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Systematic Effective Instruction 2

Going Beyond the Basics to Facilitate Higher-Order and Critical Thinking

Elizabeth Ruckert, PT, DPT, NCS, GCS and Margaret M. Plack, PT, DPT, EdD

CHAPTER OBJECTIVES

After reading this chapter, the reader will be prepared to:

• Define critical thinking.
  
• Explore a framework for developing critical thinking.
  
• Examine the role of questions, active practice, reflection, and feedback in critical thinking.
  
• Use scaffolding as a strategy to develop critical thinking.
  
• Create learning events in the classroom and clinic to facilitate higher-order thinking.

CASE EXAMPLE #1

Dori is third-year doctor of physical therapy (DPT) student currently at an outpatient clinic for her final internship. She has been a strong student throughout her didactic preparation and is very excited to be so close to graduation. However, Dori has had a tough adjustment during the first 2 weeks in the clinic. Her clinical instructor (CI) asks questions that she feels are very hard to answer. “I really have to think in a different way,” Dori said about her CI to a fellow student. Instead of asking questions about common red flags to anticipate for a patient coming in post-op, her CI asks the following types of questions:

• What was your thought process during that exercise progression? How did you decide to change exercises?
  
• How do you expect the patient to move given this surgery? Was this the same or different from what you encountered in the patient’s session?
  
• Based on what you saw today and the patient’s positive and negative prognostic factors, where do you see this patient in 8 weeks?

Dori is feeling discouraged about her current performance and her struggles in responding to her CI’s questions in an efficient and accurate way. Consider the following:

As discussed in Chapter 2, critical thinking is essential to the clinical practice of a physical therapist. Dori is struggling with her ability to answer questions at the upper levels of Bloom’s Taxonomy to support her clinical decisions. Melissa changes the delivery of patient education from passive lecture to active problem solving and engagement, with the goal of better preparing her patients for the real-world realities of living with SCI. Even for you, as a student in the physical therapy classroom today, learning how to refine your thinking skills to understand material presented in class and to be able to study, apply that information in the clinic, and use it for future professional development is important.

The purpose of this chapter is to focus on different ways to promote higher-order thinking in ourselves and our learners (student, colleague, patient) both in the classroom and the clinic. Specifically, we explore how critical thinking relates to clinical practice for both therapists and patients alike. Then we discuss specific strategies that we can use in the classroom and the clinic to achieve higher levels of learning among learners.

PART 1: COMPONENTS OF CRITICAL THINKING

Critical thinking is considered a higher-order thinking skill. When you think about Bloom’s Taxonomy, critical thinking involves the higher steps of the taxonomy pyramid, including application, analysis, synthesis, and evaluation or, in the revised taxonomy application, analysis, evaluation, and creation. In this way, it is a skill that involves not only knowing information, but also being able to reason, interpret, and create new meaning with that information. Elder and Paul¹ define critical thinking as a “mode” of thinking “in which the thinker improves the quality of his or her thinking by skillfully analyzing, assessing, and reconstructing it. Critical thinking is self-directed, self-disciplined, self-monitored, and self-corrective thinking” (p. 88). This definition of critical thinking is helpful because it emphasizes that higher-order thinking requires levels of self-evaluation and self-monitoring—to think about one’s thinking, one’s biases, one’s assumptions—and it suggests that critical thinking requires discipline and initiation or self-direction on the part of the learner. Yes, it requires considerable mental effort from the individual and, as you remember, these very same terms were used to describe the reflective process, which is integral to the development of critical thinking. Critical thinking involves a process with many different components, including the learner, the environment, and specific cognitive strategies. Figure 6-1 provides a mind map that visually represents the following conceptual framework of critical thinking:

As you read this chapter, think about the different lenses that you have when considering the concept of critical thinking. Critical thinking applies to you currently as a student in the classroom. Your professors are challenged not only with helping you to understand foundational concepts related to anatomy, physiology, examination techniques, exercise prescription, and therapeutic interventions, among others, but also with developing the way in which you think and make clinical decisions. By posing difficult questions, challenging your assumptions, consulting research evidence, and simulating patient scenarios, your professors are helping you to apply, analyze, and develop new meaning from the foundational information you learned. Each new experience, each new and more advanced concept, modifies and enhances your understanding of these foundational concepts. A helpful visual comes to mind as one thinks about the role of classroom instruction in developing critical thinking (Figure 6-2). It is not about filling your brain with all of the information possible. It is about helping you to develop a different outlook and perspective toward learning. It is also about helping students (or novice clinicians) make linkages between concepts and use frameworks or processes to support their thinking. Figures 6-2A and 6-2B help to highlight this.

Critical thinking also applies to your future role as a physical therapist, as you make challenging clinical decisions with complex patients. Physical therapists must be adaptable, flexible, and reflective in their thought processes to make clinical decisions in the best interest of their patients. In fact, errors in clinical reasoning are linked to medical errors and events that can result in significant morbidity and mortality for patients.^2,3 Later in this chapter, we discuss the Hypothesis-Oriented Algorithm for Clinicians (HOAC) I and II, which are frameworks designed to help physical therapists critically think about their patients during an episode of care.^4,5

It may be more intuitive for you to acknowledge why a student and a physical therapist require critical thinking skills; but have you ever thought about why critical thinking and problem solving are also important skills for patients to develop? Patients are constantly learning new things in therapy and must be able to apply and adapt the health information to their own lives. For example, patients need to understand the implications of a new or chronic health condition, know how to use new equipment in different environments, learn to perform and progress their home exercise program (HEP) independent of the physical therapist, and problem solve mobility challenges that they encounter. Can you think about why each of these situations requires critical thinking? A few examples are as follows:

Critical thinking involves a set of high-level cognitive skills for an individual to perform. Figure 6-3 describes the cognitive skills essential to critical thinking, as determined by the American Philosophical Association Delphi Research Report.⁶ The 6 foundational cognitive skills of critical thinkers include interpretation, analysis, evaluation, inference, explanation, and self-regulation. As you look at these skills, Bloom’s Taxonomy may come to mind. Notice how these items do not relate to basic knowledge, recognition, or identification; however, basic knowledge and understanding of concepts are assumed. These skills are at the highest levels of Bloom’s Taxonomy, including analysis, synthesis, and evaluation.

Clinical reasoning is the product of all of these cognitive skills combined. Clinical reasoning is a very high-level thinking process that enables you to answer clinical questions and to develop a clinical plan of care. Clinical reasoning, like critical thinking, does not just develop overnight. Clinical reasoning takes time and experience to develop and grow, as evidenced by the different reasoning strategies and thinking processes used by experts to make clinical decisions as compared with novice practitioners.^2,7,8 Expert practitioners use a more efficient, forward-reasoning process.^2,7–9 Forward reasoning occurs when a clinician uses past experiences to recognize patterns within a patient’s presentation and then uses those patterns to gather additional information to make informed clinical decisions. This reasoning is more efficient than the process of a novice, which tends to be driven by hypothesis formation and confirmation. Literature suggests that novices use a hypothetico-deductive process that involves starting with the big picture with a number of potential hypotheses, and slowly confirming or refuting each of them.⁹ As you might expect, this process is more time consuming and inefficient. In addition to using a forward-reasoning process, expert decision making is also characterized by a patient-centered foundation.^8,9 Resnik and Jensen⁸ report that experts were more likely than novices to encourage patient empowerment and collaborative problem solving with their patients. Expert care was further characterized by professionals who value the patient’s ideas and goals, use information from the patient to drive the session, and focus on the importance of empowering patients through education. Indeed, experts practice in a way that is tailored to the unique needs of each individual patient. Unlike the more novice clinician who remains focused on collecting clinical data to make decisions, the expert maintains focus on the patient and the patient’s perspective in addition to clinical data collection.⁹ This process requires many of the higher-order thinking cognitive skills described by Facione,⁶ not the least of which is self-regulation.

Models have been developed to provide novice practitioners with a structure for developing clinical reasoning skills in medical and health professions. Specifically relevant to physical therapy are the HOAC I and II4,5 models. With students, novice clinicians, and experienced clinicians in mind, these frameworks were created to assist clinicians in their thinking processes: gathering information, creating hypotheses, and assessing patient responses to ultimately make informed clinical decisions. The following specific question prompts included in HOAC II highlight the patient management process:

• Are the goals appropriate?
  
• Are the interventions being implemented correctly?
  
• Do the assessments (measurements) match anticipated patient problems and goals?

In a model like HOAC II, these questions help novice practitioners in particular to develop a framework for their clinical thinking process. Through a step-by-step structure, the model helps the therapist to evaluate his or her own effectiveness, consider alternate solutions, and modify or change the process. In essence, these frameworks become a structured and more deliberate method of reflecting and critical thinking for therapists; they help us to more explicitly understand the thought process behind the patient management process.

Where

Duron and colleagues¹⁰ suggest that one’s environment is critical to the development and performance of critical thinking. In earlier chapters, we discussed the importance of creating a safe learning environment, where it is okay to ask questions and make mistakes. This is also known as creating or encouraging a questioning culture or a why culture.¹¹ Think about a classroom environment in which the teacher provoked you to think in a different way, perhaps by frequently asking questions (some with no right answer) and encouraging you to do the same. Compare this process with that of a teacher whose class sessions were predictable and almost rote. How would you describe the classroom environment of the first teacher? Likely, it was more engaging and potentially had more dialogue and discussion compared with the second teacher’s classroom environment, which was likely more passive and lecture-focused. Which one made you use your higher-order thinking and problem-solving skills vs your lower-order listening and memorizing skills? Likely the first!

An authentic environment that relates to a learner’s future professional roles or a patient’s personal roles is also helpful in promoting and challenging higher-order reasoning and processing. Consider the differences in your own thinking and learning process in a physical therapy classroom as compared with observing a live patient interaction in the clinic, working with patient volunteers in a laboratory setting, or even engaging with standardized patients. As discussed in Chapter 1, Dewey^12,13 and Kolb¹⁴ both describe the central role that experience plays in learning; however, you also remember that Dewey says that experience is not enough. From experience, you must create personal meaning, reflect on how that meaning is similar to or different from prior conceptions or experiences, and apply that to future contexts.¹⁴ The context of an authentic environment also appeals to adult learners who need to know the why behind what they learn and see how knowledge can be applied to their future personal or professional needs.^15,16 Especially in professional education, an authentic environment helps to motivate learners related to the content, but the same is true for your patients. If they understand why they need to know something that you are teaching them and how they will use it in their own lives, they will likely be more motivated to learn. An example of this relates back to our initial scenario with Melissa’s redesign of the patient education session on SCI. Setting the stage about the prevalence of pressure sores following SCI and the severe health consequences of pressure sores can help to engage learners. Better yet, if a person with SCI could come and speak to the patient education group about his or her experience with pressure sores and the importance of the education, it does not get much more authentic than that!

Besides creating a questioning culture and providing authentic experiences from which to problem solve, a third important consideration for the critical thinking environment is that of time. As the therapy episode of care continues to shorten due to managed care constraints, physical therapists are becoming even more challenged to make time for questioning and problem solving with their patients. Critical thinking takes time, but we have also discussed how critical thinking is essential for patients who are reintegrating into their prior life roles after an illness or injury. Individuals need time to process information, especially when they are being asked to apply or analyze the information at a higher level. This is especially true for patients with cognitive deficits who still should be required to problem solve in therapy, but the process may take longer. This focus on the importance of critical thinking with patients in the clinic is a relatively novel concept for many health systems; yet, given the shortened lengths of stay and decreased episodes of care, patient education and problem solving becomes even more critical. How might this impact your plan for a given therapy session, your ability to bill for a patient session, and the ability of other health care team members to provide and review education topics? These are important questions to consider when working on critical thinking skills with patients.

How

Critical thinking involves both individual and social components. Literature supports the view that there is a predisposition of critical thinkers that involves “inquisitiveness, open-mindedness, systematicity, analyticity, truth-seeking, self-confidence and maturity.”^{17(p 346)} Also described as a critical spirit, the concept suggests that knowledge alone does not create a critical thinker.²⁰ Although knowledge is an important foundation for critical thinking, there are also affective and attitudinal aspects of critical thinking, such as being curious, analytical, and confident in adapting one’s views based on information or new understanding; tolerating ambiguity; and seeing the truth or best evidence.^18–20

Mindset is another aspect of the individual that is important in developing critical thinking. Higher-order thinking is challenging for a learner, so embracing a growth mindset in the classroom and the clinic is invaluable.²¹ As noted earlier in this text, growth mindset is related to the idea that intelligence and knowledge grows over time, whereas a fixed mindset suggests that intelligence is a genetically based and predetermined trait. Students with a growth mindset are more likely to look at intellectual challenges as exciting opportunities to learn, grow, and change; challenges are viewed as necessary in the learning process. Individuals with fixed mindsets, however, perceive that challenges highlight their learning deficiencies, suggest that they are not smart, and show that they are unable to make improvement. A fixed mindset causes the individual concern over how making mistakes will affect how others view him or her. Mindset, in combination with patient views about the patient-provider relationship, time, and the environment, are important factors to consider when encouraging higher-order thinking and strategies for success with this level of learning as a student, patient, and clinician.

Social learning theorists, including Bandura, Illeris, Rooter, Lave, and Wenger,23–24 describe the importance of being able to observe, gain knowledge, collaborate, and negotiate with others as part of the learning process. Specifically, Illeris²⁵ describes learning as a social process that involves content knowledge, motivation, and interaction. To learn, individuals must work and communicate with one another to make meaning and solve complex problems in different and unique situations. Learning requires critically thinking, discussing, and negotiating meaning with others, not just thinking in isolation as an individual. Collaborative knowledge generation and application help individuals to think about content in new ways and provide meaning based on different individuals’ experiences and reflections. This is directly related to many active learning strategies that are used in the classroom (discussed later in this chapter). These same concepts hold true in the clinical setting. Whether you are working with your patients one-on-one or having them work in small groups, dialogue and collaborative problem solving will enhance their learning.

If critical thinking is so important for physical therapists, patients, and students in the classroom, you might be wondering about ways in which critical thinking can be facilitated and developed. Figures 6-4A and 6-4B suggest a process for developing critical thinking, including classroom and clinic environments. We start in the classroom (see Figure 6-4A) as a student. As we describe this, you can also consider the cycle from the lens of a teacher and how a teacher can create learning events to develop critical thinking. First, critical thinking starts with just thinking or learning, as it relates to a learning objective or a learning event. A trigger will occur for the learner, related to a gap in knowledge, a mismatch in what was expected vs what occurred, or an ambiguous situation that is hard to understand. From there, questions will arise and answers will be pursued. This may involve dialoguing with classmates or peers, comparing and contrasting the knowledge with prior experiences (eg, past patients with similar presentations, didactic knowledge that compares and contrasts with new knowledge), or finding new information through research. Next, the individual will engage in active and social learning through authentic practice (if possible) to begin clarifying and applying the information gained. In the classroom, this may mean actively debating knowledge with a group member or applying new knowledge to a paper case example. As the learners apply the information to real life, they will continue to self-reflect on the information and think about how it can be applied in other new and different ways. The learners may also reflect on their own thinking, asking, “What process did I use to understand this better? How might this process help me in the future? How might I change this process for the future?” As you see, reflection is a critical component of the process. Lastly, in a classroom setting, learners will often demonstrate their new knowledge in some form, whether a paper, a written examination, or a practical examination. Feedback is also an important part of the critical thinking cycle and may happen at any point of the process. Learners can receive feedback and provide feedback (ie, to the instructor or other learning partners) related to the learning event or the learning process as a whole.

The classroom critical thinking process can also be applied to higher-order thinking, or clinical decision making, in the physical therapy clinic (see Figure 6-4B). The cycle starts upon determining the patient’s goals for your plan of care. Do you see how a patient’s goals are similar to learning objectives in the classroom? A trigger occurs when the patient is not meeting the goals or responding to treatment as expected. It causes the therapist to question why the patient is not making gains. The therapist may consult other therapists, consult available evidence, and think about prior patient experiences. Based on information collected from others and his or her own thoughts, the therapist begins the active process of collecting additional data from patient reassessment, trying different interventions, and maybe consulting with other health care providers as appropriate. This involves an ongoing process of self-reflection on the part of the therapist. The therapist gathers feedback from the patient, from other therapists, and from the patient’s performance within therapy, to continue to refine his or her learning process.

The critical thinking cycle can start at different points in the cycle; the descriptions above start with learning objectives in a scheduled classroom session or patient goals within a plan of care. Some other examples of when the critical thinking process could be triggered are as follows:

• While practicing different interventions/techniques: A therapist might reflect and realize that he or she does not know enough about the foundational information or theories that serve as the rationale for the intervention.
  
• Receiving feedback from a patient: A therapist learns that the patient does not think that therapy is helping, and this causes the therapist to self-reflect and engage in learning about the patient, his or her condition, and response in a deeper way.
  
• Questioning from a colleague: A therapist is probed to think more deeply when a colleague asks for his or her advice on a difficult and complex patient case.
  
• Designing an in-service: A therapist prepares a case report presentation for a staff in-service related to a recent complex patient case. This helps the therapist reflect on the thought process that he or she used in guiding the patient’s physical therapy management.

As you may remember from Chapter 2 on reflection, questions are at the heart of the reflective process and form the basis for the development of critical thinking. Walker²¹ actually suggests that the most important strategy in the development of critical thinking is questioning. Questions are used to confirm foundational understanding of material, pose conflicts, create problem-solving scenarios, establish debates, and facilitate reflection on prior or new knowledge. Questions can require students or patients to take a stance or position and provide justification or rationale for why they came to a certain decision or conclusion. You may also remember from Chapter 2 that why questions are an excellent way to examine assumptions and promote deeper levels of learning. The next time you are sitting in class or studying individually or with a group of peers, think about the following questions:

• How do you encourage yourself or a peer to think beyond simple recall of information?
  
• Do you typically ask questions that require a yes/no response only?
  
• Do you ask questions expecting a specific description or response?
  
• Do you ask questions that require a learner to have memorized information?

As you remember from previous discussions on questions in Chapter 2, these are examples of lower-order thinking questions. Although these types of questions are important in determining your foundational knowledge, this level of questions does not promote higher-level thinking. In fact, Duron et al¹⁰ suggests that convergent questions, or questions that require one correct response, are usually lower-order thinking questions. In contrast, divergent questions, or those that are open-ended and encourage dialogue and consideration of multiple perspectives and possibilities, relate more to higher-order thinking.¹⁰

Now think about the clinical setting. Do you approach your patient as a learner the way that you consider yourself a learner in the classroom? How do you use questions to help your patients to learn and attain their therapy goals? Consider the following:

• Do you ever pose hypothetical clinical or community scenarios to your patients/learners?
  
• Do you ever ask questions with vague information to help your patients/learners process ambiguous situations?
  
• Do you ever require your patients to justify their decisions using rationale?
  
• Do you ever ask your patients to problem solve how to manage different scenarios?

These are examples of questions that could help stimulate higher-order thinking in your patients and make them better problem solvers in the long run. Refer to Figure 6-5 to see some additional examples of lower- and higher-order questions that you might consider asking a patient in clinic.

Feedback is used to help learners make progress toward achieving a goal, outcome, or learning objective, and should be a regular part of any learning environment (classroom to clinic). As physical therapists, we are constantly deciding on the type and frequency of feedback to provide our patients on how they move and strategies for improvement. We need to consider the types of feedback that can best help our patients (and ourselves as learners as well!). In their systematic review of the literature, Hattie and Timperley26 found that feedback was among the most influential factors affecting student learning (effect size = 0.79). More recent reviews are more equivocal about the impact of feedback on learning; regardless, feedback remains an integral part of the teaching-learning process in medicine and health.^27–29 As you learned in Chapter 3, feedback can be complex and not all feedback is good feedback. To be effective, much needs to be considered when giving feedback.^26,30,31 Feedback should be specific, related to goals, and delivered using different modalities (ie, written, verbal). In terms of the timing of delivery, timely feedback is more important for a novice learner who is just learning a new task, skill, or concept; while delayed feedback will encourage the transfer of knowledge in a learner with greater expertise.³⁰ Delayed feedback helps individuals to apply knowledge in new or novel situations. Feedback should be directly related to a learning event or performance (not given in isolation), address a specific learning gap, and address a misconception or misinterpretation, but not a large deficit in fundamental understanding.²⁶

Feedback has been shown to be less effective when it is simply a form of praise, compliment, or punishment. With these considerations in mind, ask yourself the following:

• Do I give my patients specific or general feedback about their performance and/or learning?
  
• Does most of my feedback consist of a verbal “Good job!” or “Well done!” without any specific performance or goal-related information?
  
• Do I provide multiple modes of information (ie, written, visual [eg, video])?
  
• Do I update patients on their progress toward goals using the objective measures that I regularly use for assessment (eg, Timed Up and Go test, Functional Reach test)?

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