed that in terms of personal factors, a sense of achievement, curiosity and interpersonal skills were all possible facilitators of CT disposition (p<0.05), and the group with CT disposition had higher average scores. In contrast, fatigue and burn-out, inattention and following others’ opinions in decision-making were possible hindering factors. Regarding educational factors, most factors in the ‘practice and training’ section, all factors in the ‘tutor and team’ section, and some factors in the ‘educational environment’ section were impact factors on CT disposition. In the practice and traning section, academic performance (p<0.001), number of intensively reading (p<0.001), paper writing (p=0.001), participation in academic conferences (p=0.009), completion of scientific research design with reference (p<0.001), time for extracurricular reading (p=0.006), summarisation and reflection (p<0.001), asking ‘why’ (p<0.001) and knowledge of critical thinking (p<0.001) were all positively related to CT disposition. For the tutor and team section, participants with CT disposition had higher scores for the following factors (p<0.01): tutors sharing thinking methods, communicating learning and life with tutors, tutors asking heuristic questions, encouragement of using ‘possible’ and ‘potential’, advocation of logical thinking training and lifelong learning, teaching students according to their aptitude and team members’ logical thinking skills. No allow to doubt tutors hurt CT disposition (p<0.001). The use of multifunctional classrooms (p<0.001) and having active classes (TBL class, flipped class, p=0.006) in the educational environment section were also correlated with CT disposition.

Impact factors

Multivariate logistics regression analyses

Multivariate logistics regression analysis demonstrated that female (OR 1.405, 95% CI 1.042 to 1.895), curiosity (OR 1.847, 95% CI 1.459 to 2.338), completion of scientific research design with reference (OR 1.779, 95% CI 1.460 to 2.167), asking ‘why’ (OR 1.942, 95% CI 1.508 to 2.501) and team members’ logical thinking ability (OR 1.373, 95% CI 1.122 to 1.681) were the promoting factors for the development of CT disposition after adjusting for other confounding factors. However, exhaustion and burn-out (OR 0.721, 95% CI 0.526 to 0.989), inattention (OR 0.572, 95% CI 0.431 to 0.759) and following others’ opinions in decision-making (OR 0.425, 95% CI 0.337 to 0.534) and no allow of doubt to tutors (OR 0.674, 95% CI 0.561 to 0.809) may be hindering factors for the formation of CT disposition in the fully adjusted model ( table 4 , adjusted R 2 =0.323).

Multifactor regression model

This cross-sectional study explored the factors influencing the CT disposition of Chinese medical graduate students in terms of both personal and educational factors. A total of 78.9% of the participants in this study had positive CT dispositions (score ≥72, 1174/1488), and women were 40.5% more likely than men to have CT dispositions (OR 1.405, 95% CI 1.042 to 1.895). Multivariate logistics regression analysis revealed that among personal factors, curiosity was the promoting factor while exhaustion and burn-out, inattention and following others’ opinions in decision-making may be the hindering factors. For educational factors, completing the scientific research design with reference, asking ‘why’ and the high logical thinking ability of team members were associated with CT disposition. However, no allow of doubt to tutors may hinder the disposition of CT.

According to our demographic information, our study revealed a greater prevalence of CT disposition among women, aligning with Zhai’s findings. 22 Several factors may contribute to this observed gender disparity. A systematic review established that men tend to engage more with objects while women prefer interpersonal interactions. 33 Women are more inclined to engage in dialogue and foster their understanding through collaborative learning, often exhibiting a more receptive mindset. Second, a study using fractional anisotropy measures derived from diffusion tensor imaging in 425 participants, including 118 males, revealed that divergent thinking in females correlates positively with fractional anisotropy in the corpus callosum and the right superior longitudinal fasciculus. 34 Conversely, it correlates with fractional anisotropy in the right tapetum in males. Zhang et al ’s 34 research sheds light on the sex-specific structural connectivity within and between hemispheres that underpins divergent thinking. These gender differences in creativity may reflect the inherent diversity between males and females in society. However, Faramarzi and Khafri 35 reported contrasting results. They concluded that although the results differed between the sexes, the likely cause was females’ higher education level rather than a difference due to gender. Several studies concur that self-esteem is a principal determinant of CT. 22 35 Barkhordary et al , 36 in their study of 170 third-year and fourth-year nursing students in Yazd, identified a significant link between CT and self-esteem. Pilevarzadeh et al further demonstrated that students with higher self-esteem exhibit more robust CT skills. 37 Self-esteem is defined as ‘an individual’s overall subjective emotional assessment of their worth’. 38 Bleidorn et al 39 conducted a groundbreaking large-scale, cross-cultural study with an internet sample of 985 937 participants, examining gender and age differences in self-esteem across 48 nations. They discovered significant gender differences, with males consistently reporting higher self-esteem levels than females, which may influence their responses to negative feedback to some degree.

In the section on personal factors, the results of this study on personal internal and external environmental factors such as curiosity, burn-out and inattention are consistent with previous studies. 40–45 The relationship between these internal and external environmental factors and cognitive capacity has been described in cognitive load theory, 46 particularly the role of ‘working memory’, the capacity to process information. Specifically, researchers 47 reported on a consensus on CT teaching, assessment and faculty development compiled by a high-level team recommended by 32 medical schools across the USA. Learners’ personal attributes, characteristics, perspectives and behaviours are critical components of their motivation to prepare for and engage in deeper learning and laborious clinical reasoning. Distractions and interruptions, on the other hand, can reduce attention to important issues, affecting learners’ ability to engage in clinical reasoning and their CT skills. 48 Making decisions based on the opinions of others in this study may reflect the participants’ interdependent view of self, which was identified by Futami et al 49 as a negative factor for CT dispositions.

Regarding the educational factors, learning methods and research group membership characteristics were more strongly associated with CT disposition than learning frequency and learning form. Completing the scientific research design with reference and asking ‘why’ are learning methods that promote the formation of CT for medical graduate students. Research 50 suggests that CT requires a persistent effort to test any belief or supposed form of knowledge according to the evidence supporting it and the further conclusions it tends to help. Completing scientific research design with reference is the specific manifestation of evidence-based reasoning in the scientific research field, which may be why it affects the formation process of CT. Furthermore, similar to our research, much research has explored the crucial role that questioning or problem-based thinking plays in CT. 47 51–53 Our research also suggested that the teaching style of the group supervisor and the logical thinking ability of other group members also impacted CT dispositions. Although no previous research has explored the role-specific behaviours of subject mentors and peers in CT disposition from a quantitative perspective, Futami et al 49 reported higher CT scores for subjects who had connections with research experts, suggesting a positive influence of research mentors on CT. Self-esteem positively affects CT, and overbearing instructors may undermine students’ self-esteem and, thus, their CT disposition. Moreover, several authors 47 53 54 have argued that professors’ encouragement of students to express uncertainty, to question and assess the quality of knowledge learnt, and to improve team members’ logical thinking skills are all positively associated with CT, consistent with our findings.

The CT scores in our study were lower than those in several Western countries among medical students, 55 56 possibly because of differences in educational culture and methods. In China, medical education comprises three stages: primary medical education, clinical education and internships. Primary medical education introduces students to the medical world. The delivery of traditional courses used to be prescribed and even dull simply because teachers were accustomed to a conventional teaching style and were afraid of making changes to course delivery. 57 The strategies to develop reflective and CT in nursing students in eight countries indicated that reflexive CT was found in most curricula, although with diverse denominations. The principal learning strategies used were PBL, group dynamics, reflective reading, clinical practice and simulation laboratories. The evaluation methods are the knowledge test, case analysis and practical exam. 58

The importance of early clinical exposure is universally acknowledged, particularly in developing countries where its value is profoundly esteemed. For instance, the South African Health Professions Council has spearheaded educational reforms for medical professionals, enabling first-year medical students to participate in healthcare visits. These visits aim to enrich the comprehension of future professional environments and foster a more profound passion for medicine. 59 Notably, most students perceived these visits as invaluable learning experiences, leaving them better prepared for medical practice. Similarly, Chinese medical colleges offer comparable programmes spanning 1–2 weeks. A Peking University study using questionnaires and reports revealed that all students benefited from these activities, gaining perceptual knowledge of clinical work. Remarkably, 61.5% of students reported that their early clinical exposure had significantly assisted them. 60

Interestingly, there was a more significant proportion of PhD students with a CT disposition in our study. This may be because doctoral research is more in-depth and complex, requiring students to engage in more detailed, rigorous and innovative thinking based on their existing knowledge. During the research process, doctoral students must constantly question, analyse, evaluate and reconstruct knowledge, which undoubtedly exercises and enhances their CT abilities. 61 However, this does not imply that master’s students possess lower CT skills than doctoral students. The master’s programme also emphasises cultivating CT, although possibly differing in depth and breadth. Both stages have unique development paths and manifestations in terms of CT. Regardless of the stage, graduate students should focus on developing their CT skills to address challenges in academic research and life.

Our research revealed that factors influencing CT motivation appear to be more closely linked to CT tendencies in personal and educational components. Miele and Wigfield 50 suggested that the factors affecting students’ critical analytical thinking motivation can be divided into two aspects: quantity and quality, the quantitative relationship between motivation and CT, that is, whether students have sufficient motivation to make high-level spiritual efforts. This is reflected in our study regarding curiosity, burn-out, distraction, an interdependent self-view and influence by research team members. The qualitative relationship is the willingness of students to engage in CT, which corresponds to the desire to ask ‘why’ and to refer to existing evidence to complete a research design in this study. This suggests that internal motivation may play an essential role in CT and that educators should focus more on maintaining students’ motivation and building awareness than on the frequency of rigid external research training and curriculum formats. Students are actively promoted and encouraged to apply CT in practice. At the same time, the existing overly outcome-oriented reward mechanism is changed, and assessment criteria are enriched, for example, by including ‘whether you ask interesting questions’ as one of the criteria for classroom assessment to motivate people to become more proactive learners. Recently, medical education has garnered considerable attention and traditionally assumes that medical students are inherently motivated by their dedication to specialised training and a highly focused profession. However, motivation plays a crucial role in determining the quality of learning and ultimate success. Its absence may provide a plausible explanation for why teachers occasionally encounter medical students who appear discouraged, have lost interest or abandon their studies, feeling a sense of powerlessness or resignation. 62

To foster CT among medical students, educational reform should encompass several key aspects: (1) Encouraging active learning and exploration: Teachers must urge students to engage actively in the learning process, providing resources and guidance to kindle their intellectual curiosity. This will empower students to seek out challenges, pose inquiries and address them through a critical lens. 63 (2) Implementing heuristic learning and case studies: Educators should incorporate case studies, enabling students to hone their CT, discriminatory skills and decision-making abilities by analysing authentic or hypothetical scenarios. 64 65 (3) Stressing the mastery of professional knowledge: It is imperative to ensure that students grasp the fundamental theories and principles of the medical field, along with proficiency in practical medical skills. 66 (4) Nurturing teamwork skills: Group discussions, collaborative projects and similar activities should be used to cultivate teamwork among medical students. This teaches them to listen attentively, manage team dynamics, and allocate resources effectively, enhancing their CT and problem-solving capabilities. 67 (5) Providing clinical practical experience: Early exposure to clinical practice is crucial in developing students’ analytical and problem-solving skills through firsthand observation and participation in real-life case management. 68 (6) Shifting teachers’ roles: Educators must evolve into mentors and role models for CT, leading by example and inspiring students through their practices and teachings. 69 Collectively, these recommendations for educational reform will empower medical students to address intricate issues they may encounter in their future medical careers, ultimately increasing the quality and safety of healthcare services.

It is worth noting that our questionnaire incorporated many potential entries with high reliability. It mostly also showed differences between the two groups with or without CT disposition in univariate analysis but were not ultimately presented in the regression models. These factors are meaningful for the development of CT but taking into account the simplicity and informativeness of the model, other entries in the model may have represented them. Our model explained more of the variance in CT than regression models from previous studies. 49 70 71

Strengths and limitations

This study has particular strengths. First, the questionnaire for this study was scientific and practice based. The findings of previous studies on personal and educational factors were extensively referenced, and in-depth interviews were also conducted. Second, our study focused on postgraduate medical students and the sample size was relatively large. Postgraduate medical students are the key group for CT development, and the findings obtained among postgraduate medical students are more relevant and better reflect the thinking characteristics of postgraduate medical students. Research from China has considerably enriched the worldwide sample of CT influencing factors. It has been suggested that cultural context strongly influences CT, 72 but previous research on CT has mostly focused on Europe, the USA and Japan. Therefore, researching CT in Chinese populations is a valuable addition to this area. In addition, this study is the first to quantitatively explore the impact of tutor and team on CT disposition. For Chinese postgraduates, tutors and their scientific research teams are the people who have the most contact during their studies. In our previous interviews, educators, tutors and postgraduates all recognised the vital role of tutors in postgraduate education, especially in the cultivation of thinking. Based on interviews and literature extraction, we summarise the specific influence of tutors and teams and present them as numerical indicators to refine the influence of tutors on educational factors to make them more comprehensive and exact.

There are several limitations to our study. First, given the traditional constraints of cross-sectional studies, the findings of this study cannot be used as direct evidence of a causal relationship between potential influences and outcomes. Still, they can provide clues to reveal causal relationships. Second, some influencing factors, such as participation in project submissions, participation in CT courses, attempts at innovation and entrepreneurship, and exchange abroad may need to be revised when measured due to limited educational resources. The lack of opportunity for most students to participate in the projects mentioned above, even if they had the will to do so, may help obscure the correlation between CT and these factors. Our regression models did not include other factors of the same type with higher coverage, such as article writing. This suggests that specific formal factors do not significantly influence CT disposition and that bias may not affect the overall results. In addition, we did not use the CTDI-CV scale. Given the busy workload of postgraduate medical students and the fact that online surveys are challenging to monitor and quality control, to avoid as much as possible the impact of too many questions on the quality of the study and to increase the recall rate, we used a condensed version of the Critical Thinking Scale, which has a greater total explained variance than the CTDI-CV scale and has good reliability and validity.

Conclusions

In conclusion, this study provides a comprehensive scientific assessment of the factors influencing the CT disposition of Chinese medical postgraduates in terms of personal and educational factors. Being curious, completing the scientific research design with reference, asking ‘why’, and having high logical thinking ability among team members were positively associated with CT. Exhaustion and burn-out, inattention, following others’ opinions in decision-making and not allowing to doubt tutors were negatively associated with CT scores. These findings suggest that we pay more attention to factors related to motivation and internal drive in our educational practice, shift from an outcome-focused reward mechanism and focus on motivation maintenance to build students’ CT awareness.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

The research team collected data after obtaining their consent and signatures on the study’s informed consent form. The Ethics Committee of West China Hospital (tertiary), Sichuan University, approved the study in 2021 (Ethics No. 980).

Acknowledgments

The authors want to acknowledge the medical students who participated in this study.

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Funding This study was supported by the Sichuan University Postgraduate Education Reform project (GSSCU2021038).

Competing interests None declared.

Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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Introduction to Critical Thinking Skills

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K. Venkat Reddy 3 &
G. Suvarna Lakshmi 4

This chapter contains summaries of six articles that are machine generated. The summaries discuss the multitude ways in which the field of critical thinking has been understood and defined. Mostly the summaries included in the chapter project the view that critical thinking is all about certain cognitive abilities belonging to the higher order of thinking. The first summary explains the definition of critical thinking using a meta-level approach; it uses this approach because the problem of defining critical thinking is a meta-problem. The authors argue that the definitions proposed earlier were either subject-specific or skill-specific resulting in definitions that are neither universally applicable nor acceptable. The authors therefore have attempted to propose an approach that has three proper criteria that the definition should satisfy. They are: (1) rely on criteria, (2) self-correcting, and (3) sensitive to context. The summary of the second article on the skills required for the twenty-first-century education is based on the lists of skills proposed by various bodies that are broadly categorized as productive, critical, and creative thinking along with digital skills. The author proposes that the curriculum should incorporate skills that are required as per the current pace of change and the need of the hour.

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Reddy, K.V., Lakshmi, G.S. (2024). Introduction to Critical Thinking Skills. In: Reddy, K.V., Lakshmi, G.S. (eds) Critical Thinking for Professional and Language Education. Springer, Cham. https://doi.org/10.1007/978-3-031-37951-2_1

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Critical thinking: definition and how to improve its skills

Critical thinking process all ideas must be open.

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What is critical thinking?

Critical thinking is a discipline based on the ability of people to observe, elucidate and analyze information, facts and evidences in order to judge or decide if it is right or wrong.

It goes beyond mere curiosity, simple knowledge or analysis of any kind of fact or information.

People who develop this type of outlook are able to logically connect ideas and defend them with weighty opinions that ultimately help them make better decisions.

Critical thinking: definition and how to improve its skills

How to build and improve critical thinking skills?

Building and improving critical thinking skills involves focusing on a number of abilities and capacities .

To begin the critical thinking process all ideas must be open and all options must be understood as much as possible.

Even the dumbest or craziest idea can end up being the gateway to the most intelligent and successful conclusion.

The problem with having an open mind is that it is the most difficult path and often involves a greater challenge and effort. It is well known that the easy thing to do is to go with the obvious and the commonly accepted but this has no place in critical thinking.

By contrast, it is helpful not to make hasty decisions and to weigh the problem in its entirety after a first moment of awareness.

Finally, practicing active listening will help you to receive feedback from others and to understand other points of view that may help you as a reference.

Impartiality

An important point in the critical thinking process is the development of the ability to identify biases and maintain an impartial view in evaluations.

To improve this aspect it is advisable to have tools to be able to identify and recognize the prejudices and biases you have and try to leave them completely aside when thinking about the solution.

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Observation

Observation allows you to see each and every detail , no matter how small, subtle or inconsequential they may be or seem to be.

Behind the superficial information hides a universe of data, sources and experiences that help you make the best decision.

One of the pillars of critical thinking is objectivity. This forces you to base your value judgments on established facts that you will have gathered after a correct research process.

At this point in the process you should also be clear about the influencing factors to be taken into account and those that can be left out.

Remember that your research is not only about gathering a good amount of information that puts the maximum number of options, variables or situations on the table.

For the information to be of quality, it must be based on reliable and trustworthy sources.

If the information you have to collect is based on the comments and opinions of third parties, try to exercise quality control but without interference.

To do this, ask open-ended questions that bring all the nuances to the table and at the same time serve to sift out possible biases.

How to build and improve critical thinking skills?

With the research process completed, it is time to analyze the sources and information gathered.

At this point, your analytical skills will help you to discard what does not conform to unconventional thinking, to prioritize among the information that is of value, to identify possible trends and to draw your own conclusions.

One of the skills that characterize a person with critical thinking is their ability to recognize patterns and connections between all the pieces of information they handle in their research.

This allows them to draw conclusions of great relevance on which to base their predictions with weighty foundations.

Analytical thinking is sometimes confused with critical thinking. The former only uses facts and data, while the latter incorporates other nuances such as emotions, experiences or opinions.

One of the problems with critical thinking is that it can be developed to infinity and beyond. You can always keep looking for new avenues of investigation and new lines of argument by stretching inference to limits that may not be necessary.

At this point it is important to clarify that inference is the process of drawing conclusions from initial premises or hypotheses.

Knowing when to stop the research and thinking process and move on to the next stage in which you put into practice the actions considered appropriate is necessary.

Communication

The information you collect in your research is not top secret material. On the contrary, your knowledge sharing with other people who are involved in the next steps of the process is so important.

Think that your analytical ability to extract the information and your conclusions can serve to guide others .

Problem solving

It is important to note at this point that critical thinking can be aimed at solving a problem but can also be used to simply answer questions or even to identify areas for improvement in certain situations.

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Published: 02 September 2024

Ecological care in nursing practice: a Walker and Avant concept analysis

Golshan Moghbeli 1 ,
Amin Soheili 2 ,
Mansour Ghafourifard 1 , 3 ,
Shahla Shahbazi 1 &
Hanieh Aziz Karkan 1

BMC Nursing volume 23 , Article number: 614 ( 2024 ) Cite this article

Metrics details

Today, the human population faces an increasing array of emerging environmental challenges. Despite its importance, nurses often neglect ecological issues, which can compromise patient health. While the ecological nursing perspective has the potential to lead to innovative care approaches that benefit patients, the nursing profession, and the environment, the concept of ecological care lacks a clear definition and its dimensions remain unclear. This study aimed to analyze and clarify the concept of ‘ecological care’ in the nursing discipline.

Walker and Avant’s analysis method was used to identify descriptions, antecedents, consequences, and empirical referents of the concept of ‘ecological care’ in nursing. We searched the databases (PubMed, Scopus, PsycINFO, CINAHL, ERIC, SID, and IranDoc) using the keywords “ecological,” “nurse,” and “nursing” using Boolean operators “AND” and “OR” in the title and abstract fields both in English and Persian to identify relevant literature on ecological care in nursing.

Ecological care, as a multidimensional concept, encompasses ecological thinking, ecological attitude, ecological awareness, ecological sensitivity, and ecological literacy. This entails the optimal utilization of environmental factors to provide patients with high-quality care and preserve ecological sustainability through environmentally friendly behaviors.

Conclusions

The findings highlight the need to elucidate, endorse, and solidify ecological thinking in all aspects of nursing care including nursing management, education, and research, which can lead to improved care quality, patient safety, and sustainability. Within this framework, nursing educators could play an essential role in integrating ecological care into nursing education. The study emphasizes the need to integrate ecological thinking into all aspects of nursing.

Peer Review reports

Ecology, the study of interactions between living organisms and their environments, encompasses physical and social surroundings that impact all living beings. From a human science perspective, ecology emphasizes these interconnected relationships, fostering a deeper understanding of nursing and caring practices [ 1 ]. Currently, environmental concerns are considered significant threats to public health. However, healthcare professionals often lack sufficient awareness of the importance of ecological issues [ 2 ].

As the largest group of healthcare professionals, nurses play a crucial role in decisions regarding product use, energy consumption, and chemical selection in healthcare settings. However, they face a significant challenge: balancing environmental concerns and ecological principles with their professional duties [ 3 ]. Although nurses can advocate reducing exposure to harmful chemicals and adopting less toxic products, their work environments often require high energy consumption and generate substantial medical waste [ 4 ]. This medical waste encompasses both hazardous (infectious, pathological, chemical, pharmaceutical, cytotoxic, and radioactive) and non-hazardous or general waste, posing potential risks to patients, communities, and broader ecological health [ 5 ]. Multiple studies have highlighted the critical role of ecological considerations within healthcare in the overall health of ecosystems [ 6 , 7 , 8 , 9 ]. Consequently, ecological issues have become a high priority for nurses, demanding attention and action [ 10 ].

The importance of environment, ecosystems, and ecology in nursing practice has been recognized by pioneers like Florence Nightingale as the founder of modern nursing (published in 1992, originally written in 1959) [ 11 ] and subsequently by Fawcett (1984) [ 12 ]. This vision is further reflected in the International Council of Nurses (ICN) Code of Ethics, which states that “nurses contribute to the population’s health and work to achieve the sustainable development goals.” By adopting sustainable practices, nurses can significantly reduce their environmental footprint and contribute to achieving the UN 2030 Agenda for Sustainable Development [ 9 ]. Recognizing this crucial role, nursing organizations such as the American Nurses Association actively promote nurses’ participation in environmental protection initiatives [ 13 ].

The concept of ecological care in nursing, as a multidimensional concept, encompasses several aspects. Lausten (2006) proposed a nursing ecological theory to broaden nurses’ perspectives by incorporating concepts of global ecosystems, communities, and interrelationships from the ecological sciences. This theory recognizes that human interactions with the environment extend beyond the personal sphere and encompass professional activities. Consequently, nurses can integrate ecological principles into their practice, fostering new directions in care that benefit patients, healthcare professionals, and the environment [ 14 ]. Dahlberg et al. (2016) conducted an empirical study to explore how a phenomenological life-world theory could expand the concept of holistic care into “ecological care.” They argued that the traditional approach to holistic care has neglected environmental and ecological dimensions. Their findings suggested that ecological care goes beyond fighting illnesses. It emphasizes understanding patients within the context of their world, a world that they both influence and are influenced by. This approach helps patients reintegrate into their rhythm of existence [ 1 ].

Al-Shamaly (2021) highlights “ecological awareness,” which emphasizes creating a safe and comfortable patient environment through noise, light, color, and temperature control [ 15 ]. Sattler (2013) adds another dimension, suggesting that nurses can act as catalysts for transforming hospitals into environmentally sustainable spaces. This can be achieved through practices such as adopting environmentally friendly purchasing policies (e.g., waste management strategies, reduced chemical use, and proper disposal of hazardous materials such as batteries), promoting healthy food options, and favoring mercury-free products [ 16 ].

Although ecological factors could influence the quality of care, patient safety, individual and community health, resource preservation, and sustainable practices [ 16 , 17 , 18 , 19 ], nurses’ awareness of ecological care and its dimensions remains limited [ 2 ]. Moreover, there is no universally accepted definition of ecological care as a complex concept [ 20 ]. Therefore, this study aimed to analyze and clarify the concept of ‘ecological care’ within the nursing discipline.

Walker and Avant’s concept analysis method was used as a rigorous and systematic approach to identify descriptions, antecedents, consequences, and empirical referents of the concept of ‘ecological care’ in nursing. Ecological care is a widely applicable concept that extends beyond the confines of nursing care. Therefore, the literature review encompasses all the various applications of ecological care, including both implicit and explicit aspects. The stages of the concept analysis method are as follows: (A) selecting a concept, (B) determining the aims or purposes of the analysis, (C) identifying all uses of the concept that you can discover, (D) determining the defining attributes, (E) identifying a model case, (F) identifying borderline, related, contrary, invented, and illegitimate cases, (G) identifying antecedents and consequences, and (H) defining empirical referents [ 21 ].

Literature search

A systematic literature review was conducted using multiple health databases, including PubMed, Scopus, PsycINFO, CINAHL, ERIC, SID, and IranDoc. The concepts “ecological,” “nurse” and “nursing” were searched using Boolean operators “AND” and “OR” in the title and abstract fields of each database. No temporal limits were applied and articles published in either English or Persian until July 2023 were retrieved.

Initially, 1083 records were identified by searching the titles and abstracts of these databases. Subsequently, 16 additional records were manually included, resulting in a total of 1099 records. Duplicate records were removed, leading to an initial selection of 1068 records. The titles and abstracts of these records were screened, and the eligibility criteria were applied to the full text of the selected records. Eventually, 36 records met the criteria and underwent a comprehensive review of concept analysis (Fig. 1 ). A detailed overview of the included studies, including publication year, title, country, and key findings, can be found in Appendix A.

Flow diagram of the study (data search and selection process)

Concept selection

The importance of a specific concept is influenced by a variety of factors both within and outside its field over time. Consequently, concepts lacking clear definitions warrant further analysis [ 21 ]. Considering the interconnectedness of ecosystems and human health, as well as the imperative to maintain environmental sustainability, particularly within healthcare, the concept of ecology has gained prominence in nursing and other health professions. Nightingale’s emphasis on the environment underscores this importance. Given the increasing significance of ecological care in healthcare and the lack of a clear, unified definition, this concept was selected for analysis to elucidate its dimensions and characteristics.

Determining the aims of the analysis

The concept of “ecological care” has been insufficiently analyzed within the healthcare context, resulting in a lack of a clear definition. This study aims to refine the meaning of ecological care in nursing by identifying its descriptions, antecedents, consequences, and empirical referents.

Identifying the use of the concept

To explore the concept of ecological care, it is crucial to understand the distinct meanings of each word from a variety of sources such as dictionaries, thesauruses, websites, and scholarly literature.

According to the Merriam-Webster dictionary, the term ‘ecological’ is an adjective related to the science of ecology. This refers to the environment of living things or the relationships between living things and their environments [ 22 ].

According to the Merriam-Webster dictionary, the term ‘care’ functions both as a noun, representing responsibility for or attention to health, well-being, safety, or solicitude, and as a verb, meaning to feel interest or concern and to provide care [ 23 ].

Ecological care in nursing literature

The concept of ecological care, originating from the theory of biological ecology, aims to offer solutions that effectively minimize the adverse impacts of nursing care on the ecosystem [ 14 ]. Ecological care can be classified into two types: individuals and professionals. The individual approach focuses on raising public awareness, shaping attitudes and behaviors, and promoting responsible actions regarding energy consumption, the production of toxic substances (such as greenhouse gases), chemical usage, and healthy and organic diet adoption. Conversely, the professional approach emphasizes the importance of sensitivity, awareness, attitude, behavior, and responsible actions among individuals when carrying out their professional responsibilities [ 9 , 24 ].

Clinical environments require ecological care, which can be achieved through two distinct approaches: environmental and organizational care. Environmental care involves maintaining equipment and machines, ensuring workplace safety, minimizing risks, managing noise levels, optimizing lighting conditions, regulating temperature, and employing creative designs to create a comfortable and relaxing environment. It also involves facilitating visits from family members and pets and improving patients’ sleep quality. Additionally, the use of digital technology helps ensure a healthy and safe treatment environment for patients in the Intensive Care Units (ICU). On the other hand, organizational care focuses on time and resource management. This includes strategies such as reducing paper and ink consumption by utilizing electronic records, which aids in efficient time management. Organizational care aims to streamline nurses’ tasks and improve overall work efficiency by minimizing their workload and improving access to patient information. Finally, waste management practices play a crucial role in maintaining an environmentally conscious approach in healthcare settings [ 15 ].

Determining the defining attributes

Ecological thinking.

According to Balgopal and Wallace (2009), ecological thinking is a combination of ecological understanding and ecological awareness [ 25 ]. Understanding ecology involves understanding concepts such as biotic, abiotic, and biological interactions. This serves as the initial stage of ecological thinking, which is further developed by comprehending the impact of human activities on the ecosystem [ 26 ]. Ecological understanding can be conceptualized as a continuum, with one end representing the capacity to identify problems and propose ecological decisions, considering their potential consequences. On the other end of the continuum is a lack of understanding, where the ability to explain the impact of human actions on the ecosystem is insufficient [ 25 ].

Ecological thinking causes a transformation in people’s presuppositions and attitudes towards the surrounding world, enabling them to recognize that we are interconnected and evolving alongside nature. Embracing an ecological perspective requires acknowledging ourselves as integral components of nature rather than being superior to it. This encompassing concept embodies various underlying principles such as ecology, wholeness, interdependence, diversity, partnership, energy flows, flexibility, cycles, and sustainability [ 17 , 27 ]. Hes and de Plessis (2014) refer to this set of principles as the ‘ecological worldview.’ Shifting towards an ecological perspective entail altering our perspective on the world and ourselves. The fundamental essence of this transformation involves moving away from egocentric and anthropocentric thinking, which emphasizes separateness, and instead adopting a holistic perception that aims to counterbalance environmental damage. Enhancing ecological thinking can be achieved through the instruction of ecological concepts and behaviors [ 28 ].

Ecological attitude

Ecological attitude is a complex construct that encompasses various key components such as emotions, perceptions, personal norms, values, and relationships with the environment. The emotional dimension of ecological attitude plays a pivotal role in preparing individuals to address environmental issues and cultivate ecological behaviors in all aspects of life [ 29 , 30 , 31 ], as it determines the extent to which individuals will act in environmentally responsible ways [ 32 ].

Predicting a specific behavior entails possessing a specific attitude towards that behavior, as attitudes alone do not guarantee behavior, but predict or influence it [ 2 , 33 ]. Ecological behavior can be defined as the actions taken by a nurse to protect the environment, and it varies depending on the individual’s context and circumstances. Achieving the goal of ecological behavior can be challenging in certain situations, but it is crucial to promote sustainable living and preserve the planet’s natural resources [ 31 ].

Ecological awareness

Ecological awareness refers to knowledge, attitudes, and behaviors related to the environment. Its focus is on increasing responsibility toward achieving ecological sustainability [ 34 ]. One of its important characteristics is the perception of natural objects from a subject’s perspective [ 35 ]. As a theoretical and practical science, ecological awareness includes two stages: awareness of environmental changes, and feelings of concern about environmental problems and trying to solve them. People with ecological awareness try to be actively responsible for their interactions with the environment and exhibit positive behaviors towards the surrounding environment [ 9 , 20 ].

Ecological awareness is also a level of cognitive thinking that enables nurses to focus on protecting the environment while providing nursing care. This concept requires nurses to pay attention to the potential of nature and the surrounding environment that promotes, maintains, and restores human health [ 9 , 14 ]. This raises important questions about whether nurses are aware of the positive effects of recycling medical equipment and materials, or the harmful effects of greenhouse gases (CO2, NO, etc.) caused by fossil fuels and smoke from medical waste incinerators. It also highlights how much nurses are aware of the impact of their care activities on ecosystem damage and public health [ 9 , 19 , 36 ]. The role of nurses with ecological awareness is crucial in raising awareness among colleagues, managers, patients, and students [ 8 , 37 , 38 , 39 ].

Ecological sensitivity

Ecological sensitivity refers to the inclination to actively address environmental threats and the extent to which healthcare providers demonstrate awareness of hazardous and protective circumstances [ 40 ]. Individuals with varying psychological traits, such as extroversion or introversion, exhibit distinct levels of sensitivity to environmental health [ 41 ].

Ecological sensitivity is a multidimensional concept that contributes significantly to sustainable development. This serves as an emotional foundation for cultivating an ecological worldview and establishing personal norms for pro-environmental actions. This dynamic framework takes shape within families during childhood and is strengthened throughout professional life. Therefore, an essential initial step in enhancing ecological sensitivity among healthcare providers is to impart ecological education and raise awareness levels [ 42 , 43 , 44 ]. The development of ecological sensitivity is influenced by various factors, including families, educational institutions, mass media, and non-governmental organizations [ 45 , 46 , 47 ]. In general, nurses who actively engage in staying informed about ecological news and trends, participate in ecological protection activities and events, and demonstrate awareness of ecologically detrimental behaviors, both in themselves and their colleagues exhibit higher levels of ecological sensitivity [ 42 , 43 ].

Ecological literacy

Ecological literacy is a crucial concept that includes three core components: cognitive, emotional, and behavioral. According to UNESCO, there are five key characteristics of ecological literacy: awareness and sensitivity to the environment; comprehension of environmental issues; having values and sentiments towards environmental concerns; possessing skills, desire, and commitment; and actively engaging in identifying and resolving ecological problems. Generally, ecological literacy can be defined as the integration of environmental sensitivity, knowledge, skills, attitudes, values, responsibilities, and active engagement, which enables nurses to make informed and responsible decisions to promote environmental sustainability [ 48 , 49 ].

Model and additional cases

A model case serves as a paradigmatic illustration of the application of a concept encompassing all its defining elements. In addition to the model case, two other types of cases are presented: (A) the borderline case, which shares most of the essential characteristics of the concept but exhibits some differences; and (B) the contrary case, which presents an apparent example that contrasts with the concept, highlighting what it is not [ 21 ].

A 65-year-old woman was admitted to the neurology ward with a diagnosis of transient ischemic attack during the night shift. The attending nurse approached the patient’s bedside and introduced herself and the inpatient department. During the evaluation, the nurse observed the patients’ uneasiness, homesickness, and concerns regarding sleep disturbance due to changes in sleeping arrangements. She addressed the situation by repositioning the patient’s bed next to the window, aiming to provide a more comfortable environment and alleviate feelings of homesickness. Careful attention was paid to ensure that the bed and equipment were securely locked. During medication administration, the nurse utilized a tablet for dosage calculations, opting for a paperless approach to reduce waste. Proper disposal procedures were followed after medication administration, with empty vials discarded in the chemical waste bin, and needles placed in a safety box. During the initiation of infusion, the nurse noticed loose screws on the electronic infusion device and promptly sought assistance from a colleague to rectify the issue. Toward the end of her tasks, the nurse dimmed unnecessary lights in the ward and adjusted the alarm range of the device to an audible level for more comfort. Immediately before leaving the ward, the nurse noticed a leaking water tap and promptly contacted the facility manager to initiate immediate remedial action.

Borderline case

The head nurse of the pediatric ward conducted a clinical round when she heard the cries of a hospitalized 4-year-old child who was upset due to the absence of her cherished doll. Regrettably, the nurses disregarded the situation and continued down the corridor. Several months later, the nurse was invited to join a committee responsible for making decisions regarding hospital equipment procurement. Drawing from the recent knowledge acquired through a TV program highlighting the hazards of mercury to human health, she recommended the acquisition of mercury-free medical equipment.

Contrary case

A nurse, aged 35, with ten years of experience in surgery, approached the patient who had undergone laparotomy to perform a dressing change. The nurse inadvertently wore a pair of sterile gloves instead of non-sterile gloves while removing the contaminated dressing and disposed of it in the general waste bin. Subsequently, sterile gloves were replaced with a fresh pair, the wound was cleansed using six sterile gauzes, and an additional seven gauzes were applied to dress the surgical site, although a smaller quantity would have sufficed. During the hand washing process, the nurse’s mobile phone rang, and without turning off the water tap, he engaged in a conversation until the patient’s family intervened and turned off the tap. Finally, despite the patient expressing mild pain at the surgical site, the nurse chose to administer a painkiller instead of utilizing non-pharmacological methods to alleviate pain.

Identify antecedents and consequences

Walker and Avant (2011) provided a clear definition of antecedents as events or attributes that precede the occurrence of a concept, whereas consequences refer to events that ensue from the concept’s occurrence [ 21 ]. In this study, it was crucial to identify and examine the associated antecedents and consequences (Fig. 2 ). Therefore, the antecedents and consequences investigated are as follows:

Attributes, antecedents, and consequences of ecological caring in nursing practice

Antecedents

The ecological care provided by nurses can be influenced by both personal characteristics and organizational policies. Personal characteristics include creativity, innovation, responsibility, environmental friendliness [ 41 ], kindness, empathy, and strong communication skills [ 9 ]. Meanwhile, organizational policies encompass the establishment of a supportive organizational culture, provision of training courses [ 14 ], and design of a creative and humanitarian environment within hospitals and healthcare facilities. Moreover, ensuring a safe environment equipped with adequate resources, services, technology, and competent human resources is essential for delivering ecological care in therapeutic settings [ 15 ].

Consequences

Ecological care yields numerous benefits to patients, their families, healthcare providers, healthcare systems, and the environment. Among these benefits, one of the most significant is the provision of high-quality holistic care, which leads to increased patient satisfaction. Additionally, ecological care contributes to patient and staff safety by minimizing hospital infections, conserving energy (electricity, gases, and water), optimizing equipment and time utilization, reducing employee workload, managing hospital procurement costs, and eliminating hospital waste. It also plays a vital role in preventing the entry of pathogens, chemical pollutants, and radioactive substances into the water, soil, and air. Furthermore, ecological care promotes ecological sustainability, safeguards the ecosystem, and helps protect food and agricultural resources by preventing food waste in the hospital setting. These considerations highlight the wide-ranging positive consequences of ecological care [ 14 , 41 ].

Empirical referents

According to Walker and Avant (2011), the final step in concept analysis is to identify the empirical referents of attributes. Empirical referents do not directly serve as instruments for measuring a concept, but they provide illustrations of how defining characteristics or attributes can be recognized or measured. By presenting real-world examples, empirical referents assist in measuring the concept and validating its significance [ 21 ]. Although this study did not identify a specific independent instrument for measuring ecological care in nursing, the following examples demonstrate instruments that measure the defining characteristics or attributes of the concept.

The Nurse’s Environmental Awareness Tool (NEAT) was developed by Schenk et al. in 2015 to measure nurses’ awareness of and behaviors associated with the environmental impact of their practices. The NEAT consists of 48 two-part items in six subscales and three paired subsets as follows: nurse awareness scales, nurse professional ecological behaviors scales, and personal ecological behaviors scales [ 9 ].

The Ecological Risk Perception Scale, developed by Slimak and Dietz in 2006, examines not only the attributes of the risk itself but also the characteristics of individuals perceiving the risk. Consisting of 24 ecological risk items, the scale encompasses four subscales: ecological, chemical, global, and biological [ 50 ].

The Environmental Literacy Questionnaire (ELQ) was derived from part of Michigan State University’s project and was originally used by Kaplowitz and Levine (2005) [ 51 ]. Later, Kahyaoğlu (2011) revised the ELQ. The revised version consisted of four components: knowledge (11 items), attitude (12 items), uses (19 items), and concern (9 items) [ 52 ].

Based on the current analysis, ecological care is a multidimensional integration of thinking, attitudes, awareness, sensitivity, and literacy to deliver high-quality holistic care while maintaining environmental sustainability and promoting energy conservation.

Analysis of the concept of ecological care has significant implications for the nursing profession. Given the limited exploration of ecological care within nursing practice, conducting an analysis can empower nurses to utilize ecological factors in delivering high-quality care and embracing environmentally friendly behaviors. The objective of this study was to present a comprehensive and practical definition of ecological care, thereby establishing a shared platform for not only nurses but also other healthcare professionals to promote pro-environmental behaviors.

Backes et al. (2011) conducted a study aiming to comprehend the meaning of ecological care from the perspective of students and teachers in the healthcare field at a Public Institution of Higher Education. The study revealed several categories, including (a) ecological care as a result of relationships, interactions, and communication with the global environment (main category); (b) the development of ecological awareness (causal conditions); (c) the connection of ecological care with different systems (context); (d) the perception of human-environment-health interaction (intervention); (e) the need to foster ecological consciousness through new references (strategy); and (f) a sense of motivation to understand ecological care (result). While this study acknowledged ecological awareness and conscience as integral components of ecological care, other attributes of the concept, such as adopting an ecological perspective; ecological literacy; and the impact of values, beliefs, and organizational culture on providing holistic care, were not extensively explained [ 20 ].

The findings of a study conducted by Dahlberg et al. (2016) revealed how ecological care facilitates patients to rediscover their place in a world characterized by interconnectedness. The role of ecological care extends beyond perceiving patients within a web of relationships; it encompasses assisting patients in re-establishing their sense of self and comprehending the world anew. Ecological care entails not only combating illness but also acknowledging patients as individuals influenced by and influencing the world. Such care endeavors to facilitate rhythmic movement and create space for activity and rest, being cared for and actively participating in one’s recovery, withdrawing from the world, and re-engaging with it. This study also highlights the use of the term ecological perspective to enhance the understanding of optimal care for patients. In this study, the novel attributes of the concept of ecological care are introduced. However, the potential impacts of constructive and destructive human activities on ecosystems remain unexplored [ 1 ]. In contrast, we refer to ecological sustainability and energy conservation as significant consequences of ecological care in nursing.

In a focused ethnographic study, Al-Shamaly (2021) explored the culture of multidimensional “caring-for” practice among ICU nurses. The inclusive nature of this culture encompasses caring for oneself, patients and their families, and colleagues (including nurses and other team members) as well as ecological consciousness within the ICU environment and organization. Ecological consciousness involves caring for equipment and machines, ensuring workplace safety, reducing hazards, transitioning towards a paperless unit, maintaining thorough documentation, and demonstrating commitment and concern for the organization’s budget regarding staff and resources [ 15 ]. While this study comprehensively addresses the practical aspects of the concept, it constrains the concept of ecological care solely to ecological consciousness. However, our study revealed that ecological care is a multidimensional, and complex phenomenon that extends beyond ecological consciousness. In another study, religious values were identified as a crucial factor in promoting an ecological care orientation that can be incorporated into daily life through religious education, considering the religious and cultural context of each country. These values are instilled into individuals from childhood to adulthood through various learning activities. Therefore, religious education plays a pivotal role in shaping individuals’ commitment to ecological care [ 53 ]. According to this study, religious values significantly contribute to the development of ecological thinking and the manifestation of ecological behavior.

Moreover, a previous study by Akkuzu (2016) introduced ecological intelligence as a new type of conscience, defined as a combination of environmental awareness and the sensitivity of human beings towards adverse global alterations in nature. This understanding empowers individuals to recognize the perils faced by their communities and comprehend the underlying causes. Furthermore, it equips them with the knowledge necessary to address these perils collectively and devise effective solutions [ 54 ].

Implications for nursing practice

While our analysis primarily focused on the ecological perspective, we contend that a profound understanding of this concept is imperative for establishing cultural and political frameworks within the healthcare system. This study contributes to the limited body of research on nursing by highlighting the essentiality of ecological and holistic thinking in the domains of caregiving, treatment, management, and education. Consequently, it has the potential to yield substantial impacts in ensuring the safety of patients and healthcare providers, enhancing the quality of care, and improving patient and family satisfaction.

Limitations

The conceptual analysis is subject to several limitations. Firstly, the literature search was confined to studies published in English and Persian, potentially limiting the diversity of perspectives from other countries, cultures, and languages. To mitigate this limitation, future studies should conduct a comprehensive search in multiple languages to ensure a more holistic understanding of ecological care in nursing practice. Secondly, the analysis is susceptible to selection bias, extraction bias, and analysis bias. To address these limitations, the study selection process, data extraction, and analysis were independently conducted by two researchers. Despite these limitations, the studies were described accurately and systematically, contributing valuable insights into the concept of ecological care in nursing practice.

The results of the present analysis provide a definition of ecological care in nursing that may guide the profession to new directions of care, striving for the greater good of the patient, the profession of caring, and the environment. It is clear that more research is needed to discover the neglected importance of the environment in holistic care and to identify phenomena related to this concept in practical nursing. The literature review shows that the educational field, as the most effective factor, plays a significant role in the formation of ecological literacy and worldviews and the creation of the perceptions, attitudes, and behaviors of ecological care. In this regard, nursing professors and instructors, as the most important role models, significantly contribute to the development of the identity and character of ecological care for today’s students and future nurses.

Data availability

The data supporting the findings of this study are available upon request from the corresponding author. The data were not publicly available because of privacy or ethical restrictions.

Abbreviations

Carbon dioxide

Nitric oxide

The United Nations Educational, Scientific and Cultural Organization

Nurse’s Environmental Awareness Tool

Environmental Literacy Questionnaire

Intensive Care Unit

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Acknowledgements

This study was extracted from a research project approved and supported by the Student Research Committee, Tabriz University of Medical Sciences (grant number: 73361). The authors would like to thank all those who spent valuable time participating in this research. We are also immensely grateful to the “anonymous” reviewers for their valuable insights.

The present study was financially supported by Tabriz University of Medical Sciences, Tehran, Iran.

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Golshan Moghbeli, Mansour Ghafourifard, Shahla Shahbazi & Hanieh Aziz Karkan

Department of Nursing, Khoy University of Medical Sciences, Khoy, Iran

Amin Soheili

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Contributions

GM, AS: original concept and study design; GM, HA, ShS: data collection; GM, HA, AS, MGh: data analysis and interpretation; GM, HA, AS, MGh, ShS: manuscript preparation and final critique; GM, MGh: study supervision.

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This study was approved by the ethics committee of Tabriz Tehran University of Medical Sciences (code of ethics: IR.TBZMED.REC.1402.614). All methods were carried out in accordance with relevant guidelines and regulations of Walker and Avant’s concept analysis method and qualitative research.

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Moghbeli, G., Soheili, A., Ghafourifard, M. et al. Ecological care in nursing practice: a Walker and Avant concept analysis. BMC Nurs 23 , 614 (2024). https://doi.org/10.1186/s12912-024-02279-z

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There are several reasons why it is important to have a set of critical thinking skills that can be applied to medicine and health. As the scenario in Sect. 1.1 illustrates, we cannot evade the relentless exposure to medical and health messages that is part of our daily lives. We would be naïve to think that all, or even most, of these messages are conveying claims that represent some ideal ...
Incorporating Critical Thinking Skills in Medical Education
Richards stresses that it is essential for medical educators to make a concerted effort to build critical thinking skills into their curriculums. To do so, they must consider three key pillars: Using case-based learning: "The first pillar is to really contextualize everything in cases, in patients, and in the care of other human beings," he ...
Critical Thinking in Medicine: All You Wanted To Know
Beyer (1995), provides the most basic definition of Critical Thinking as "making reasoned judgments". In another understanding, it is the ability to think clearly and rationally about what to do and/or what to believe. It also includes the ability to engage in reflective and independent thinking. A person with critical thinking skills is ...
Inculcating Critical Thinking Skills in Medical Students: Ways and
Critical thinking is a high-level thinking process that can be used in conceptual learning for students. [1] It is defined as the ability to identify and analyze problems as well as seek and evaluate relevant information to reach an appropriate conclusion. [2] Thus, critical thinking enables medical students to assess their needs for learning ...
A systematic review on critical thinking in medical education
Abstract. Background: Critical thinking is the ability to raise discriminating questions in an attempt to search for better ideas, a deeper understanding and better solutions relating to a given issue. Objective: This systematic review provides a summary of efforts that have been made to enhance and assess critical thinking in medical education.
Teaching Clinical Reasoning and Critical Thinking
The terms "critical thinking" and "clinical reasoning" are used frequently in medical education, often synonymously, but they are rarely explicitly defined. ... from the role of System 1 and System 2 thinking to the impact of cognitive biases on critical thinking, can allow medical educators to effectively teach clinical reasoning ...
What Are Critical Thinking Skills and Why Are They Important?
According to the University of the People in California, having critical thinking skills is important because they are [1]: Universal. Crucial for the economy. Essential for improving language and presentation skills. Very helpful in promoting creativity. Important for self-reflection.
Defining Critical Thinking
Critical thinking...the awakening of the intellect to the study of itself. Critical thinking is a rich concept that has been developing throughout the past 2,500 years. The term "critical thinking" has its roots in the mid-late 20th century. ... A Definition Critical thinking is that mode of thinking - about any subject, content, or problem ...
Thinking critically about critical thinking: ability, disposition or
Qualitative content analysis was conducted to identify patterns and themes. Results: The definitions mostly described critical thinking as a process or an ability; a minority of respondents described it as a personal disposition. In the scenarios, however, the majority of the actions manifesting an absence of critical thinking resulted from ...
Thinking critically
Evaluating information and critical thinking (Word document, 629 KB) Learn how to think critically about your information sources, and evaluate information that you find to ensure that it is reliable, accurate, of good quality, and relevant to your assignment. The Fake News Game.
Teaching and Assessing Critical Thinking and Clinical Reasoning Skills
215. Teaching and Assessing Critical Thinking and Clinical Reasoning Skills in Medical Education. of teaching which dates back to 470-399 BC dur ing Socrates era (Paul, Elder, & Bartell, 1997 ...
PDF A Glossary of Critical Thinking Terms & Concepts
The network of critical thinking terms in this glossary is in no way exhaustive. Many more terms might be added to it. For example, one important concept in critical thinking is captured in the term 'intellectual standards,' which is defined as 'criteria used to evaluate _____ 1 See critical thinking forms and manifestations.
Critical thinking
Critical thinking is the analysis of available facts, evidence, observations, and arguments in order to form a judgement by the application of rational, skeptical, and unbiased analyses and evaluation. [1] In modern times, the use of the phrase critical thinking can be traced to John Dewey, who used the phrase reflective thinking. [2] The application of critical thinking includes self-directed ...
Exploring the link of personality traits and tutors' instruction on
Objectives This study aimed to investigate the associations between critical thinking (CT) disposition and personal characteristics and tutors' guidance among medical graduate students, which may provide a theoretical basis for cultivating CT. Design A cross-sectional study was conducted. Setting This study was conducted in Sichuan and Chongqing from November to December 2021. Participants A ...
Introduction to Critical Thinking Skills
The first summary explains the definition of critical thinking using a meta-level approach; it uses this approach because the problem of defining critical thinking is a meta-problem. The authors argue that the definitions proposed earlier were either subject-specific or skill-specific resulting in definitions that are neither universally ...
Critical thinking
thinking [thingk´ing] ideational mental activity (in contrast to emotional activity); the flow of ideas, symbols, and associations that brings forth concepts and reasons. autistic thinking self-absorption; preoccupation with inner thoughts, daydreams, fantasies, delusions, drives, and personal logic. It is egocentric, subjective thinking lacking ...
Critical thinking: definition and how to improve its skills
Critical thinking is based on the observation and analysis of facts and evidences to return rational, skeptical and unbiased judgments. This type of thinking involves a series of skills that can be created but also improved, as we will see throughout this article in which we will begin by defining the concept and end with tips to build and improve the skills related to critical thinking.
The Imperative of Critical Thinking in Higher Education
On the other hand, critical thinking uses a dynamic and iterative cognitive effort that actively questions hypotheses, seeks evidence, and evaluates arguments. To differentiate between ordinary and critical thinking, for illustration, consider a packaged fruit juice advertisement with a persuasive message about its benefits.
What are Critical Thinking Skills and Why are They Important?
In everyday life, critical thinking might involve analyzing news reports to identify potential biases or considering the long-term implications of a major financial decision. How to build critical thinking skills for better decision-making. Building critical thinking skills requires practice and a deliberate approach.
Governance, long term thinking and leadership experience critical to
The Minerals Income Investment Fund (MIIF) is on track to increase its Assets Under Management (AUM) to over US$3 billion by December 2026, its Board Chairman, Professor Douglas Boateng has said.
Ecological care in nursing practice: a Walker and Avant concept
Today, the human population faces an increasing array of emerging environmental challenges. Despite its importance, nurses often neglect ecological issues, which can compromise patient health. While the ecological nursing perspective has the potential to lead to innovative care approaches that benefit patients, the nursing profession, and the environment, the concept of ecological care lacks a ...

Medical Student Guide For Critical Thinking

Definition of Critical Thinking

Steps to critical thinking

1. Determine the issue or question

2. Research

4. Be careful about confirmation bias

5. Synthesis

6. Make a decision

Why is critical thinking so important for medical students?

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Critical Thinking in Medicine

An encyclopedia of cognitive errors

A smattering of examples

Some juicy quotes

Conclusion: Well worth reading for doctors and for everyone else

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Inculcating Critical Thinking Skills in Medical Students: Ways and Means

Rajiv Mahajan

What is Critical Thinking and why it is Needed?

Strategies and Tools to Promote and Assess the Critical Thinking Skills of Medical Students

Problem-based learning

Case-based learning

Think, pair, and share strategy

Flipped classroom teaching

Reflective writing

Script concordance test

Defining Critical Thinking

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Thinking critically about critical thinking: ability, disposition or both?

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STRENGTHS AND LIMITATIONS OF THIS STUDY

Introduction

Study design and participants

Sampling procedure

Procedure and data collection

Critical Thinking Measurement Scale

Potential Influencing Factors Questionnaire

Supplemental material

Data collection and organisation

Students and public involvement

Statistical analysis

Essential characteristics

Distribution of CT disposition

CT scores are linearly correlated with impact factor scores

Factors influencing CT disposition

Multivariate logistics regression analyses

Strengths and limitations

Conclusions

Ethics statements

Ethics approval

Acknowledgments

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Introduction to Critical Thinking Skills

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