Developing “Critical Thinking” in healthcare

Many years ago while preparing for a scuba diving leadership exam, I participated in a simulation exercise. A team of divers and myself left a small rural harbour heading out into the vast Atlantic ocean in a Zodiac inflatable.

The plan was to dive a submerged pinnacle rock face 25 kilometres from shore in 50 meters of water. We were around 20 minutes into our journey when suddenly (scenario started) a diver fell over the side of the sponson and into the water. We were travelling at around 15 knots and someone shouted man over board.

Upon retrieving the diver into the Zodiac, I was asked by the diving officer to show him which way we needed to travel to get back to the harbour, as the diver was unconscious (simulated) and this was an emergency! It was at that point that everyone paused and looked to me for guidance. I looked around and started mumbling as my brain scrambled to make sense of the unfolding sequence of events. IN THAT MOMENT I WAS COMPLETELY LOST at sea.

Finally, I stopped babbling, took a deep breath and a voice in my head said, slow down and focus on the solution. It was then I thought of consulting the dive plan slate (had a navigation course with bearings on it), discussed it with the other divers, formulated a plan and was slowly able to piece together a logical route back to the harbour as our emergency played out!

As a clinician I have also had to deal with many challenging situations in the past. I heavily relied upon the use of “critical thinking” to develop solutions to complex problems through discussion, critiquing those solutions or recommendations, while then formulating an action plan, and applying it.

So how do we prepare clinicians to apply “critical thinking” during acute or stressful clinical care events? In fact, how does any business prepare its staff for those stressful and challenging “critical thinking” events in their business?

Cognitive psychology is the basic science that explores how people reason, formulate judgements and make decisions. The recurrent observation is that people make mistakes when they encounter complex problems.

Healthcare systems are evolving and emphasis should be placed on healthcare professionals to develop creative and critical thinking skills so that they can administer optimal patient care.
Critical thinking skills have been linked to improved patient outcomes, better quality patient care and improved safety outcomes. While problem-solving tends to focus on the identification and resolution of a problem, critical thinking involves asking skilled questions and critiquing solutions.

Critical thinking includes “analysis, inference, interpretation, explanation, synthesis and self –regulation”. Don’t forget Blooms Taxonomy and the 6 levels of the cognitive domain! Coupled with structured practice and repetition in a simulated learning environment clinicians can become more competent and confident in applying critical thinking during clinical care and creating new learnings.

Now lets road test this in a cardiac arrest hospital scenario!

During a resuscitation event in a hospital setting, its likely that a code or MET team have arrived on scene to support the team that activated the CODE/MET. Often in these early few minutes the scene can be disjointed and chaotic and desperately requires team leadership to formally bring all of the elements together, adding a cohesive and structured approach to caring for the patient and bringing out the best from all clinicians involved.

The need to apply critical thinking in this scenario could determine the patient’s potential survival. The leader is often the most senior clinician, either a senior nurse or doctor and it is their responsibility to form the team and allocate tasks to clinicians with relevant skills (CPR, Airway, defibrillation, IV Access for cardiac arrest drugs, and reversible causes). That said, it is not always the case that a team forms quickly, with clear role delineation, as this requires someone to take a leadership role and sometimes it gets over crowded!

However, assuming this leadership role is established, and roles are allocated, it is now down to the team leader and the team members to work in a synchronous way to reverse the causes of cardiac arrest and restore spontaneous cardiac output for the patient. In this scenario the team leader has a weighty responsibility and must critically think through the key reversible causes of cardiac arrest while requiring input from team members as required. As happens so often in this scenario cognitive aids can be overlooked, and therefor memory recall is relied upon during a stressful event.

Many lessons have been learned from the aviation industry regarding the use of check lists in an emergency, just like the cognitive aids we have in clinical settings, such as the advanced life support algorithms developed by the International Liaison Committee on Resuscitation (ILCOR) and taught by the Australian Resuscitation Council and many in hospital resuscitation courses.

The team leader is like the conductor of an orchestra. The use of critical thinking skills in this setting should see cognitive bias pushed aside, team members asked for input regarding how to treat the underlying cause of the cardiac arrest, closing the communication loop across required interventions, allowing people to perform in their allocated roles, while recognising when someone is fatigued and may need to be replaced or rested. Also, recapping or summarising for the team to ensure everyone is on the same page, especially as other clinicians arrive to help and join the team.

Critical thinking will also require the clinical team leader to think ahead of time, planning the use of additional resources, expertise or specialties, especially for post resuscitation care, such as the catheterisation laboratory (Cath Lab), targeted temperature management, etc.  

Based on the above scenario it is evident that critical thinking skills are not intuitive but need to be developed and coached over time, and using a guiding hand.

It is everyone’s responsibility to develop their critical thinking skills, however, it is more important for organisations to recognise the importance of investing in simulation-based education to support structured safe practice and rehearsal of these critical thinking skills in simulated learning environments. Finally, learning outcomes can be achieved through structured instructor led debriefing.

The below video “A hospital mistake results in a cardiac arrest” is a good example of critical thinking and effective leadership in play, however, an error was missed due to poor communication during the initial management of the patient. A consequence of this led to the treatment of the patient moving down a traumatic cardiac arrest management pathway, which led to some undesired additional patient interventions. At least it was a happy ending!

Also check out;

Critical Thinking in Critical Care: Five Strategies to Improve Teaching
and Learning in the Intensive Care Unit

Check out Mater Educations simulation debriefing programs @