A recently completed Delphi study of critical thinking in nursing (Rubenfeld and Scheffer, 1998) identified skills and attitudes or orientations (habits of the mind) that describe critical thinking in nursing practice. 

 Operationalize these generally stated skills and habits of mind into behaviors that a student can practice and a preceptor can evaluate.  Identify practice examples below.

After you identify some of the specific examples of critical thinking in your practice, two general strategies will assist you in facilitating development of the student's critical thinking:  questioning techniques and role modeling.

Asking questions of oneself, or reflecting, develops expertise in both practice and precepting.  Ford and Profetto-McGrath (1994) proposed a model of critical thinking which is represented in the diagram below.

Ford and Profetto-McGrath suggest that when we encounter a situation, we reflect critically on our knowledge base.  This reflection guides us to select and incorporate other pieces of information in the situation.  For example, when you approach a patient, you choose to collect particular assessment data, based upon your education and previous experience.  Further reflection upon this knowledge will lead you to select and implement action.  After acting, you reflect upon the actions you have taken.  Reflecting on the effectiveness or ineffectiveness of actions you took leads to new knowledge--that you will continue to take your chosen approach with the patient, or you will modify your approach.  In the process you have added to the knowledge base which you will take with you into future encounters with patients.  Reflect on your management of particular patients and identify the relevant questions you can pose to students to guide them in the process of critical reflection.

Recall the levels of the cognitive domain.  The three most complex levels:  analysis, synthesis, and evaluation are the critical thinking levels.  However, asking questions in the three lower levels are often prerequisite to critical thinking questions, unless the student is quite proficient in the care of the patient you are discussing.  The boxes which follow suggest some questions that facilitate both assessing and teaching  at the knowledge-comprehension-application levels at the and at the critical thinking levels of the cognitive domain.

Sample knowledge-Comprehension-Application Questions 

 Sample Critical Thinking Questions 

The questions that you ask display your own critical thinking.  You ask questions about the most important aspects of care and students quickly learn priorities and significance from the aspects that you choose to question.

Ask questions that allow you to assess the student's knowledge base in relation to a particular patient.  For example, the student has assessed a patient who has congestive heart failure and found that the patient has tachycardia.  Ask the student, "Would you expect this patient to have tachycardia?  Why?"

Require the student to do a critical appraisal of treatment from time to time.  When more than one treatment alternative seems reasonable, require the student to review pertinent current research to justify one choice over another for the particular patient in question.  Assist the student to narrow down the question to improve precision of a literature search.  For example, rather than looking for evidence about the effect of digoxin in heart failure, refine the question to something like:  Will elderly patients (like Mr. D) who are in sinus rhythm, have systolic dysfunction, and resultant heart failure following myocardial infarction, have fewer exacerbations if digoxin is added to their diuretic therapy?

Guyatt and Nishikawa (1993) suggest the following outline for student presentation of critical appraisal.

Interrupt the student when necessary to redirect priorities or to show an alternate approach.  Intervening may help the student incorporate the corrections more readily than would a critique after the fact. 

Unlike teaching psychomotor skills, with critical thinking we most often see only the results of the student's thought process and not the thought process itself.  To make the thought process a available for your corrective feedback, ask questions such as, "What did you notice that caused you to pursue that sequence?  How was this like a previous encounter with a patient?  Draw a decision tree to show me how you arrived at that conclusion."

Encourage the student to compare and contrast the treatment plans and responses of similar patients and to identify the features that account for differing responses.

Use the physical examination as an occasion for stimulating critical thinking with questions such as those in the box below.

Encourage the student to partner with a student peer to practice presenting cases.  Instruct the student to present the case succinctly and maintain eye contact with the partner.  Instruct the student to complete the presentation and then ask the partner to give a 30-second summary of what was presented.  Eliciting and examining alternative perspectives is an important part of critical thinking.  This can be practiced with a peer by presenting the case without diagnoses and asking the partner to state and defend diagnoses based upon the information presented.  For example, advise a student to listen to a fellow student when he or she presents a case.  Instruct the student to help the fellow student fill in the gaps in his or her presentation.  This practice will sharpen the case presentation skills of both students.

Pause before you give the student answers and information and challenge yourself to ask the student a question that will help him or her to discover the answer.