Systematic Effective Instruction 2: Going Beyond the Basics to Facilitate Higher-Order and Critical Thinking


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


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.


What comes to mind when you think about critical thinking (or clinical reasoning)?

  • What is critical thinking (or clinical reasoning)?
  • How can one develop critical thinking (or clinical reasoning) skills?
  • Why is critical thinking (or clinical reasoning) important for a physical therapist?


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:

  • Why might Dori be having such difficulty answering these questions?
  • At what level of Bloom’s Taxonomy were the CI’s questions?
  • What strategies can Dori use to help her think through her responses?


Melissa is a physical therapy student working in the acute rehabilitation setting of a local hospital on the spinal cord injury (SCI) service. With an occupational therapist, nurse, social worker, and psychologist, Melissa helps to lead some of the educational sessions for patients adapting to life with an SCI. Education is provided in a group setting of 8 to 10 patients once/day. Today, Melissa’s session is focusing on maintaining skin integrity. Previously, Melissa’s CI taught this material using a PowerPoint presentation and asked the patients some questions at the end of the presentation to assess their understanding. In general, the participants seemed disengaged, and Melissa wondered if they would really be able to apply the information when out of the hospital and back in the community setting.

As part of Melissa’s quality improvement project for her internship, she changes the format of today’s education session in an effort to improve the patients’ learning. She starts with a brief PowerPoint discussion that includes the goals of the session and key points related to pressure relief strategies and equipment management. Next, Melissa asks the patients to work in small groups to problem solve patient cases of individuals with SCI living in the community and experiment with equipment. The participants discuss answers to the following types of questions:

  • What do you do if an air cushion becomes damaged and loses its air while away from home?
  • How do you perform pressure relief if a patient is flying in an airplane for 5 hours across the country?
  • How do you choose the proper equipment for a tub/shower transfer?

They then practice the skills, self-assess their own performance, and give feedback to each other. Melissa also walks around the room to provide immediate feedback in case anyone feels uncertain. The patients present their solutions to the rest of the group for more discussion, and Melissa asks some open-ended questions to extend their thinking. Finally, she assesses their knowledge using a quiz related to key points. Consider the following:

  • What strategies did Melissa use to raise the level of learning for her patients?
  • What level of Bloom’s Taxonomy were Melissa’s questions for the small groups?
  • Why is problem solving important for our patients?

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.


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:


Figure 6-1. Mind map of critical thinking. (Designed by Elizabeth Ruckert; Created by Kristen Wolf, student physical therapist at the George Washington University graduating class of 2017)

  • Who critical thinking applies to (student, patient, clinician)
  • What critical thinking involves (higher-order cognitive skills)’
  • Where critical thinking happens (classroom, clinic, other)
  • How critical thinking occurs (individually and collectively)


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


Developing critical thinking skills is essential for students, therapists, and educators, but why is it also critical for you to help your patients develop and refine their critical thinking skills?

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:


Figure 6-2. Role of classroom instruction in developing critical thinking. (Adapted from Hattie J, Timperley H. The power of feedback. Review of Educational Research. 2007;77(1):81-112; Designed by Elizabeth Ruckert & Linda Cotton; Created by Linda Cotton, Multimedia Specialist, The George Washington University.)

  • Understanding a new health condition means not only understanding the pathology, but also how that affects an individual and how the choices he or she makes can influence that pathology. For example, a patient with diabetes must understand the implications of his or her food and exercise-related decisions and the potential consequences, as well as what to do if a negative consequence, such as hyperglycemia, arises. Ideally, a patient should create a process for choosing foods to eat, the best time for exercise, and a plan for how family/caregivers should respond if he or she has a hyperglycemic issue. These are all higher-order thinking activities.
  • A patient adapting to new equipment must be able to problem solve how the equipment will influence his or her ability to get around his or her home and community. Hopefully, that assistive device improves the patient’s accessibility, but not always. For example, a patient who tore his or her anterior cruciate ligament and is now on crutches will need to problem solve how to get around the environments important for his or her school and social roles (ie, getting up and down the flight of stairs to an apartment entrance or in and out of a friend’s car who is transporting the patient to and from school). This involves planning and creative problem solving on the part of the patient.
  • Learning a new HEP involves critical thinking to consider the home equipment, resources, and/or space needed to perform the exercises; to prioritize which exercises to perform if time is short on a given day or if the patient feels sore; and to know how to progress or regress the exercise on a given day to ensure adequate challenge. Higher-order thinking about a home exercise program may also involve thinking through potential barriers that may prevent the person from performing the exercises and creating strategies to overcome them.


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.2,79 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.


Figure 6-3. Foundational cognitive skills and critical thinkers. (Adapted from Facione PA. Critical Thinking: A Statement of Expert Consensus for Purposes of Educational Assessment and Instruction: Executive Summary: “The Delphi Report.” Millbrae, CA: The California Academic Press; 1990.

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.


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, Dewey12,13 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.


Take a moment to reflect on your individual attitudes and thoughts related to critical thinking by answering the following:

  • Would you use words such as inquisitive and open-minded in describing your process of knowledge acquisition?
  • Do you have self-confidence when confronted with a situation that is ambiguous or that you need to think deeper about?
  • Is your learning guided by a structured and systematic process?


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.1820

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.


Individual Aspects of Critical Thinking

How well do you embody the characteristics related to critical thinking? If you do not, how can you create an individualized learning plan or set goals to help move you out of your comfort zone and expand your thinking? Make it manageable! Your goals may not apply to all of the characteristics, but they should apply to a few, including inquisitiveness, analyticity, and open-mindedness.

  • Do you ask questions often? Do you thrive in a questioning culture? Do you appreciate questions?
  • Do you consider yourself open- or closed-minded? What strategies can help you to keep more of an open mind when approaching new learning situations?
  • Are you confident in yourself and your knowledge base on a given topic? Are you comfortable with not knowing? Do you tolerate ambiguity?
  • Would you describe yourself as having a growth mindset?
  • Do you continually self-regulate by monitoring your decisions and what is influencing the decisions that you are making?
  • How might your answers to these questions affect your ability to engage in critical thinking in the classroom?
  • How might your answers to these questions affect your ability to teach your patients to be critical thinkers?
  • What did you learn that you can use to help your patients be better critical thinkers and problem solvers?

In addition to these individual aspects of critical thinking, it is important to also acknowledge a social component. As a DPT student, you likely feel very familiar with the social aspects of learning. Classroom discussions, group projects, and even informal activities in class and laboratory involve talking and working with others to negotiate the meaning of a given topic. Indeed, the social component of the learning environment should not be underestimated in facilitating higher-order learning.

Social learning theorists, including Bandura, Illeris, Rooter, Lave, and Wenger,2324 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.


Take time to review and reflect on the critical thinking concept map and the foundational cognitive skills presented at the beginning of this section and answer the following:


  • Critical thinking is important in many aspects of your evolution toward becoming a physical therapist—and not just as a student in the classroom.
  • Understanding how to promote critical thinking among patients in clinic and among peers/colleagues in clinical practice is important for maximizing therapy outcomes.
  • Critical thinking involves higher-order cognitive processes that encompass the higher levels of Bloom’s Taxonomy, as well as aspects of self-regulation and self-evaluation.
  • Critical thinking occurs not only as an individual, but also has a social or collective component.


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.


Figure 6-4. (A) Process for developing critical thinking in the classroom.



Figure 6-4. (B) Process for developing critical thinking in the clinic. (Adapted from Duron R, Limbach B, Waugh W. Critical thinking framework for any discipline. International Journal of Teaching and Learning in Higher Education. 2006;17(2):160-166.)

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:

Notice that, in all cases, the trigger leads to reflection on the part of the individual. Also, regardless of the trigger, did you notice the importance of questions and feedback in the higher-order critical thinking cycle? These are hallmark strategies used by teachers in the classroom, and should also be used by you, as a teacher in the clinic. Let us take some time to discuss more about the role of questions and feedback as you help patients to learn in the clinical setting.


Figure 6-5. Examples of lower- and higher-order questions you might consider asking a patient in clinic.

Using Questions for Critical Thinking

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.

Using Feedback for Critical Thinking

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.2729 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)?


Feedback should:

  • Be directly related to a learning event or performance (not given in isolation).
  • Address a specific learning gap.
  • Address a misconception or misinterpretation, but not a complete lack of understanding.26

Feedback should not:

  • Simply be a form of praise, compliment, or punishment.

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May 30, 2017 | Posted by in NURSING | Comments Off on Systematic Effective Instruction 2: Going Beyond the Basics to Facilitate Higher-Order and Critical Thinking

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