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Critical thinking in healthcare and education

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• Peer review
• Jonathan M Sharples , professor 1 ,
• Andrew D Oxman , research director 2 ,
• Kamal R Mahtani , clinical lecturer 3 ,
• Iain Chalmers , coordinator 4 ,
• Sandy Oliver , professor 1 ,
• Kevan Collins , chief executive 5 ,
• Astrid Austvoll-Dahlgren , senior researcher 2 ,
• Tammy Hoffmann , professor 6
• 1 EPPI-Centre, UCL Department of Social Science, London, UK
• 2 Global Health Unit, Norwegian Institute of Public Health, Oslo, Norway
• 3 Centre for Evidence-Based Medicine, Oxford University, Oxford, UK
• 4 James Lind Initiative, Oxford, UK
• 5 Education Endowment Foundation, London, UK
• 6 Centre for Research in Evidence-Based Practice, Bond University, Gold Coast, Australia
• Correspondence to: J M Sharples Jonathan.Sharples{at}eefoundation.org.uk

Critical thinking is just one skill crucial to evidence based practice in healthcare and education, write Jonathan Sharples and colleagues , who see exciting opportunities for cross sector collaboration

Imagine you are a primary care doctor. A patient comes into your office with acute, atypical chest pain. Immediately you consider the patient’s sex and age, and you begin to think about what questions to ask and what diagnoses and diagnostic tests to consider. You will also need to think about what treatments to consider and how to communicate with the patient and potentially with the patient’s family and other healthcare providers. Some of what you do will be done reflexively, with little explicit thought, but caring for most patients also requires you to think critically about what you are going to do.

Critical thinking, the ability to think clearly and rationally about what to do or what to believe, is essential for the practice of medicine. Few doctors are likely to argue with this. Yet, until recently, the UK regulator the General Medical Council and similar bodies in North America did not mention “critical thinking” anywhere in their standards for licensing and accreditation, 1 and critical thinking is not explicitly taught or assessed in most education programmes for health professionals. 2

Moreover, although more than 2800 articles indexed by PubMed have “critical thinking” in the title or abstract, most are about nursing. We argue that it is important for clinicians and patients to learn to think critically and that the teaching and learning of these skills should be considered explicitly. Given the shared interest in critical thinking with broader education, we also highlight why healthcare and education professionals and researchers need to work together to enable people to think critically about the health choices they make throughout life.

Essential skills for doctors and patients

Critical thinking …

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The Value of Critical Thinking in Nursing

• How Nurses Use Critical Thinking
• How to Improve Critical Thinking
• Common Mistakes

Some experts describe a person’s ability to question belief systems, test previously held assumptions, and recognize ambiguity as evidence of critical thinking. Others identify specific skills that demonstrate critical thinking, such as the ability to identify problems and biases, infer and draw conclusions, and determine the relevance of information to a situation.

Nicholas McGowan, BSN, RN, CCRN, has been a critical care nurse for 10 years in neurological trauma nursing and cardiovascular and surgical intensive care. He defines critical thinking as “necessary for problem-solving and decision-making by healthcare providers. It is a process where people use a logical process to gather information and take purposeful action based on their evaluation.”

“This cognitive process is vital for excellent patient outcomes because it requires that nurses make clinical decisions utilizing a variety of different lenses, such as fairness, ethics, and evidence-based practice,” he says.

How Do Nurses Use Critical Thinking?

Successful nurses think beyond their assigned tasks to deliver excellent care for their patients. For example, a nurse might be tasked with changing a wound dressing, delivering medications, and monitoring vital signs during a shift. However, it requires critical thinking skills to understand how a difference in the wound may affect blood pressure and temperature and when those changes may require immediate medical intervention.

Nurses care for many patients during their shifts. Strong critical thinking skills are crucial when juggling various tasks so patient safety and care are not compromised.

Jenna Liphart Rhoads, Ph.D., RN, is a nurse educator with a clinical background in surgical-trauma adult critical care, where critical thinking and action were essential to the safety of her patients. She talks about examples of critical thinking in a healthcare environment, saying:

“Nurses must also critically think to determine which patient to see first, which medications to pass first, and the order in which to organize their day caring for patients. Patient conditions and environments are continually in flux, therefore nurses must constantly be evaluating and re-evaluating information they gather (assess) to keep their patients safe.”

The COVID-19 pandemic created hospital care situations where critical thinking was essential. It was expected of the nurses on the general floor and in intensive care units. Crystal Slaughter is an advanced practice nurse in the intensive care unit (ICU) and a nurse educator. She observed critical thinking throughout the pandemic as she watched intensive care nurses test the boundaries of previously held beliefs and master providing excellent care while preserving resources.

“Nurses are at the patient’s bedside and are often the first ones to detect issues. Then, the nurse needs to gather the appropriate subjective and objective data from the patient in order to frame a concise problem statement or question for the physician or advanced practice provider,” she explains.

Top 5 Ways Nurses Can Improve Critical Thinking Skills

We asked our experts for the top five strategies nurses can use to purposefully improve their critical thinking skills.

Case-Based Approach

Slaughter is a fan of the case-based approach to learning critical thinking skills.

In much the same way a detective would approach a mystery, she mentors her students to ask questions about the situation that help determine the information they have and the information they need. “What is going on? What information am I missing? Can I get that information? What does that information mean for the patient? How quickly do I need to act?”

Consider forming a group and working with a mentor who can guide you through case studies. This provides you with a learner-centered environment in which you can analyze data to reach conclusions and develop communication, analytical, and collaborative skills with your colleagues.

Practice Self-Reflection

Rhoads is an advocate for self-reflection. “Nurses should reflect upon what went well or did not go well in their workday and identify areas of improvement or situations in which they should have reached out for help.” Self-reflection is a form of personal analysis to observe and evaluate situations and how you responded.

This gives you the opportunity to discover mistakes you may have made and to establish new behavior patterns that may help you make better decisions. You likely already do this. For example, after a disagreement or contentious meeting, you may go over the conversation in your head and think about ways you could have responded.

It’s important to go through the decisions you made during your day and determine if you should have gotten more information before acting or if you could have asked better questions.

During self-reflection, you may try thinking about the problem in reverse. This may not give you an immediate answer, but can help you see the situation with fresh eyes and a new perspective. How would the outcome of the day be different if you planned the dressing change in reverse with the assumption you would find a wound infection? How does this information change your plan for the next dressing change?

Develop a Questioning Mind

McGowan has learned that “critical thinking is a self-driven process. It isn’t something that can simply be taught. Rather, it is something that you practice and cultivate with experience. To develop critical thinking skills, you have to be curious and inquisitive.”

To gain critical thinking skills, you must undergo a purposeful process of learning strategies and using them consistently so they become a habit. One of those strategies is developing a questioning mind. Meaningful questions lead to useful answers and are at the core of critical thinking .

However, learning to ask insightful questions is a skill you must develop. Faced with staff and nursing shortages , declining patient conditions, and a rising number of tasks to be completed, it may be difficult to do more than finish the task in front of you. Yet, questions drive active learning and train your brain to see the world differently and take nothing for granted.

It is easier to practice questioning in a non-stressful, quiet environment until it becomes a habit. Then, in the moment when your patient’s care depends on your ability to ask the right questions, you can be ready to rise to the occasion.

Practice Self-Awareness in the Moment

Critical thinking in nursing requires self-awareness and being present in the moment. During a hectic shift, it is easy to lose focus as you struggle to finish every task needed for your patients. Passing medication, changing dressings, and hanging intravenous lines all while trying to assess your patient’s mental and emotional status can affect your focus and how you manage stress as a nurse .

Staying present helps you to be proactive in your thinking and anticipate what might happen, such as bringing extra lubricant for a catheterization or extra gloves for a dressing change.

By staying present, you are also better able to practice active listening. This raises your assessment skills and gives you more information as a basis for your interventions and decisions.

Use a Process

As you are developing critical thinking skills, it can be helpful to use a process. For example:

• Ask questions.
• Gather information.
• Implement a strategy.
• Evaluate the results.
• Consider another point of view.

These are the fundamental steps of the nursing process (assess, diagnose, plan, implement, evaluate). The last step will help you overcome one of the common problems of critical thinking in nursing — personal bias.

Common Critical Thinking Pitfalls in Nursing

Your brain uses a set of processes to make inferences about what’s happening around you. In some cases, your unreliable biases can lead you down the wrong path. McGowan places personal biases at the top of his list of common pitfalls to critical thinking in nursing.

“We all form biases based on our own experiences. However, nurses have to learn to separate their own biases from each patient encounter to avoid making false assumptions that may interfere with their care,” he says. Successful critical thinkers accept they have personal biases and learn to look out for them. Awareness of your biases is the first step to understanding if your personal bias is contributing to the wrong decision.

New nurses may be overwhelmed by the transition from academics to clinical practice, leading to a task-oriented mindset and a common new nurse mistake ; this conflicts with critical thinking skills.

“Consider a patient whose blood pressure is low but who also needs to take a blood pressure medication at a scheduled time. A task-oriented nurse may provide the medication without regard for the patient’s blood pressure because medication administration is a task that must be completed,” Slaughter says. “A nurse employing critical thinking skills would address the low blood pressure, review the patient’s blood pressure history and trends, and potentially call the physician to discuss whether medication should be withheld.”

Fear and pride may also stand in the way of developing critical thinking skills. Your belief system and worldview provide comfort and guidance, but this can impede your judgment when you are faced with an individual whose belief system or cultural practices are not the same as yours. Fear or pride may prevent you from pursuing a line of questioning that would benefit the patient. Nurses with strong critical thinking skills exhibit:

• Learn from their mistakes and the mistakes of other nurses
• Look forward to integrating changes that improve patient care
• Treat each patient interaction as a part of a whole
• Evaluate new events based on past knowledge and adjust decision-making as needed
• Solve problems with their colleagues
• Are self-confident
• Acknowledge biases and seek to ensure these do not impact patient care

An Essential Skill for All Nurses

Critical thinking in nursing protects patient health and contributes to professional development and career advancement. Administrative and clinical nursing leaders are required to have strong critical thinking skills to be successful in their positions.

By using the strategies in this guide during your daily life and in your nursing role, you can intentionally improve your critical thinking abilities and be rewarded with better patient outcomes and potential career advancement.

Frequently Asked Questions About Critical Thinking in Nursing

How are critical thinking skills utilized in nursing practice.

Nursing practice utilizes critical thinking skills to provide the best care for patients. Often, the patient’s cause of pain or health issue is not immediately clear. Nursing professionals need to use their knowledge to determine what might be causing distress, collect vital information, and make quick decisions on how best to handle the situation.

How does nursing school develop critical thinking skills?

Nursing school gives students the knowledge professional nurses use to make important healthcare decisions for their patients. Students learn about diseases, anatomy, and physiology, and how to improve the patient’s overall well-being. Learners also participate in supervised clinical experiences, where they practice using their critical thinking skills to make decisions in professional settings.

Do only nurse managers use critical thinking?

Nurse managers certainly use critical thinking skills in their daily duties. But when working in a health setting, anyone giving care to patients uses their critical thinking skills. Everyone — including licensed practical nurses, registered nurses, and advanced nurse practitioners —needs to flex their critical thinking skills to make potentially life-saving decisions.

Meet Our Contributors

Crystal Slaughter is a core faculty member in Walden University’s RN-to-BSN program. She has worked as an advanced practice registered nurse with an intensivist/pulmonary service to provide care to hospitalized ICU patients and in inpatient palliative care. Slaughter’s clinical interests lie in nursing education and evidence-based practice initiatives to promote improving patient care.

Jenna Liphart Rhoads is a nurse educator and freelance author and editor. She earned a BSN from Saint Francis Medical Center College of Nursing and an MS in nursing education from Northern Illinois University. Rhoads earned a Ph.D. in education with a concentration in nursing education from Capella University where she researched the moderation effects of emotional intelligence on the relationship of stress and GPA in military veteran nursing students. Her clinical background includes surgical-trauma adult critical care, interventional radiology procedures, and conscious sedation in adult and pediatric populations.

Nicholas McGowan is a critical care nurse with 10 years of experience in cardiovascular, surgical intensive care, and neurological trauma nursing. McGowan also has a background in education, leadership, and public speaking. He is an online learner who builds on his foundation of critical care nursing, which he uses directly at the bedside where he still practices. In addition, McGowan hosts an online course at Critical Care Academy where he helps nurses achieve critical care (CCRN) certification.

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Cultivating Critical Thinking in Healthcare

Critical thinking skills have been linked to improved patient outcomes, better quality patient care and improved safety outcomes in healthcare (Jacob et al. 2017).

Given this, it's necessary for educators in healthcare to stimulate and lead further dialogue about how these skills are taught , assessed and integrated into the design and development of staff and nurse education and training programs (Papp et al. 2014).

So, what exactly is critical thinking and how can healthcare educators cultivate it amongst their staff?

What is Critical Thinking?

In general terms, ‘ critical thinking ’ is often used, and perhaps confused, with problem-solving and clinical decision-making skills .

In practice, however, problem-solving tends to focus on the identification and resolution of a problem, whilst critical thinking goes beyond this to incorporate asking skilled questions and critiquing solutions .

Several formal definitions of critical thinking can be found in literature, but in the view of Kahlke and Eva (2018), most of these definitions have limitations. That said, Papp et al. (2014) offer a useful starting point, suggesting that critical thinking is:

‘The ability to apply higher order cognitive skills and the disposition to be deliberate about thinking that leads to action that is logical and appropriate.’

The Foundation for Critical Thinking (2017) expands on this and suggests that:

‘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 analysing, assessing, and reconstructing it.’

They go on to suggest that critical thinking is:

• Self-directed
• Self-disciplined
• Self-monitored
• Self-corrective.

Key Qualities and Characteristics of a Critical Thinker

Given that critical thinking is a process that encompasses conceptualisation , application , analysis , synthesis , evaluation and reflection , what qualities should be expected from a critical thinker?

In answering this question, Fortepiani (2018) suggests that critical thinkers should be able to:

• Formulate clear and precise questions
• Gather, assess and interpret relevant information
• Reach relevant well-reasoned conclusions and solutions
• Think open-mindedly, recognising their own assumptions
• Communicate effectively with others on solutions to complex problems.

All of these qualities are important, however, good communication skills are generally considered to be the bedrock of critical thinking. Why? Because they help to create a dialogue that invites questions, reflections and an open-minded approach, as well as generating a positive learning environment needed to support all forms of communication.

Lippincott Solutions (2018) outlines a broad spectrum of characteristics attributed to strong critical thinkers. They include:

• Inquisitiveness with regard to a wide range of issues
• A concern to become and remain well-informed
• Alertness to opportunities to use critical thinking
• Self-confidence in one’s own abilities to reason
• Open mindedness regarding divergent world views
• Flexibility in considering alternatives and opinions
• Understanding the opinions of other people
• Fair-mindedness in appraising reasoning
• Honesty in facing one’s own biases, prejudices, stereotypes or egocentric tendencies
• A willingness to reconsider and revise views where honest reflection suggests that change is warranted.

Papp et al. (2014) also helpfully suggest that the following five milestones can be used as a guide to help develop competency in critical thinking:

Stage 1: Unreflective Thinker

At this stage, the unreflective thinker can’t examine their own actions and cognitive processes and is unaware of different approaches to thinking.

Stage 2: Beginning Critical Thinker

Here, the learner begins to think critically and starts to recognise cognitive differences in other people. However, external motivation  is needed to sustain reflection on the learners’ own thought processes.

Stage 3: Practicing Critical Thinker

By now, the learner is familiar with their own thinking processes and makes a conscious effort to practice critical thinking.

Stage 4: Advanced Critical Thinker

As an advanced critical thinker, the learner is able to identify different cognitive processes and consciously uses critical thinking skills.

Stage 5: Accomplished Critical Thinker

At this stage, the skilled critical thinker can take charge of their thinking and habitually monitors, revises and rethinks approaches for continual improvement of their cognitive strategies.

Facilitating Critical Thinking in Healthcare

A common challenge for many educators and facilitators in healthcare is encouraging students to move away from passive learning towards active learning situations that require critical thinking skills.

Just as there are similarities among the definitions of critical thinking across subject areas and levels, there are also several generally recognised hallmarks of teaching for critical thinking . These include:

• Promoting interaction among students as they learn
• Asking open ended questions that do not assume one right answer
• Allowing sufficient time to reflect on the questions asked or problems posed
• Teaching for transfer - helping learners to see how a newly acquired skill can apply to other situations and experiences.

(Lippincott Solutions 2018)

Snyder and Snyder (2008) also make the point that it’s helpful for educators and facilitators to be aware of any initial resistance that learners may have and try to guide them through the process. They should aim to create a learning environment where learners can feel comfortable thinking through an answer rather than simply having an answer given to them.

Examples include using peer coaching techniques , mentoring or preceptorship to engage students in active learning and critical thinking skills, or integrating project-based learning activities that require students to apply their knowledge in a realistic healthcare environment.

Carvalhoa et al. (2017) also advocate problem-based learning as a widely used and successful way of stimulating critical thinking skills in the learner. This view is echoed by Tsui-Mei (2015), who notes that critical thinking, systematic analysis and curiosity significantly improve after practice-based learning .

Integrating Critical Thinking Skills Into Curriculum Design

Most educators agree that critical thinking can’t easily be developed if the program curriculum is not designed to support it. This means that a deep understanding of the nature and value of critical thinking skills needs to be present from the outset of the curriculum design process , and not just bolted on as an afterthought.

In the view of Fortepiani (2018), critical thinking skills can be summarised by the statement that 'thinking is driven by questions', which means that teaching materials need to be designed in such a way as to encourage students to expand their learning by asking questions that generate further questions and stimulate the thinking process. Ideal questions are those that:

• Embrace complexity
• Challenge assumptions and points of view
• Question the source of information
• Explore variable interpretations and potential implications of information.

To put it another way, asking questions with limiting, thought-stopping answers inhibits the development of critical thinking. This means that educators must ideally be critical thinkers themselves .

Drawing these threads together, The Foundation for Critical Thinking (2017) offers us a simple reminder that even though it’s human nature to be ‘thinking’ most of the time, most thoughts, if not guided and structured, tend to be biased, distorted, partial, uninformed or even prejudiced.

They also note that the quality of work depends precisely on the quality of the practitioners’ thought processes. Given that practitioners are being asked to meet the challenge of ever more complex care, the importance of cultivating critical thinking skills, alongside advanced problem-solving skills , seems to be taking on new importance.

Additional Resources

• The Emotionally Intelligent Nurse | Ausmed Article
• Refining Competency-Based Assessment | Ausmed Article
• Socratic Questioning in Healthcare | Ausmed Article
• Carvalhoa, D P S R P et al. 2017, 'Strategies Used for the Promotion of Critical Thinking in Nursing Undergraduate Education: A Systematic Review', Nurse Education Today , vol. 57, pp. 103-10, viewed 7 December 2018, https://www.sciencedirect.com/science/article/abs/pii/S0260691717301715
• Fortepiani, L A 2017, 'Critical Thinking or Traditional Teaching For Health Professionals', PECOP Blog , 16 January, viewed 7 December 2018, https://blog.lifescitrc.org/pecop/2017/01/16/critical-thinking-or-traditional-teaching-for-health-professions/
• Jacob, E, Duffield, C & Jacob, D 2017, 'A Protocol For the Development of a Critical Thinking Assessment Tool for Nurses Using a Delphi Technique', Journal of Advanced Nursing, vol. 73, no. 8, pp. 1982-1988, viewed 7 December 2018, https://onlinelibrary.wiley.com/doi/10.1111/jan.13306
• Kahlke, R & Eva, K 2018, 'Constructing Critical Thinking in Health Professional Education', Perspectives on Medical Education , vol. 7, no. 3, pp. 156-165, viewed 7 December 2018, https://link.springer.com/article/10.1007/s40037-018-0415-z
• Lippincott Solutions 2018, 'Turning New Nurses Into Critical Thinkers', Lippincott Solutions , viewed 10 December 2018, https://www.wolterskluwer.com/en/expert-insights/turning-new-nurses-into-critical-thinkers
• Papp, K K 2014, 'Milestones of Critical Thinking: A Developmental Model for Medicine and Nursing', Academic Medicine , vol. 89, no. 5, pp. 715-720, https://journals.lww.com/academicmedicine/Fulltext/2014/05000/Milestones_of_Critical_Thinking___A_Developmental.14.aspx
• Snyder, L G & Snyder, M J 2008, 'Teaching Critical Thinking and Problem Solving Skills', The Delta Pi Epsilon Journal , vol. L, no. 2, pp. 90-99, viewed 7 December 2018, https://dme.childrenshospital.org/wp-content/uploads/2019/02/Optional-_Teaching-Critical-Thinking-and-Problem-Solving-Skills.pdf
• The Foundation for Critical Thinking 2017, Defining Critical Thinking , The Foundation for Critical Thinking, viewed 7 December 2018, https://www.criticalthinking.org/pages/our-conception-of-critical-thinking/411
• Tsui-Mei, H, Lee-Chun, H & Chen-Ju MSN, K 2015, 'How Mental Health Nurses Improve Their Critical Thinking Through Problem-Based Learning', Journal for Nurses in Professional Development , vol. 31, no. 3, pp. 170-175, viewed 7 December 2018, https://journals.lww.com/jnsdonline/Abstract/2015/05000/How_Mental_Health_Nurses_Improve_Their_Critical.8.aspx

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Critical Thinking in Nursing: Tips to Develop the Skill

4 min read • February, 09 2024

Critical thinking in nursing helps caregivers make decisions that lead to optimal patient care. In school, educators and clinical instructors introduced you to critical-thinking examples in nursing. These educators encouraged using learning tools for assessment, diagnosis, planning, implementation, and evaluation.

Nurturing these invaluable skills continues once you begin practicing. Critical thinking is essential to providing quality patient care and should continue to grow throughout your nursing career until it becomes second nature. 

What Is Critical Thinking in Nursing?

Critical thinking in nursing involves identifying a problem, determining the best solution, and implementing an effective method to resolve the issue using clinical decision-making skills.

Reflection comes next. Carefully consider whether your actions led to the right solution or if there may have been a better course of action.

Remember, there's no one-size-fits-all treatment method — you must determine what's best for each patient.

How Is Critical Thinking Important for Nurses? 

As a patient's primary contact, a nurse is typically the first to notice changes in their status. One example of critical thinking in nursing is interpreting these changes with an open mind. Make impartial decisions based on evidence rather than opinions. By applying critical-thinking skills to anticipate and understand your patients' needs, you can positively impact their quality of care and outcomes.

Elements of Critical Thinking in Nursing

To assess situations and make informed decisions, nurses must integrate these specific elements into their practice:

• Clinical judgment. Prioritize a patient's care needs and make adjustments as changes occur. Gather the necessary information and determine what nursing intervention is needed. Keep in mind that there may be multiple options. Use your critical-thinking skills to interpret and understand the importance of test results and the patient’s clinical presentation, including their vital signs. Then prioritize interventions and anticipate potential complications. 
• Patient safety. Recognize deviations from the norm and take action to prevent harm to the patient. Suppose you don't think a change in a patient's medication is appropriate for their treatment. Before giving the medication, question the physician's rationale for the modification to avoid a potential error. 
• Communication and collaboration. Ask relevant questions and actively listen to others while avoiding judgment. Promoting a collaborative environment may lead to improved patient outcomes and interdisciplinary communication. 
• Problem-solving skills. Practicing your problem-solving skills can improve your critical-thinking skills. Analyze the problem, consider alternate solutions, and implement the most appropriate one. Besides assessing patient conditions, you can apply these skills to other challenges, such as staffing issues . 

How to Develop and Apply Critical-Thinking Skills in Nursing

Critical-thinking skills develop as you gain experience and advance in your career. The ability to predict and respond to nursing challenges increases as you expand your knowledge and encounter real-life patient care scenarios outside of what you learned from a textbook. 

Here are five ways to nurture your critical-thinking skills:

• Be a lifelong learner. Continuous learning through educational courses and professional development lets you stay current with evidence-based practice . That knowledge helps you make informed decisions in stressful moments.  
• Practice reflection. Allow time each day to reflect on successes and areas for improvement. This self-awareness can help identify your strengths, weaknesses, and personal biases to guide your decision-making.
• Open your mind. Don't assume you're right. Ask for opinions and consider the viewpoints of other nurses, mentors , and interdisciplinary team members.
• Use critical-thinking tools. Structure your thinking by incorporating nursing process steps or a SWOT analysis (strengths, weaknesses, opportunities, and threats) to organize information, evaluate options, and identify underlying issues.
• Be curious. Challenge assumptions by asking questions to ensure current care methods are valid, relevant, and supported by evidence-based practice .

Critical thinking in nursing is invaluable for safe, effective, patient-centered care. You can successfully navigate challenges in the ever-changing health care environment by continually developing and applying these skills.

Images sourced from Getty Images

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Open Access

Peer-reviewed

Research Article

Teaching methods for critical thinking in health education of children up to high school: A scoping review

Contributed equally to this work with: Anna Prokop-Dorner, Aleksandra Piłat-Kobla

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Software, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Department of Medical Sociology, Chair of Epidemiology and Preventive Medicine, Jagiellonian University Medical College, Kraków, Poland

Roles Conceptualization, Data curation, Funding acquisition, Writing – review & editing

Affiliation Institute of Sociology, Jagiellonian University, Kraków, Poland

Roles Conceptualization, Data curation, Funding acquisition, Project administration, Resources, Writing – review & editing

Affiliation Institute of Intercultural Studies, Jagiellonian University, Kraków, Poland

Roles Data curation, Writing – review & editing

Affiliation LIGHT Project, Institute of Sociology, Jagiellonian University, Kraków, Poland

Affiliation Medical Faculty Student’s Research Group for Systematic Reviews, Jagiellonian University Medical College, Kraków, Poland

Affiliation Department of Epidemiology, Chair of Epidemiology and Preventive Medicine, Jagiellonian University Medical College, Kraków, Poland

Affiliation Department of Hygiene and Dietetics, Chair of Epidemiology and Preventive Medicine, Jagiellonian University Medical College, Kraków, Poland

•  [ ... ],

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Writing – review & editing

Affiliation Chair of Epidemiology and Preventive Medicine, Jagiellonian University Medical College, Kraków, Poland

• [ view all ]
• [ view less ]
• Anna Prokop-Dorner, 
• Aleksandra Piłat-Kobla, 
• Magdalena Ślusarczyk, 
• Maria Świątkiewicz-Mośny, 
• Natalia Ożegalska-Łukasik, 
• Aleksandra Potysz-Rzyman, 
• Marianna Zarychta, 
• Albert Juszczyk, 
• Dominika Kondyjowska, 

• Published: July 18, 2024
• https://doi.org/10.1371/journal.pone.0307094
• Peer Review
• Reader Comments

According to the World Health Organization, the improvement of people’s health literacy is one of the fundamental public health challenges in the 21st century. The key issue in teaching health literacy is to develop critical thinking skills. As health literacy and critical thinking should be developed at school age, we reviewed teaching methods or educational interventions used in empirical studies focused on the development of critical thinking regarding health and implemented by teachers in preschools, primary schools, or secondary schools. We searched seven databases (Medline, Embase, Web of Science, ERIC, ProqQuest, PsycArticles, and CINAHL) from inception to 20 September 2023 for any type of empirical studies. Due to the heterogeneity in interventions and inadequate reporting of results, a descriptive synthesis of studies was performed in addition to quantitative analysis. Of the 15919 initial records, 115 studies were included in the review. Most of the educational interventions focused on lifestyle-related health issues such as substance use, sexual and reproductive health, and nutrition. The popularity of health issues changed over time and depended on the geographical context. Six dimensions that differentiated the teaching methods were identified: central teaching component, central educator, pupils’ activity level, teaching context, educational materials, and significance of critical thinking. Many educational interventions did not address the development of critical thinking skills in a comprehensive manner, and the significance of critical thinking varied greatly. Interventions in which critical thinking had high and very high significance applied mainly problem-solving methods and involved pupils’ activity. The evidence on the effectiveness of the teaching methods that develop critical thinking is limited because most articles failed to provide detailed information on the teaching methods or did not examine their effects. We recommend that a checklist is developed to facilitate a detailed description of health educational interventions and thus promoting their replicability.

Study registration: The protocol of the review was registered in the OSF Registries on 13 January 2022 (doi: https://doi.org/10.17605/OSF.IO/46TEZ ).

Citation: Prokop-Dorner A, Piłat-Kobla A, Ślusarczyk M, Świątkiewicz-Mośny M, Ożegalska-Łukasik N, Potysz-Rzyman A, et al. (2024) Teaching methods for critical thinking in health education of children up to high school: A scoping review. PLoS ONE 19(7): e0307094. https://doi.org/10.1371/journal.pone.0307094

Editor: Bogdan Nadolu, West University of Timisoara: Universitatea de Vest din Timisoara, ROMANIA

Received: February 7, 2024; Accepted: June 28, 2024; Published: July 18, 2024

Copyright: © 2024 Prokop-Dorner et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: This work is the result of research project Diagnosis and developing health capital - Health Literacy of primary school students (Project no. UMO-2020/39/B/HS6/00977) funded by the National Science Centre. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The protocol of the review was registered in the OSF Registries on 13 January 2022 (doi: https://doi.org/10.17605/OSF.IO/46TEZ ).

Competing interests: The authors have declared that no competing interests exist.

Introduction

One of the major public health challenges in the 21st century is to improve people’s health literacy [ 1 ]. Health literacy refers to an individual’s ability to seek, understand, and use health information. Health literacy skills are essential for claim evaluation, data interpretation, and risk assessment. The key issue in learning health literacy is to develop knowledge, skills, motivation, and self-awareness that translate into individuals’ autonomy, independence, and empowerment. These qualities enable individuals to deal with health and its determinants.

In its definition of health literacy, the World Health Organization stresses the importance of social competences, such as communication and critical thinking, which are necessary for making adequate health decisions both on daily basis [ 2 ] and in extraordinary circumstances, such as the pandemic [ 3 ]. The fundamental goal of acquiring health literacy is to develop critical thinking skills. Critical thinking means that people are able to analyze and evaluate their thought processes in order to improve them [ 4 ]. According to a widely used definition, critical thinking is “a reasoned, reflective thinking focused on deciding what to believe or do” [ 5 ]. Today, we live in a world of information, and critical thinking skills can help us think logically and clearly. The competence of critical thinking is essential because it allows people to think independently.

Considering the abundance of easily available, but not verified, information as well as global health threats such as the coronavirus disease 2019 (COVID-19) pandemic, critical thinking skills become especially important in such life domains as health [ 3 ]. People need these skills to critically assess and use information relevant to their health, and it is the key to make evidence-based health choices. For example, the COVID-19 pandemic can be viewed not only as a public health threat but also as an infodemic [ 6 ], because there was overabundance of fake news, misinformation, and conspiracy theories that have undermined the trust in health institutions and treatment procedures [ 7 – 32 ]. Machete et al [ 33 ] conducted a systematic review including 22 articles that were synthesized and used as evidence to determine the role of critical thinking in identifying fake news. The study confirmed that critical thinking skills are essential to recognize fake news.

In this context, it seems crucial to teach critical thinking to pupils (i.e., children up to high-school level). Fostering critical thinking is widely recognized as an integral part of developing health literacy. There are several strategies that are recommended for teaching critical thinking, including classroom discussions [ 34 ], problem-based learning [ 35 ], and questioning techniques [ 36 , 37 ]. There is also evidence that peer-to-peer interaction is one of the teaching behaviors related to student gains in critical thinking [ 38 ]. However, most of these recommendations are based on theoretical works or do not relate to health-related topics. Moreover, these works refer to higher-education students, including students in a specific field (such as nursing or economics).

In this scoping review, we focused on the concept of health literacy and critical thinking as one of its main dimensions. We aimed to identify and review the teaching methods or pedagogical interventions used in empirical studies on the development of critical thinking regarding health and implemented by teachers in preschools as well as primary or secondary schools (level of education 0, 1, 2, and 3 according to the International Standard Classification of Education [ISCED]). The article presents the methods used in this process, quantitative and qualitative results, discussions of the findings, and conclusions.

Materials and methods

We conducted the scoping review in accordance with the Joanna Briggs Institute [ 39 ] methodology for scoping reviews and in our reporting we adhered to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) reporting statement with extension for scoping reviews [ 40 ]. We provided the filled-out checklist in S1 Table . In the development of our review we followed the methods outlined in the protocol registered in the OSF Registries on 13 January 2022 [ 41 ].

Criteria for study inclusion

For this scoping review, we considered any type of qualitative and quantitative empirical studies focusing on the development of critical thinking within the framework of health education at school by teaching subjects with content related to health (biology, chemistry, science, physical education, wellness, sexual education, health education, digital education, math, and critical thinking as a subject). Moreover, we included studies that provided information about teaching methods, training activities, or pedagogical interventions implemented by teachers or other school educators. Finally, we considered empirical studies referring to pupils in preschool, primary (elementary) or secondary (high) schools (ISCED 0, 1, 2, 3) and to teachers from those schools.

Search strategy

We searched the following databases: Medline, Embase, Science Citation Index with Abstracts, ERIC, ProqQuest, PsycArticles, and CINAHL.

We employed the text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles, to develop a full search strategy for each database (see S2 Table ). We used the following terms in the key search strategy: “health knowledge”, “health education”, “health literacy”, “critical thinking”, “schools”, “education”, “informed choice”, “choice behaviour”, “decision making”, “curriculum”, and “teaching methods”. We adapted the search strategy, including the relevant keywords and index terms, for each included database and/or information source. We screened the reference list of all included sources of evidence for additional studies. We searched databases from inception to 20 September 2023. Due to limited resources, we only included studies in English.

Study selection and data collection

Following the search, we collated all identified citations, uploaded them into Endnote X8 (Clarivate Analytics, PA, USA), and screened using the Covidence online tool ( covidence.org ). We removed any duplicates using Covidence.

We performed the three rounds of calibration exercises, using 50 abstracts each downloaded into an MS Excel spreadsheet (which ensured a common understanding of the inclusion and exclusion criteria). Next, 14 authors (MMB, MŚM, MŚ, APK, APD, NO, DS, APR, MZ, PW, WŻ, MM, SW, DK) working independently and in pairs screened the studies with respect to meeting eligibility criteria based the titles and abstracts. Thus, we obtained the full texts of potentially eligible articles. After four rounds of calibration exercises using five full texts each, 10 authors (MMB, DS, PW, SW, DK, MM, WŻ, APK, MWG, APD) working independently and in pairs screened the studies with respect to meeting eligibility criteria using their full texts. Third reviewer (MMB) resolved disagreements arising at any stage of the study selection. The core team developed and piloted the extraction form in Excel (MMB, MSM, MŚ, APD, APK, APR, MZ), and following four rounds of calibration exercises, eight reviewers (MM, SW, PW, DK, WŻ, AJ, MWG, AM) worked in pairs to extract data from the included studies into the prepiloted form. The pairs of reviewers independently extracted the data. Due to heterogeneity in interventions and inadequate reporting of results, we performed a descriptive synthesis of studies. The extracted data included specific details about the study methods, context (e.g., type of school, school location, study population), interventions, description of teaching methods focusing on critical thinking, and key findings relevant to the objectives of this review. Three authors (MMB, APD, APK) additionally checked all extractions.

Qualitative data synthesis

To further analyze the teaching methods, we conducted a qualitative synthesis [ 42 ]. Based on the primary analysis of the extracted data, two authors (APD and APK) developed and tested a coding book in MAXQDA 2024 based on 5% of the included articles. We resolved any discrepancies in coding at this stage by discussion. We used the final coding book to code detailed information on the teaching methods and the practical strategies of their implementation provided in the articles and in external sources such as further publications or websites of the interventions. The process of summarizing and comparing the coded data as well as using graphical tools to identify patterns allowed us to precisely categorize the teaching methods into analytical themes (six dimensions of teaching methods). These themes were developed from free codes and descriptive themes.

A total of 15919 records of 15909 studies were initially identified. After removing duplicates, 15150 studies were screened on the basis of the title and abstract. This yielded 1056 potentially relevant studies, which were screened based on full texts. Of the 1056 studies, 243 (25.5%) were excluded because they did not concern the development of critical thinking. Other studies were excluded because they were only theoretical (n = 174), did not concern the population of interest (n = 171), did not address health literacy (n = 132), did not provide information about the teaching methods used (n = 99), or for other reasons (n = 116). The list of the excluded studies, along with reasons for exclusion, is available on the project website in the OSF Registries [ 17 ]. We identified 118 eligible studies, of which 3 were still ongoing [ 43 – 45 ]. Finally, we included 115 completed studies ( Fig 1 ).

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The included studies met the eligibility criteria and described the teaching methods used, but most of them (80%) did not examine the effectiveness of these teaching methods but interventions used in the study. Below we present the findings first referring to the quantitative and then to qualitative analysis.

Description of the included studies

A total of 115 studies were included in this scoping review, including 65 studies reporting quantitative methods [ 46 – 113 ], 25 studies reporting mixed methods [ 114 – 140 ], and 25 studies reporting qualitative methods [ 7 – 32 ] (See S3 Table ). Some educational interventions were described in more than one article. In such cases, the records were merged and assessed as one study [ 16 , 17 , 56 , 70 – 72 , 119 ]. The most common study design was cluster randomized (25 articles, 22%) and quasi-experimental (20 articles, 17%). The dates of article publication covered nearly 40 years. More than a half of the eligible articles were published after 2010 (74 articles, 64%) and only 12 studies were published before 2000 (10%). The included studies were conducted in various cultural contexts, but mostly in the Western societies of North America (52 articles, 45%) and Europe (34 articles, 30%). Only 14 studies were conducted in Asia (12%); 8, in Africa (7%); 5, in Australia (4%); and 2, in South America (2%). In one article, there was no information on the country [ 137 ].

Educational interventions conducted in North America covered a broad range of topics and addressed psychoactive substance use [ 21 , 26 , 50 , 52 , 53 , 58 , 61 , 65 , 67 , 75 , 80 , 83 , 85 , 92 , 95 , 117 , 140 ], lifestyle (including nutrition, physical activity) [ 57 , 60 , 63 , 77 , 87 , 89 , 96 , 100 , 135 ], sexual and reproductive health (SRH) [ 19 , 49 , 82 , 94 , 98 , 108 , 120 , 127 , 128 ] (including AIDS and HIV prevention [ 21 , 59 , 73 , 86 , 93 ]), public health [ 18 , 31 , 66 , 69 , 78 , 79 , 87 , 90 , 111 ], and somatic health [ 25 , 87 , 123 , 131 , 140 ]. The topic of mental health has only emerged in publications from the last three years [ 100 , 104 , 138 ].

Most studies conducted in Europe concerned lifestyle, including both nutrition and/or physical activity interventions [ 7 , 9 , 11 , 22 , 24 , 46 , 91 , 97 , 103 , 106 , 109 , 126 , 134 ], public health [ 8 , 12 , 13 , 29 , 47 , 88 , 101 , 105 , 139 ], and psychoactive substance use [ 7 , 15 , 48 , 51 , 84 , 114 , 122 ]. Four papers concerned somatic health [ 22 , 30 , 97 , 125 ] and five–mental health [ 68 , 97 , 99 , 109 , 113 ]. Only two educational intervention addressed sexual health [ 28 , 115 ].

Most studies conducted in Asia addressed sexual health [ 14 , 56 , 119 , 132 , 136 , 141 ], including AIDS and HIV prevention [ 56 , 116 , 119 , 133 , 136 ]. Mental health was addressed by three studies [ 64 , 112 , 141 ], psychoactive substance use by two [ 74 , 84 ]; and somatic health by one study [ 121 ]. In the last three years, studies have emerged whose educational interventions focused on lifestyle [ 27 , 110 ]. Among African studies reporting on educational interventions, there were six articles that focused on SRH [ 10 , 55 , 62 , 118 , 124 , 132 ], and one intervention that was dedicated to health claims [ 130 ].

Finally, research conducted in Australia concerned such health topics as psychoactive substance use [ 70 – 72 , 81 ], lifestyle [ 16 , 17 ], as well as public [ 23 , 102 ] and mental health [ 23 ], while an educational intervention conducted in South America covered the topic of SRH [ 20 ].

Health issues in education interventions

Interventions reported in the included articles addressed a broad range of health issues, and the thematic focus of the interventions had changed over time ( Table 1 ). Until 2000, the prevailing topics in health education were substance use and SRH, in the following decades also nutrition, issues connected with public health, physical activity, as well as somatic and mental health gained interested of teachers and stakeholders in the field.

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Almost one in three studies published over the last 40 years tested substance use interventions (27%). Half of them discussed nicotine [ 50 , 51 , 53 , 58 , 61 , 67 , 70 , 74 , 75 , 80 , 83 , 85 , 95 , 114 ] and drugs [ 21 , 26 , 52 , 53 , 65 , 70 – 72 , 74 , 76 , 81 , 84 , 85 , 87 , 140 ] and four in ten concerned alcohol [ 15 , 48 , 53 , 71 , 72 , 83 , 85 , 92 , 117 , 122 , 137 ].

The same number of interventions (31; 27,5%) covered SRH, and specifically sexual health [ 10 , 28 , 55 , 78 , 112 , 115 , 132 ], reproductive health [ 20 , 49 , 62 , 82 , 94 , 115 , 120 , 127 , 136 ], sexual abstinence [ 20 , 49 , 55 , 73 , 82 , 124 , 127 , 128 , 136 ], contraceptive methods [ 62 , 94 , 120 , 124 ], menstruation [ 14 ], gender roles [ 32 , 108 , 119 , 132 ], healthy relationships [ 32 , 55 , 119 ], sexually transmitted disease [ 82 , 86 , 118 , 119 ], and AIDS and HIV prevention [ 21 , 55 , 56 , 59 , 73 , 82 , 86 , 116 , 118 , 119 , 124 , 133 , 136 ].

Slightly less studies (27; 23,5%) tested an intervention on nutrition (23,5%) [ 8 , 11 , 16 , 17 , 22 , 23 , 46 , 57 , 60 , 77 , 87 , 89 , 91 , 96 , 97 , 103 , 109 , 110 , 112 , 123 , 125 , 126 , 135 , 140 – 142 ]. Public health problems, such as health care [ 21 ], violence [ 13 , 18 , 78 ], global health [ 8 ], organ donation [ 88 ], anti-microbial resistance [ 107 ], zoonosis [ 101 ], use of medicine [ 12 ], and bioethical dilemmas linked to health [ 47 ], social inequalities [ 31 ] were taught in 25% of reported interventions. Various forms of physical activity were promoted in every tenth intervention (11%) [ 7 , 9 , 16 , 17 , 63 , 77 , 87 , 89 , 97 , 135 , 142 ].

Specific somatic health issues such as cancer, cardiovascular system, diabetes, eye or oral health were discussed in 11% of the articles [ 22 , 25 , 30 , 64 , 87 , 97 , 112 , 121 , 125 , 131 ]. Even fewer articles reported interventions on mental health issues, such as emotional regulation [ 64 , 89 , 97 ], resilience [ 23 ] and healthy relationships [ 23 , 111 , 119 ]. Nearly every third tested intervention covered more than one health issue [ 7 , 16 , 17 , 21 – 23 , 50 , 55 , 64 , 77 , 78 , 82 , 86 , 87 , 89 , 97 , 109 , 111 , 112 , 119 , 124 – 127 , 135 , 136 , 140 , 141 ]. Topics such as epidemic or pandemic were discussed only in a few articles, mainly with regards to HIV and AIDS [ 73 , 116 , 133 ] or social inequality during the COVID-19 pandemic [ 31 ]. Vaccinations were discussed in interventions generally linked to infectious disease [ 66 ] or aimed at increasing the uptake of specific vaccination, i.e. HPV [ 102 ].

Interventions reported in 94 articles (82%) were initiated by external bodies, such as universities, and were tested in several schools in a selected region ( Table 2 ). Nearly half (51) of the studies tested regionally based interventions. In 31 studies, the interventions were tested locally, typically in one or in several schools. The remaining interventions were evaluated in bigger samples, either on a national (16 articles) or international level (5 articles). Nine of the interventions were pilot interventions. Moreover, the studied interventions varied in terms of the level of education. Most of them were tested in high schools/secondary schools (60, 52%); 30, in primary/elementary schools (26%); 24, in middle schools (21%); and only 1 intervention was tested in preschools. Interventions were conducted by schoolteachers, peer educators, or both. Half of the studied interventions were preceded by teachers’ training (57 articles, 50%) and/or peer leaders training (13 articles, 11%). Only every third intervention provided pupils with additional materials, such as booklets [ 22 , 32 , 74 , 77 , 102 , 124 ], handouts [ 49 , 78 , 117 ], audiovisual materials [ 20 , 74 , 90 , 99 , 107 , 115 ], textbooks [ 84 , 85 , 130 ], recipes [ 57 ] newsletters [ 28 , 46 ], exercise book [ 129 ], and student guide [ 111 ].

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Interventions tested in the included articles were typically taught in class (50%), most often in an interdisciplinary form as part of multiple school subjects, such as health education or sexual health education, math, family life education, social sciences, media literacy, language, philosophy, home economy, science, and, less typically, during a single subject such as health education (23 articles), biology (3 articles), science (3 articles), sexual health education (3 articles), language (2 articles), critical thinking (1 article), social sciences (1 article), math (1 article), home economics (1 article), and physical education (1 article). Almost all of the 115 interventions were described as having “positive results”. However, in all those cases, the evaluation concerned the entire intervention rather than single teaching methods.

Dimensions of teaching methods used in health education

We noted a vast diversity of approaches to teaching critical thinking in health education that were tested in the included studies. To comprehensively describe this variety, we identified six dimensions that differentiated the methods based on their important characteristics listed in Fig 2 .

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Central teaching component.

When we looked at the teaching methods from the perspective of the central component that organized the teaching process, we distinguished four components: practice, problem solving, exposition to stimuli, and factual content. The application of the didactical approaches in health education over five decades is presented in Table 3 . While hands-on and expositional approaches prevailed in the 1980s, 1990s, and the first two decades of the 21st century, the importance of problem-solving methods has become more visible since 2011.

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The teaching methods with practice as the central component provided pupils with instructions on where to gain knowledge, how to practice new skills, and how to develop new habits through experience. Pupils participated in or conducted practical activities that reflected the discussed issues. Typically, the practice-oriented methods were dedicated to developing either cognitive skills and emotional regulation or manual abilities and physical fitness. The former was used when fostering the skills of goal setting [ 77 , 85 , 87 , 100 , 137 ], decision-making [ 12 , 25 , 27 , 29 , 46 , 61 , 70 – 72 , 74 , 76 , 77 , 80 , 84 , 85 , 89 , 97 , 102 , 111 , 120 , 123 , 126 , 134 – 136 , 138 ], stress management [ 85 , 99 ], peer pressure resistance [ 21 , 61 , 80 , 85 , 95 ], emotions regulation [ 85 , 89 ], peaceful conflict resolution techniques [ 29 , 111 , 139 ], differentiating healthy from unhealthy practice [ 11 , 92 , 123 , 134 , 135 ], assertiveness [ 87 , 111 ], as well as values clarification and/or self-monitoring [ 46 , 77 , 84 , 89 , 120 ]. On the other hand, the subcategory of manual abilities and physical fitness included first aid [ 72 ], creative tasks [ 21 , 73 , 121 ], sports [ 9 , 27 , 60 , 63 , 80 , 87 , 106 , 109 ], testing samples [ 140 ], daily menu composition and/or food preparation [ 24 , 46 , 96 , 103 , 123 , 126 , 134 , 137 , 142 ], project work [ 16 , 57 , 69 ], or making a video [ 14 , 31 , 67 ].

When problem-solving is the central component of a teaching approach, pupils typically detect new knowledge and apply it in a particular situation. Pupils use “triggers” from a case study or scenario to define their own learning objectives. These methods include case study analysis [ 11 , 13 , 66 , 69 – 72 , 88 , 115 , 116 , 130 , 133 ], problem-based learning [ 89 , 110 , 122 , 123 , 125 ], collaborative scenario-based discussions [ 11 , 123 ], storytelling [ 84 , 110 ], debate [ 52 , 91 , 136 ], Socratic questions [ 52 , 95 ], brainstorming [ 7 , 13 , 14 , 64 , 84 , 133 ], and educational games [ 16 , 17 , 52 , 74 , 84 , 85 , 91 , 95 , 116 , 118 , 126 , 134 , 137 ].

Teaching methods centered on exposition offer external or internal stimuli to intensify the learning process. These methods provide pupils with an opportunity to observe particular environments and collect impressions from the external stimuli to foster the understanding of a given issue (e.g., a field trip to a sexually transmitted disease clinic [ 86 ] to university hospital to talk with medical professionals and patients [ 21 , 140 ]). Alternatively, they presented posters [ 27 , 102 ], video games [ 103 , 111 ], videos dedicated to the health topic [ 98 , 107 , 108 , 110 ] or allow pupils to recreate situations, reflect values, or express themselves with drama [ 10 ], role-playing [ 13 , 26 , 54 , 74 , 90 , 95 ], music, and dance composition [ 136 ].

Finally, in a traditional method focusing on factual content, knowledge is delivered to pupils by means of lectures, formal presentations, or textbook work. In this approach, the teacher is the primary source of information, and pupils are recipients of information. In our analysis, factual content methods were applied in 38 (34.7%) interventions [ 15 , 17 , 19 , 21 , 22 , 27 , 46 , 54 , 57 , 67 – 69 , 72 , 74 , 80 , 88 , 90 , 92 , 94 , 96 , 97 , 101 , 102 , 107 , 112 , 116 , 120 , 123 , 124 , 130 , 132 , 135 – 137 ].

In 73 interventions (63.5%), more than one component was used to reach the educational objectives. Most frequently, the authors of the intervention used all methods simultaneously [ 17 , 69 – 72 , 74 , 94 , 120 , 130 , 137 ]. They also mixed the problem-solving and practice methods [ 24 , 30 , 73 , 85 , 89 , 91 , 122 , 126 , 141 ], less often problem solving, practice methods and exposition [ 32 , 84 , 113 , 140 ] or problem-solving and exposition [ 98 , 106 , 110 , 111 ] and the exposition and practice methods [ 12 , 27 , 102 , 103 , 121 ]. The patterns of applying various central teaching components in the intervention addressing various health issues were grouped into seven thematic categories and presented in Table 4 . While practice was central to organizing the teaching process for most health issues (more than 50% of interventions related to all health topics but SRH applied practical teaching methods), it was especially prevalent in interventions teaching about nutrition and physical activity. Problem-solving and exposition were frequently, or relatively frequently, used in interventions regarding substance use and SRH. More than 60% of the interventions on somatic health, nutrition, and physical activity were built around more than one teaching component.

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The level of pupils’ activity and central educator.

The tested teaching methods differed in terms of the level of pupils’ activity. Most methods were based on the active participation of pupils and included a number of individual activities (e.g., reflection on values, goal setting, self-monitoring [ 87 , 137 ]) or group activities (e.g., scenario writing [ 133 ], analyzing case and proposing a solution [ 29 , 115 ]). On the other hand, in relatively few interventions, pupils were to remain passive (e.g., listening to a lecture, watching a video [ 25 , 57 , 74 ]). Some interventions were based on both of these forms of involvement [ 21 , 28 , 30 , 46 , 66 , 69 , 90 , 98 , 101 , 103 , 107 , 111 , 112 , 120 , 135 , 136 , 139 , 142 ].

Peers play a crucial role in shaping the health behaviors of children and teenagers: they offer mutual support and serve as a role model and a trusted source of information [ 127 ]. This social dynamic was used in educational interventions across countries for over 40 years. A peer-to-peer approach was applied in 54 tested interventions [ 8 , 10 , 14 – 17 , 21 – 23 , 26 , 28 , 29 , 31 , 32 , 46 , 48 , 55 , 57 , 58 , 61 , 62 , 80 , 81 , 85 , 86 , 90 , 92 , 93 , 95 , 98 , 99 , 102 , 106 , 110 , 112 – 114 , 117 , 119 , 127 , 128 , 131 , 133 , 136 , 137 , 139 , 140 ], either as a main or complementary teaching strategy. With peer-to-peer method as the main strategy, selected pupils typically participated in training for peer leaders and offered workshops, prepared presentations, or moderated discussions with other pupils [ 15 – 17 , 31 , 55 , 57 , 58 , 62 , 80 , 81 , 93 , 95 , 114 , 117 , 127 , 136 ]. As a complementary strategy, the peer-to-peer approach was typically used at the end of the intervention. After going through the educational process, pupils created educational materials and presented them to their younger colleagues [ 10 , 14 , 21 – 23 , 26 , 46 , 56 , 61 , 85 , 90 , 92 , 119 , 133 , 137 ]. In 43 interventions, the teacher’s role was central to the teaching process. Teachers structured the lessons, introduced content, proposed tasks, and distributed homework assignments, often according to detailed instructions [ 12 , 13 , 18 – 20 , 22 – 24 , 28 , 29 , 46 , 49 , 51 – 53 , 60 , 65 , 67 , 68 , 77 , 78 , 80 , 82 , 85 , 88 , 90 , 92 , 97 , 98 , 101 , 102 , 104 , 106 , 112 , 117 , 120 , 124 , 125 , 128 , 130 – 134 ]. In every fourth intervention, teacher-centered and peer-to-peer methods were combined [ 12 , 13 , 19 , 20 , 22 – 24 , 46 , 53 , 65 , 67 , 80 , 85 , 90 , 92 , 96 , 117 , 120 , 125 , 128 , 131 , 133 ]. Data on the central educator were missing in almost 37 articles.

Educational materials.

To facilitate the learning process, every fourth of the interventions provided educational materials [ 7 – 9 , 21 , 22 , 25 , 27 , 30 , 32 , 46 , 49 , 62 , 69 , 74 , 76 , 77 , 81 , 83 , 84 , 91 , 93 , 97 , 104 , 105 , 107 , 111 , 115 , 122 , 132 , 135 , 140 , 141 ], such as student activity books, brochures, fact sheets, activity sheets, handouts. In a number of interventions, audiovisual materials created specifically to support the teaching objectives were provided [ 20 , 74 , 90 , 115 ].

In 30% of the interventions, the learning process resulted in pupils creating some artefacts. Some of those creative works served as a souvenir and were supposed to remind pupils of the health issue they were taught about [ 125 , 137 ]. Other works had additional educational purposes, such as a poster exhibition [ 23 , 28 , 29 , 31 , 32 , 47 , 73 , 77 , 83 , 86 , 107 ], creating a cartoon about the rational use of medicines [ 12 ], shooting a video about the process of making reusable sanitary cloth pads [ 14 ], developing an educational website on cancer prevention for children that was posted on the website of the Yale Cancer Center [ 131 ]. In some interventions, children prepared and consumed foods with certain nutritional values (e.g., low-fat, high-fiber products [ 77 , 87 ]) or foods from different cultural contexts [ 8 ].

In one in three interventions, computer, internet, or other technological tools were used to support the educational process. The application of teaching methods was typically supported by internet search [ 11 , 13 , 22 , 50 , 60 , 66 , 73 , 75 , 97 , 100 , 102 , 103 , 105 , 108 , 115 , 122 , 131 , 132 ], creating presentations [ 20 , 22 , 29 , 30 , 46 , 47 , 54 , 74 , 111 , 140 ], communicating or analyzing social media [ 7 , 8 , 11 , 13 , 17 , 20 , 30 , 31 , 108 , 122 ], using applications, both those generally available, i.e. interactive web-based quiz and those developed for the intervention [ 12 , 88 , 91 , 99 , 102 , 106 , 110 , 115 , 118 ], or computer games [ 84 , 103 , 107 , 111 , 118 , 134 ].

Teaching context.

Within the model of health promoting schools, introduced by the World Health Organization after the release of the Ottawa Charter during the first International Conference on Health Promotion in Ottawa, Canada, in 1986, the socio-ecological perspective on health education was applied in schools [ 23 ]. As a result, a number of educational interventions on health involved activities engaging the whole school community [ 10 , 15 , 16 , 21 , 24 , 26 , 27 , 32 , 46 , 57 , 78 , 81 , 86 , 87 , 96 , 99 , 100 , 103 , 109 , 113 , 119 , 124 , 137 , 141 , 142 ] or even a broader local community [ 45 , 63 , 66 , 69 , 89 , 93 , 102 , 103 , 112 , 116 , 131 , 133 , 141 , 143 , 145 ], and not just standard classroom teaching. In some studies, not only was the pupil-teacher relationship explored, but also contacts with other social actors were arranged. Twenty-three interventions engaged pupils’ parents and caregivers [ 23 , 27 , 28 , 30 , 32 , 46 , 48 , 52 , 59 , 72 , 77 , 78 , 87 , 93 , 94 , 97 , 102 , 111 , 113 , 115 , 119 , 126 , 128 ]; 12, external experts and scientists [ 12 , 16 , 17 , 19 , 73 , 77 , 86 , 90 , 103 , 115 , 118 , 124 , 132 , 135 ]; and 8, other social actors [ 8 , 21 , 23 , 31 , 99 , 117 , 120 , 138 ] such as school administrators, local leaders, or school nurses. The involvement of parents in some interventions ranged from providing information materials [ 78 ] to providing technical support (e.g., parents who were farmers provided soil for planters [ 126 ]). Parents were also involved through shared activities [ 97 ], or they were offered to participate in classes on communicating personal and family’s values about sexuality to teenagers [ 52 , 94 , 115 , 128 ], or they received newsletters or magazines with health information, heart-healthy recipes, and hands-on activities to do at home [ 46 , 87 , 93 ].

Significance of critical thinking.

The stage of eligibility criteria assessment showed that critical thinking was included only in a small proportion of health education interventions for children and adolescents. However, the interventions described in the included publications varied with regards to: 1) the methods applied to develop critical thinking skills; and 2) the extent to which they provided details on the teaching process. Based on the information and additional materials provided in the articles, we used those two parameters to evaluate the significance of critical thinking in the tested interventions on a four-point scale (low, moderate, high, and very high significance) ( Table 5 ).

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Most interventions (42 articles, 36%) described only one method addressing critical thinking and failed to provide details of the activities. In these interventions, critical thinking was classified as having a low level of significance. The most common approaches reported by the authors were group discussions or debates [ 7 , 9 , 15 , 20 , 26 , 47 , 53 , 59 , 62 , 63 , 69 , 76 , 93 , 109 , 117 ], Socratic discussions [ 52 , 95 ], question boxes [ 94 , 124 ], unspecified decision-making exercises [ 23 – 25 , 49 , 55 , 65 , 68 , 74 , 77 , 85 , 97 , 112 , 127 , 134 ], or reflection activities [ 118 ]. The low significance of critical thinking teaching methods was noted in interventions from all decades. Critical thinking educational methods were most commonly applied in interventions regarding substance use and SRH ( Table 6 ). Half of the intervention addressing physical activity and more than 40% addressing psychoactive substance use and SRH demonstrated a low significance of critical thinking.

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In 21 interventions, more than one method stimulating critical thinking was listed. Critical thinking in these interventions was classified as having moderate significance. However, activities for developing critical thinking skills constituted a small part of a broader educational program or the articles did not provide details suggesting otherwise [ 12 , 17 , 21 , 29 , 48 , 50 , 54 , 57 , 60 , 75 , 82 – 84 , 86 , 92 , 99 , 100 , 108 , 110 , 114 , 119 , 121 , 128 , 132 , 139 , 143 , 144 ]. Apart from discussion or decision-making exercises, these interventions typically involved other methods facilitating critical thinking, such as situational role playing, problem-solving, participation in developing educational activities on health, designing wall magazines, assessing individual or community health resources, analyzing media information, and solving case studies For about 30% of the interventions addressing psychoactive substance use and SRH teaching critical thinking was of a moderate importance.

The interventions classified as showing a high or very high significance of critical thinking included multiple teaching methods stimulating critical thinking skills and provided a detailed description of the whole educational process, a relationship between the teaching objectives and applied teaching methods, and how they were translated into specific learning activities, materials, and outcomes.

Twenty-seven interventions characterized by high significance of critical thinking [ 11 , 13 , 14 , 22 , 28 , 30 , 32 , 64 , 67 , 70 – 73 , 80 , 89 , 98 , 102 , 105 , 106 , 111 , 113 , 120 , 122 , 123 , 126 , 131 , 140 – 142 ] discussed a broader scope of health literacy skills, with critical thinking being only one of those skills. On the other hand, interventions with a very high level of significance [ 8 , 10 , 18 , 31 , 61 , 88 , 96 , 115 , 125 , 130 , 133 , 135 , 137 , 138 ] were dedicated to critical thinking and comprehensively addressed a set of skills involved. Reporting on educational interventions that approached critical thinking in a more complex manner became more common after 2000. Critical thinking gained more significant coverage in more than half of the interventions focused on nutrition (52%). We observed high or very high significance of critical thinking in interventions teaching about somatic health (46%), physical activity (46%) and public health (45%) ( Table 6 ).

High and very high significance was demonstrated especially for interventions that incorporated problem-solving as opposed to those with practice as the central component. The latter interventions were characterized mainly by low significance of methods addressing critical thinking ( Table 7 ).

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Examples of the most interesting interventions in which critical thinking had high or very high significance are described in Table 8 .

https://doi.org/10.1371/journal.pone.0307094.t008

Summary of the main results

Our scoping review demonstrated a large variety of educational interventions regarding health issues over time and across continents. The interventions reported in the included articles focused mainly on lifestyle-related health issues, which reflect the dynamic changes in the discourse on the health of children and adolescents as well as in the priorities of health prevention programs [ 145 – 147 ]. Healthy lifestyle interventions implemented before 2011 typically aimed at developing knowledge, skills, and/or attitudes related to substance use, SRH, and broader problems of public health. Subsequent interventions seem to reflect the more recent conceptualization of healthy lifestyle in relation to an increase in obesity in children [ 148 ], as they additionally cover habits linked to nutrition and physical activity. More specific aspects of individual health, such as particular somatic or mental health disorders, seem to be receiving more attention in health education interventions in 21st century. The regional dynamics of the coverage of health topics, as observed in our review, can be explained by various regional health challenges and local socio-cultural determinants of health.

A similar diversity was noted in the teaching methods applied in the interventions studied over the period of 40 years. While older interventions (before 2001) primarily focused on exposing students to external or internal stimuli, delivering factual content or practical activities to promote health behaviors, the more recent interventions design the educational process around problem-solving tasks. The teaching methods used in the interventions addressing nutrition and physical activity were mostly oriented towards developing practical skills, while those applied in the interventions addressing sexual health or substance use emphasized problem-solving skills. Mixing those various components was a strategy applied in interventions addressing all thematic areas.

In some interventions, the teaching process was accompanied by various types of educational materials, and sometimes pupils created educational artefacts themselves. Most teaching methods used in the studied interventions encouraged pupils to actively participate in the learning process, express their opinions in writing, or develop various types of educational materials. Such approaches facilitate the integration of knowledge, skills, and essential components of attitudes. Some articles tested interventions that engaged peer educators in promoting healthy choices, presenting useful skills, and explaining health information. While most of the available evidence suggests the effectiveness of peer-to-peer teaching in higher education [ 149 , 150 ], a recent scoping review of studies on peer education in health interventions for adolescents revealed that involving peer-to-peer education may be a promising strategy for health improvement also on lower educational levels [ 151 ]. The way of shaping health behaviors in the included interventions focused not only on expanding the knowledge of individual pupils as well as training their health-related skills, but also encompassed the broader social context of pupils: their families, local communities, or intercultural contacts. Moreover, in some interventions, pupils met medical professionals, patients and their caregivers, or external experts and scientists, sometimes in their work setting.

In summary, there is evidence to suggest that peer-to peer interaction is one of the teaching strategies related to student gains in critical thinking. Therefore, leaving the role of the central educator to pupils and designing interventions that engage pupils in individual and group activities (such as problem solving, developing educational materials or artefacts) are possibly those dimensions of the teaching methods that offer greatest benefits in terms of learning critical thinking skills.

Importance of critical thinking in health education of children up to high school

The extent to which the included interventions covered critical thinking skills varied widely. This heterogeneity is associated with the year of the publication and the dynamics of pedagogical discourse. The growing demands of the contemporary information society [ 22 ] and changing public health challenges in the past four decades has resulted in a growing appreciation of teaching critical thinking. The increase in the complexity of integrating critical thinking into educational interventions is particularly evident in the publications released from 2021.

Strengths and limitations

To our best knowledge, this is the first study to comprehensively review the existing literature on the teaching methods for critical thinking in the health education of children up to high school. The review was conducted by an interdisciplinary team and was based on an extensive literature search including all types of research from all continents.

Our review also has some limitations. As our search was performed in 20 September 2023, there is a considerable disproportion in the number of articles between decades, with fewer articles categorized as those published from 2021 as compared with the earlier decades. Moreover, the studies and interventions included in the review were highly heterogenous, and the description of some teaching methods was not satisfactory, limiting possibility to replicate them. Some of the included studies only listed the teaching methods without any additional information. Developing reporting checklist for health education interventions in school context- such as to TIDieR checklist [ 152 ] available for interventions in general or GREET [ 153 ] for evidence-based practice educational interventions, may improve future reporting and replicability of such interventions. Moreover, as we were interested in the educational programs stably functioning in the school setting and engaging school-based actors, we excluded interventions that were implemented only by external educators, external leaders, medical school students, or medical professionals. Future studies should map the methods applied in extracurricular interventions. Finally, we included only articles in English; thus, we potentially missed out on studies published in other languages.

Conclusions

Our review showed that health education interventions in children and adolescents usually did not address the development of critical thinking skills in a comprehensive manner. Interventions in which critical thinking had high and very high significance applied mainly problem-solving methods and involved pupils’ activity. The evidence on the effectiveness of the teaching methods that develop critical thinking skills is limited because most articles failed to provide detailed information on the teaching methods or did not examine their effects. Therefore, to facilitate further research in this field, we recommend that the teaching strategies used in the interventions are described in greater detail and that the effectiveness of individual teaching methods is assessed and reported. The development of a reporting checklist to describe health education interventions is warranted.

Supporting information

S1 table. preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (prisma-scr) checklist..

https://doi.org/10.1371/journal.pone.0307094.s001

S2 Table. Search strategies.

https://doi.org/10.1371/journal.pone.0307094.s002

S3 Table. Characteristics of the included studies.

https://doi.org/10.1371/journal.pone.0307094.s003

Acknowledgments

We thank dr Magdalena Koperny for creating the search strategy.

• 1. WHO. Health literacy. The solid facts. Copenhagen, Denmark: World Health Organization 2013.
• View Article
• PubMed/NCBI
• Google Scholar
• 4. Richard P, Elder L. Critical Thinking. London: Rowman & Littlefield; 2020.
• 33. Machete P, Turpin M. The Use of Critical Thinking to Identify Fake News: A Systematic Literature Review. In: Hattingh M, Matthee M., Smuts H., Pappas I., Dwivedi Y.K., Mäntymäki M., editor. Lecture Notes in Computer Science 12067: Springer Cham; 2020. p. 235–46.
• 34. Hansen W. Lee SMK. Improving Classroom Discussion in Economics Courses. The International Handbook on Teaching and Learning Economics: Edward Elgar Publishing; 2011.
• 39. Aromataris E, Munn Z. JBI Manual for Evidence Synthesis: JBI; 2020. Available from: https://synthesismanual.jbi.globa .
• 41. Światkiewicz-Mośny M, Ślusarczyk M, Prokop-Dorner A, Piłat-Kobla A, Potysz-Rzyman A, Ozegalska-Lukasik N, et al. Teaching methods for critical thinking in health education in children up to high school. OSF. 2022. https://doi.org/10.17605/OSF.IO/46TEZ
• 102. Davies C, Marshall HS, Brotherton JML, McCaffery K, Kang M, Macartney K, et al. Complex intervention to promote human papillomavirus (HPV) vaccine uptake in school settings: A cluster-randomized trial. Preventive Medicine. 2023;172((Davies C., [email protected] ; Macartney K.; Skinner S.R.) Specialty of Child and Adolescent Health, Faculty of Medicine and Health, The University of Sydney, NSW, Australia(Davies C., [email protected] ) Sydney Infectious Diseases In). https://doi.org/10.1016/j.ypmed.2023.107542 pmid:37172767
• 104. Klim-Conforti P, Zaheer R, Levitt AJ, Cheung AH, Schaffer A, Fefergrad M, et al. The impact of a children’s literature-based cognitive behavioural therapy skills curriculum on middle-school youth who self-report clinically relevant and non-clinical mental health symptomatology. Journal of Affective Disorders Reports. 2023;12((Klim-Conforti P., [email protected] ) Member of the College of Psychologists of Ontario, Toronto, ON, Canada(Klim-Conforti P., [email protected] ) Institute of Medical Science, Faculty of Medicine, University of Toronto, ON, Canada(Zahe). https://doi.org/10.1016/j.jadr.2023.100471
• 134. Kostanjevec S, Erjavšek M, Jedrinović S, Bevčič M, Luštek A, Kozina FL. Development of an Educational Computer Game for Nutrition Education. Reading: Academic Conferences International Limited; 2017. p. 343–51.
• 145. WHO. Guideline: implementing effective actions for improving adolescent nutrition. World Health Organization., 2018.
• 148. Wijnhoven Trudy vRJ, Breda João. WHO European Childhood Obesity Surveillance Initiative: implementation of round 1 (‎2007/2008)‎ and round 2 (‎2009/2010)‎. WHO. Regional Office for Europe, 2014.

• Research article
• Open access
• Published: 18 February 2013

Understanding critical health literacy: a concept analysis

• Susie Sykes 1 ,
• Jane Wills 1 ,
• Gillian Rowlands 1 &
• Keith Popple 1  

BMC Public Health volume  13 , Article number:  150 ( 2013 ) Cite this article

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Interest in and debates around health literacy have grown over the last two decades and key to the discussions has been the distinction made between basic functional health literacy, communicative/interactive health literacy and critical health literacy. Of these, critical health literacy is the least well developed and differing interpretations of its constituents and relevance exist. The aim of this study is to rigorously analyse the concept of critical health literacy in order to offer some clarity of definition upon which appropriate theory, well grounded practice and potential measurement tools can be based.

The study uses a theoretical and colloquial evolutionary concept analysis method to systematically identify the features associated with this concept. A unique characteristic of this method is that it practically combines an analysis of the literature with in depth interviews undertaken with practitioners and policy makers who have an interest in the field. The study also analyses how the concept is understood across the contexts of time, place, discipline and use by health professionals, policy makers and academics.

Findings revealed a distinct set of characteristics of advanced personal skills, health knowledge, information skills, effective interaction between service providers and users, informed decision making and empowerment including political action as key features of critical health literacy. The potential consequences of critical health literacy identified are in improving health outcomes, creating more effective use of health services and reducing inequalities in health thus demonstrating the relevance of this concept to public health and health promotion.

Conclusions

While critical health literacy is shown to be a unique concept, there remain significant contextual variations in understanding particularly between academics, practitioners and policy makers. Key attributes presented as part of this concept when it was first introduced in the literature, particularly those around empowerment, social and political action and the existence of the concept at both an individual and population level, have been lost in more recent representations. This has resulted in critical health literacy becoming restricted to a higher order cognitive individual skill rather than a driver for political and social change. The paper argues that in order to retain the uniqueness and usefulness of the concept in practice efforts should be made to avoid this dilution of meaning.

Peer Review reports

Health Literacy is a term that has attracted increasing attention over the last two decades. As interest in the field of health literacy has grown, definitions have widened. Although health literacy has been argued to be a ‘ repackaging of a number of other important concepts central to the ideological commitments, and the theory and practice of health promotion’ [ 1 ] p287], the concept has generated considerable debate and achieved rapid currency in policy making [ 2 , 3 ]. Much of the debate has centered on delineating the concept: the domains it may include, how it is manifested and measured and whether and how the concept impacts on health outcomes and health inequalities [ 4 – 6 ]. Instrumental to these debates has been the contribution made by Nutbeam [ 7 ] who distinguished between basic functional health literacy, communicative interactive health literacy and critical health literacy. It is this third face of health literacy, that Nutbeam [ 7 ] presents as the cognitive and skills development outcomes which are oriented towards supporting effective social and political action as well as individual action, that this article seeks to explore.

Taken literally, the ‘critical’ aspect of critical health literacy, can be a higher level cognitive ability as suggested by McLaughlin and DeVoogd [ 8 ]. If health literacy is the ability to access, understand, appraise and apply health information [ 9 ], then critical health literacy is potentially a higher order process that could be developed through education to critically appraise information of relevance to health. This is in keeping with much of the emphasis of health literacy research which is on the skills and abilities of individuals and their participation in the creation of health. Critical health literacy is elsewhere [ 10 ] seen as empowerment where being critically health literate might mean acting individually or collectively to improve health through the political system or membership of social movements. Just as health literacy might be seen as ‘new wine into old bottles’ [ 11 ] p289] of empowerment [ 1 , 11 ], so critical health literacy, with its focus on community capacity to act on social and economic determinants of health, is redolent of community development. Exploring critical health literacy from this angle and borrowing from Freire [ 12 ], critical health literacy is, like community development, a process in which citizens become aware of issues, participate in critical dialogue, and become involved in decision making for health [ 4 ]. Although the 7 th Global Conference on Health Promotion [ 13 ] identified improving health literacy as a means for fostering community involvement and empowerment, critical health literacy may be seen as the neglected domain of health literacy, rarely achieving any focus or interventions that claim to be working towards this outcome. There are those that argue that the lack of attention given to the psychological constructs within the definition of critical health literacy results in health literacy acquiring a rather cognitive focus and that health outcomes are more likely to be achieved when the dichotomy between knowledge and psychological constructs are overcome [ 14 ]. Critical health literacy may offer the opportunity to achieve this. The lack of attention the concept has been given may be due to a lack of conceptual models and frameworks that explore critical health literacy [ 7 , 15 ]. Alternatively, it may be the result of difficulties and confusion in grasping what exactly empowerment based skills involve and how the concept can be taken forward [ 16 ]. While such confusion exists any potential that this concept may have to offer cannot be realised and tools to measure it accurately cannot be developed. A systematic analysis of the concept of critical health literacy that explores definitions and understandings of the term in both academic literature and as held by practitioners and policy makers may help to reveal whether it is indeed a useful and unique concept.

A search of Medline using the term ‘health literacy’ showed 4115 articles had been published since 1991. A separate Medline search using the term critical health literacy identified only 39 articles. Much of the literature on health literacy focuses on different typologies that attempt to distinguish different domains or components of health literacy [ 4 , 17 , 18 ]. Chinn’s recent [ 19 ] review and critical analysis of critical health literacy identifies three domains that make up the concept; that of critical appraisal of information, understanding social determinants of health and collective action. This is an important contribution in creating clarity of meaning and understanding. However, there is a real need to analyse the concept in a far more systematic and rigorous way.

Concepts are important in describing and explaining phenomena and examples from numerous professional fields show that they underpin and explain practice for example the concepts of faith, [ 20 ] and self-care [ 21 ] yet they may be poorly delineated. As concepts become more widely used in the literature, their use may become expanded and as a result become confused with similar concepts [ 22 ] resulting in difficulties in communicating the phenomena, in evaluating its strengths and weaknesses [ 23 ] as well as to assess its unique nature. The relationship between concepts and theory is discussed widely with theory often being described as being built from ‘conceptual bricks’ [ 24 , 25 ]. Part of the literature on health literacy posits that there is a causal pathway whereby low levels of health literacy contribute to ill health [ 5 ] and that health literacy is an outcome that is co-created by patients and health care professionals [ 6 ]. Such theories are built on a concept of health literacy and yet it is acknowledged that confusion exists around the concept [ 26 ] therefore providing a poor basis for theory. Critical health literacy, while being seen as part of an emerging ‘third generation of health literacy development’ [ 27 ]p2], also displays elements of confusion and overlap with other concepts. This is then a crucial time to systematically and rigorously analyse the concept itself to enable appropriate theory, well grounded practice and accurate measurement tools to emerge.

Concept analysis is a well established methodology that has been used to analyse many concepts key to public health and health promotion including cultural competence [ 28 ] empowerment [ 29 ], participation [ 30 ] equity [ 31 ] and critical media health literacy [ 32 ]. There are numerous methods of concept analysis adopting slightly different approaches but which always follow a systematic and staged process of identification and analysis. Common to most of the methods [ 23 , 25 , 33 , 34 ] is the systematic analysis of key elements of the concept such as (a) the attributes of the concept which refers to the key characteristics that define the concept, (b) references or what the concept is used to refer to, (c) antecedents or the factors that need to be in place in order for the concept to occur, (d) consequences or what happens as a result of the concept, (e) surrogate terms that could be used instead of the concept and (f) resemblant terms or other concepts that show similarity.

Concepts are abstractions that are expressed in some form and through repeated public interaction a concept becomes associated with a particular set of attributes and is thus publicly manifested though behavior and linguistics [ 35 ]. As a result, concepts are subject to continual change and definitions and characteristics may vary according to different contexts such as time, place, discipline and theoretical perspective [ 23 ] Rodgers offers the example of the concept of ‘health’ which is understood very differently according to contexts and has in some contexts of time, culture and discipline focused on the absence of disease while in other contexts alludes to more positive understandings associated with well-being [ 23 ]. As concepts are subject to continual change they do not have a strict set of attributes but rather a cluster of attributes which may be prioritised differently by different groups of people or at different times. This understanding of concepts and the importance of acknowledging and identifying the contextual variations led to the adoption of the evolutionary concept analysis method developed by Rodgers [ 23 ] with its emphasis on inductive processes and its commitment to contextualism.

This study has adapted the evolutionary concept analysis process developed by Rodgers [ 35 ] in order to incorporate the ideas of Risjord [ 36 , 37 ] who argues that there is a need for a further contextual distinction to be made beyond time, place and discipline. This distinction is between a ‘theoretical concept analysis’ which aims to represent concepts as they appear in a particular body of scientific and theoretical literature and a ‘colloquial concept analysis’ which aims to represent the concept as used by a particular group of people. The method adopted here acknowledges that a gap frequently exists between academic understandings of a concept and the understandings of practitioners who may be less influenced by theoretical ideas and more influenced by experience and the practicalities of delivery. An analysis that seeks to understand a concept holistically and across its contextual realms needs to explore both sets of understandings. Risjord [ 36 , 37 ] presents these two aspects as two distinct approaches with different aims. However, he goes on to argue that there is space for a mixed analysis and that some forms of concept analysis do require both so that the phenomena can be understood across different contextual settings. While Risjord has not applied the approach, this study has incorporated these ideas into an adaptation of the evolutionary concept analysis in order to capture both the theoretical and practice based understandings of the concept. The result is a method that has six stages represented in Figure 1 whereby the theoretical representations of critical health literacy are examined through a scrutiny of the relevant literature and the colloquial interpretations of the concept are examined through interviews with practitioners and policy makers with an interest in the field.

Stages of the evolutionary concept analysis process applied to critical health literacy.

The sampling of the theoretical and colloquial data were undertaken concurrently. Theoretical sampling involved literature identified through databases including CINAHL, ASSIA, Medline, ERIC, Education Research Complete, Cochrane, Centre for Reviews and Dissemination, CommunityWise, IBSS, British Nursing Index and the Index to Theses. This was complemented by a search via Google and Google scholar and a citation search.

Searches were set to return any article produced, in English, since 1995 using the search term ‘critical health literacy’. From all of the searches, a total of 39 different articles were found. Of these, six were subsequently removed for lack of relevancy (if the concept was only mentioned once but not described or discussed) and one was unavailable via the British Library. A final total of 32 articles were included in the theoretical analysis.

The colloquial sample included two groups of professionals with an expressed interest in the field of health literacy; policy makers (those working at a strategic, planning or policy level either nationally or locally) and practitioners (those working in a health context directly with members of the public through the provision of projects or services). The UK Health Literacy Group ( http://www.healthliteracy.org.uk/ ), a special interest group for the Society for Academic Primary Care, was identified as a point of access for both these groups as its membership consists primarily of practitioners and providers from health care services and non-governmental organisations, policy makers and academics with an interest in health literacy. It was important to access a special interest group because participants needed to have an awareness of the concept in order to discuss their understanding of it. A general sample of practitioners and policy makers would not have enabled this insight. Academics were screened out of the membership list as their views had already been captured through the theoretical concept analysis. Those members who had not given permission to be contacted by other members were also excluded. A total of 30 practitioners and nine policy makers meeting the inclusion criteria were identified. These were invited, by email, to participate in a telephone interview as part of the study. A total of eight practitioners and five policy makers took part in the study between April and May 2011.

The theoretical data were read initially as a familiarisation process, then reread once or twice more to identify specifically the attributes, surrogate terms, resemblant terms, references, antecedents and consequences that related to critical health literacy within the text. As the data was collected, phrases, themes and quotations relating to the above elements were recorded onto a data matrix. The colloquial data was collected through semi structured interviews carried out by telephone due to the wide geographic locations of the participants. The interviews were in depth and lasted up to 45 minutes. The interview schedule was designed carefully to represent the same areas of inquiry that were used to interrogate the theoretical data. Each interview was recorded and transcribed.

The research project complies with the ethical principles outlined in the World Medical Association Declaration of Helsinki ( http://www.wma.net/en/30publications/10policies/b3/ ) and was submitted to and approved by London South Bank University’s Research Ethics Committee.

This section contains the key findings of the combined analysis and includes the most significant contextual variations that emerged as part of the process.

Attributes: what are the key characteristics of critical health literacy?

Key characteristics include having advanced personal and social skills including confidence, social and communication skills, self efficacy and interpersonal skills. As Wang [ 38 ] states:

‘It implies a significant level of …personal skills and confidence.’ [ 38 ] p 271]

It also involves the ability to access, manage, assess the credibility, understand and critically appraise information on health related issues:

“Being able to decipher information, decode, but on top of that to have an understanding, a critical awareness of what underlies that information, so it would be a conceptual awareness.’ (participant 4)

This entails having a level of health knowledge including a level of familiarity with health terms and medical terminology, being informed about health issues and understanding these issues:

‘It’s about whether individuals have an understanding around a wide range of issues to do with health’ (participant 21)

Another characteristic of critical health literacy is being able to contextualize information, apply it to one’s own situation, judge risk, act on information and thus share the decision making with health professionals. The focus on an ability to contextualise information was captured by Kickbush [ 39 ]:

‘…involves understanding and ability to judge, sift and use information provided in the context of one’s own life – this is the key element of critical health literacy…’ [ 39 ] p292]

Whilst these characteristics relate to individual abilities, critical health literacy is also seen as arising from the relationship between services and individuals and an ability to interact effectively. This involves an ability to navigate services but beyond this to advocate and articulate oneself confidently when communicating with a health professional and where necessary question or challenge a professional in a constructive way as one participant demonstrated in their reflection on their own experience as a patient:

‘I don’t just receive information, sitting there quietly absorbing it and making sense of it. What I need to do is also question, including occasionally challenging.’ (Participant 20)

This level of effective interaction is not only dependent on the skills of the individual but also on the skills of the professional who must be able to explain things clearly and provide information that is appropriate for patients. The contextual analysis showed a variation on this point between the colloquial and theoretical data. The professional participants placed an emphasis on the skills and role of the health practitioners in the creation and existence of critical health literacy. This was a theme that was only touched upon within the academic literature but which was central to the colloquial sample who stressed that critical health literacy would only exist if there was a commitment from health practitioners to provide accessible information and to engage in shared decision making.

Another characteristic of critical health literacy can be broadly described as empowerment by which a person has an understanding of the determinants and the policy context of health, an understanding of opportunities to challenge these determinants and policy and motivation and actual action at apolitical and social level. The most frequently cited reference to this point was that made by Nutbeam [ 7 ]:

‘…the cognitive and skills development outcomes which are oriented towards supporting effective social and political action…’ [ 7 ] p 265]

This empowerment may exist at an individual level but may also demonstrate collective understanding and exist at a population or community level. As such it represents an asset rather than a deficit or lack of skills in an individual or community. The contextual analysis showed, however, quite stark variation in how this theme was understood and prioritised within the different contexts analysed. While this characteristic of empowerment was a strong and clearly articulated attribute within some of the academic articles [ 7 , 38 , 40 , 41 ] and by some of the colloquial sample, it was not universally emphasised. The analysis of theoretical literature shows that there has been a decrease in reference to empowerment, action at a social and political level and the conceptualisation of critical health literacy existing at a population as well as an individual level over the last five years. The contextual analysis also demonstrated that sources from a medical discipline were less likely to identify political and social action as an attribute of critical health literacy than were public health sources which focused more on cognitive critical analysis and decision making skills [ 42 , 43 ]. None of the empirical articles that derived from original research identified this as an attribute while theoretical articles [ 7 , 44 – 47 ] were much more likely to.

The final attribute is that of critical health literacy being a learned and movable state that may change with time or the circumstances of peoples lives: References: what is critical health literacy used to refer to?

‘I think the main things are that, you know, that I feel people can maybe move up and down the levels. Depending on the kind of situation they’re in.’ (participant 14)

The concept of health literacy is most commonly used in reference to individuals and is seen as a set of skills or competencies. For some [ 7 , 48 , 49 ] it could also refer to communities or population groups as well as individuals and some (largely within the colloquial sample), also used it in reference to a relationship between individuals and professionals.

Antecedents: what needs to be in place for critical health literacy to occur?

Familiarity with health issues and services as well as an interest and motivation to find out more about health issues is a precursor of critical health literacy:

‘even well educated people can struggle with health literacy because of the lack of familiarity and very often going very long periods without even having to engage with health services or think much about personal health.’ (participant 20)

This motivation may be triggered by personal experience of particular health issues, through social influences or through personal determination.

In order for critical health literacy to emerge an individual would have a wide skill set of literacy and language skills, critical appraisal skills, cognitive skills, personal and social skills and functional and interactive health literacy skills. While the majority of the theoretical and colloquial data argued that functional and interactive health literacy skills and actual literacy and language skills needed to be in place in order for critical health literacy to emerge, there were a minority who strongly opposed this position. For this minority, who often referred to a the Frierian approaches of critical consciousness raising [ 12 ] as indeed did Nutbeam’s original article [ 7 ], the existence of functional literacy skills of individuals was a less important area of focus:

‘..they may be great at speaking and listening, they may be able to stand up for themselves quite well and may have an understanding of critical health literacy that isn’t dependent on their reading and writing… so those basic literacy reading and writing skills are a building block for critical health literacy but not an absolute requirement in some cases’ (participant 4)

For critical health literacy to be developed there would be formal, structured but supportive learning environments with a change in focus for health education programmes away from information giving to skills development and understanding of health inequalities and the determinants of health based on principles of community development:

‘Within this paradigm, health education may involve the communication of information, and development of skills which investigate the political feasibility and organizational possibilities of various forms of action to address social, economic and environmental determinants of health.’ [ 7 ] p 265]

Another antecedent was political will, that is political recognition of the value of critical health literacy as well as the drive and resources coming from a political level to support the development of critical health literacy skills:

‘But I think it needs – it does need – if there was a policy drive. If there was a condition around a policy drive to bring together people who matter, people who sign up to it.’ (Participant 39)

The contextual analysis again showed some mixed understandings and emphasis in this area. Professionals were far more likely to emphasise the theme of political will in creating critical health literacy including the need for any work to develop critical health literacy to be resourced and led at a political and strategic level in order for it to be effectively implemented. This was an area that received very little discussion in the academic literature.

The development of communication skills amongst health professionals to ensure information is presented in an understandable way and that there is a commitment to shared decision making was seen by professionals and policy makers to be important.

Consequences of critical health literacy: what happens as a result of critical health literacy?

The consequences of critical health literacy that were identified in the literature and by professionals and policy makers were supposed or anticipated rather than demonstrated through research and four themes were identified. The first theme was an increase in self efficacy including increased levels of personal involvement, action and control over health issues that affected an individual’s life, shared decision making and self management of care as captured by Ishikawa and Yano [ 49 ].

‘…may be related to perceived control over one’s health and self-efficacy to participate in the health care process directly.’ p118

Critical health literacy would also result in improved quality of life, health behaviour and outcomes:

‘Being able to kind of look after your health and respond to your own health issues. So, my personal point of view, obviously better health outcomes.’ (participant 14)

A critically health literate person would make more effective and efficient use of services:

‘Critical health literacy as a compass, guiding patients successfully through complex and non transparent health markets.’ [ 50 ] p38]

Critical health literacy was also seen as an individual and population outcome in which there would be increased levels of social capital, understanding and questioning of the determinants and inequalities of health and increased levels of social and political action and change. The contextual analysis again showed that this has been identified as a consequence less frequently in papers published in the last five years. The contextual analysis also identified that theoretical data from Public Health sources identified a far broader set of consequences, including empowerment and political action, than those in the medical literature which focused far more on improved heath related behaviour and outcomes as well as use of services.

Surrogate terms – do the characteristics mirror those of another concept?

It is possible that the characteristics of a concept may mirror those of other concepts which become known as surrogate terms. While the literature and professionals identified several surrogate terms, none emerged frequently or consistently suggesting there is no other term that captures the same characteristics of this term.

Resemblant terms – do the characteristics resemble those of other concepts?

Again, the literature and participants referred to a large number of terms that reflected some, though not all of the attributes, antecedents and consequences of critical health literacy. Those that emerged most frequently and appear to have the most in common with critical health literacy were empowerment, self-efficacy, health literacy, critical appraisal, critical consciousness and advocacy.

It is recognized that the sample size of the colloquial data is small and represents only a UK perspective but is likely to represent how the concept is used in discourse and policy. No other studies have been identified that seek to explore the concept from both a theoretical and professional perspective. Interviews were in depth and the highly systematic analysis of the concept of critical health literacy presents a more detailed and nuanced understanding than previous discussions. The analysis shows the concept to be a distinct concept with a unique set of attributes and antecedents. Analysis of the contextual variations of the concept (that is, the differences studied in how the concept is understood across time, geography, discipline and across the theoretical and colloquial data), however, reveals that there is not a consensus of understanding of the term and that, in particular, there are distinct differences in the way that academics and professionals interpret the term. Thus, the findings do not represent a definitive list but rather a cluster of attributes, which may be prioritised differently in different contexts, based on the principles of ‘family resemblances’ [ 51 ] These differences demonstrate the importance of a systematic clarification of the concept, such as this study provides, before work can be done to look at how the concept and theories around it might be developed, how it might be applied in practice and its existence measured.

A key finding to emerge from this study is that critical health literacy is a unique concept. Several resemblant concepts were identified, the most frequently mentioned being empowerment. Indeed Tones [ 1 ] argues that the meaning of health literacy has already been more appropriately mapped by the existing conceptualization of community and individual empowerment. There are many definitions of empowerment and several concept analyses have been undertaken [ 52 , 53 ] suggesting that it too is widely used to describe an outcome but its characteristics are less clear. Gibson’s [ 28 ] concept analysis of empowerment, which is frequently referenced, shows a clear overlap of attributes, antecedents and consequences with critical health literacy. However, there are key distinctions. In particular, attributes of empowerment do not include direct reference to the theme of information skills, which is so central to critical health literacy. The ability to access, understand and manage health information as well as the ability to assess its credibility and to critically analyse and where appropriate challenge the information may possibly be skills held by an ‘empowered’ individual or community but they are not essential to empowerment in the way that they are to critical health literacy.

Despite the unique nature of the concept, the study identified several contextual variations in its interpretation and use and these need to be looked at more closely. The term critical health literacy has become part of the debates on health literacy, stemming largely from an original paper by Nutbeam [ 7 ]. In his article, Nutbeam presents Freebody and Luke’s [ 54 ] classification of literacy into basic/functional literacy, communicative/interactive literacy and critical literacy. Within this framework, critical literacy is defined as ‘ more advanced cognitive skills, which together with social skills, can be applied to critically analyse information, and to use this information to exert greater control over life events and situations.’ [ 7 ] p264] He later goes on to apply this to a health context and provides a more specific and applied explanation of ‘critical health literacy’ which discusses far more explicitly the attribute of ‘skills which investigate the political feasibility and organisational possibility of various forms of action to address social, economic and environmental determinants of health’ and the links to population health as well as individual health: ‘This type of health literacy can be more obviously linked to population benefit, alongside benefits to the individual.’ [ 7 ] p265]. Subsequent citations of Nutbeam’s work, however, frequently use the definition of critical literacy as a definition of critical health literacy [ 42 , 49 , 55 ] to the point at which it has almost become the accepted definition. While this definition alludes to greater individual control over life events, its lack of specific reference to social and political action and existence at a population level means these elements are in danger of becoming lost so distorting the original meaning and emphasis.

It is not possible to be conclusive about the reasons why the interpretation of critical literacy has, in some quarters, superseded Nutbeam’s more comprehensive, applied and political definition of critical health literacy. However, the dominance of one interpretation over another cannot be overlooked as it limits the concept to a higher order cognitive individual skill rather than a driver for political and social change. In order to understand whether this enhances the concept for theoretical and practical use or whether it simply dilutes it and makes it more resemblant of other existing concepts, it is important to consider the possible reasons for this fundamental change in conceptual understanding. One possible reason is that the debates around health literacy have been dominated by the functional domain which focuses on technical, practical and individual skills sets [ 19 ]. Within this dominant discourse assuming critical health literacy to simply be a set of higher order cognitive skills may be a natural progression. Secondly, acknowledging the place of social and political action and existence at a population level within the definition of critical health literacy requires a consideration of how such skills could be developed and measured, a challenge that is perhaps more complex and which receives less attention. Indeed, a socially and politically activated community with a critical understanding of health and its determinants may be a less desirable outcome for some. Thirdly, it could also be because the paradigm in which the discourse has taken place has narrowed the interpretation. The debates around both health literacy and critical health literacy have remained largely within the health field and this has perhaps constrained interpretations. Zarcadoolas et al. [ 4 ] have pointed to the need to make use of the developing knowledge of other academic arenas and other types of literacies such as science literacy, cultural literacy and civic literacy and their relevance for making health decisions.

It is useful to look at other professional fields. There are, for example, clear overlaps between the consequences or potential outcomes of critical health literacy and the objectives of community development work and yet the search for this study revealed no citations within the community development literature, despite this apparent affinity. This illustrates the contextual influence on concepts highlighted by Rodgers [ 23 ] and raises the question of why, if critical health literacy has currency and utility, the concept is not deployed outside the health field. Is it because the concept is not useful within community development because it lacks relevancy, is it because there is too little theoretical basis to inform the complex pathways of the community development process or is it simply because the concept is too new and has yet to find an entrance into the community development discourse? Taking the concept beyond the debates of the health environment might allow the fuller, more political and community based definition of critical health literacy to be understood and developed while identifying potential routes for the development of critical health literacy.

A further difference in understanding revealed by this study is the relationship between critical health literacy and the other domains of functional and interactive/communicative health literacy. The majority of both colloquial and theoretical data argue that functional and interactive health literacy including actual literacy and language skills need to be in place in order for critical health literacy to emerge. Sections of the data however either opposed this position or placed less emphasis on the importance of technical skills arguing that critical health literacy can emerge without the existence of such technical skills. This group make comparisons to Freierian approaches of critical consciousness raising [ 12 ], as does Nutbeam’s original article [ 7 ] whereby a liberatory education is achieved through raising levels of awareness, in particular awareness of oppression, rather than through a functional curriculum. However, if the existence of information skills is key to critical health literacy and is one of the attributes that makes it a distinct and unique concept, the link with literacy skills cannot be ignored. The information skills described may equally be applied to non written sources such as discussion based or visually presented information. However in a world where the vast majority of health information remains in written form a level of fundamental literacy skills must remain an advantage.

The role of health professionals in creating critical health literacy which was referred to by professionals and policy makers, turns critical health literacy from a set of skills and competencies existing within, and owned by, an individual or community into a transactional concept. As such, it depends on the motivation and development of skills within the individual or community but also requires collaborative efforts at a structural level in order to fully prosper. The inclusion in the colloquial data of a need for there to be a political will and driver in order for critical health literacy to develop, demonstrates that when applying the academic ideas in a practice context, professionals clearly locate responsibilities beyond the individual level. This maps shifts in focus of discussions around health literacy. In 2004, for example, the Institute of Medicine Committee on Health Literacy, called for policy makers to consider the interaction between the skills of individuals and the demands of social systems and make needed correctives [ 9 ]. This development of the concept is part of a natural evolution that is in line with the evolution of the broader concept of health literacy, rather than an area of disagreement between the theoretical and colloquial data.

This evolutionary concept analysis of critical health literacy has provided a thorough and systematic analysis of the definition and use of the concept of critical health literacy across several contexts including both theoretical literature and the colloquial data from practitioners and policy makers. It reveals a unique set of characteristics of advanced personal skills, health knowledge, information skills, effective interaction between service providers and users, informed decision making and empowerment including political action indicating that this is indeed a distinct concept rather than a repackaged established concept. Not only is it a distinct concept but the potential consequences identified by this study, as well as its relationship to Health Literacy, demonstrate its importance to public health and health promotion in improving health outcomes, creating more effective use of health services and reducing inequalities in health. However, the contextual analysis shows that there is not consistency in how the term is understood by academics, practitioners and policy makers and that some of the key attributes initially presented as part of this concept, particularly those around empowerment and social and political action existing at an individual and population level, are in danger of losing their importance. In order to prevent the concept losing its unique nature, this narrowing of its definition must be avoided and the concept must not be allowed to get lost in the wider health literacy debate. This might be achieved through further research and discussion to examine how critical health literacy might be developed in practice and ultimately measured. From this the link with health outcomes can more easily be explored. In order to do this, a closer engagement with the field of community development to explore the concept further within this professional context of skills, understandings and associations with empowerment and political action is recommended.

Authors’ information

SS is Senior Lecturer in Public Health and Health Promotion with a particular interest and professional background in health promotion, community development and policy making. She is currently part way through a PhD exploring the concept of critical health literacy and its usefulness and relevance to public health practice.

JW is Professor of Health Promotion and has published widely on the discourse and practice of health promotion and latterly, on the utility of health literacy as a concept to explain the empowerment of individuals and communities and their abilities to access information and navigate health systems.

GR is an academic General Practitioner. She is Professor of Primary Care and Public Health in the Faculty of Health and Social Care at London South Bank University, UK. Her research focus is on Health Inequalities, in particular the impact of low Health Literacy on health. She is the UK Department of Health GP Health Literacy Champion. She set up, and now chairs, a Health Literacy group to raise awareness of HL and develop the HL evidence-base in the UK.

KP is Professor and Head of Social Work at London South Bank University. He has published extensively in the areas of community development and social work and is joint editor with Gary Craig, Marjorie Mayo, Mae Shaw and Marilyn Taylor of The Community Development Reader published in 2011 by Policy Press. With Paul Stepney he jointly authored the text Social Work and the Community: a critical context for practice , published in 2008 by Palgrave. He is a member of the editorial board of the British Journal of Social Work , and the Community Development Journal.

Tones K: Health Literacy: new wine in old bottles. Health Educ Res. 2002, 17 (3): 287-290. 10.1093/her/17.3.287.

Article   PubMed   Google Scholar  

US Department of Health and Human Sciences: National action plan to improve health literacy. 2010, Washington DC, available at http://www.health.gov/communication/hlactionplan/ last accessed 22nd Feb. 2013,

Google Scholar  

European Commission: Together for Health: A strategic approach for the EU 2008–2013. 2007, Brussels: European Commission, available at http://ec.europa.eu/health-eu/doc/whitepaper_en.pdf . last accessed Jan 13 th 2013,

Zarcadoolas C, Pleasant A, Greer D: Elaborating a definition of health literacy: a commentary. J Health Commun. 2005, 8: 119-121.

Article   Google Scholar  

Berkman N, Sheridan S, Donahue K, Halpern D, Crotty K: Low Health Literacy and Health Outcomes: An updated systematic review. Annals of Internal Medicine. 2011, 155 (2): 97-107.

Rudd R, Keller D: Health literacy: new developments and research. Journal of Communication in Health Care. 2009, 2 (3): 240-257. 10.1179/175380609790912689.

Nutbeam D: Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21 st century. Health Promot Int. 2000, 15: 259-267. 10.1093/heapro/15.3.259.

McLaughlin M, DeVoogd G: Critical literacy as comprehension: expanding reader response. Journal of Adolescent and Adult Literacy. 2004, 48 (1): 52-62. 10.1598/JAAL.48.1.5.

Health Literacy: a prescription to end confusion. Edited by: Nielson-Bohlman L, Panzer A, Kindig D. 2004, Washington DC: National Academies Press

Jochelson K: Health literacy review paper. National social marketing centre. 2009, available at http://www.chpcp.org/servicecoord/chronicdisease/HealthLit/Health%20Literacy%20Review%20Paper-%20Dr%20Karen%20Jocelson%202008.pdf last accessed Jan 13th 2013,

Wills J: Health Literacy: new packaging for health education or radical movement?. Int J Public Health. 2009, 54 (1): 3-4. 10.1007/s00038-008-8141-7.

Friere P: Pedagogy of the Oppressed. 1970, New York: Continuum/Seabody

WHO: Health literacy and health promotion, definitions, concepts and examples in the east Mediterranean region, 7th global conference on health promotion working paper. 2009, Nairobi: WHO, [available at http://www.who.int/healthpromotion/conferences/7gchp/Track1_Inner.pdf ] last accessed Jan 14th 2013,

Camerini L, Schulz P, Nakamoto K: Differential effects of health knowledge and health empowerment over patients’ self management and health outcomes: a cross sectional evaluation. Patient Educ Couns. 2012, 89 (2): 337-344. 10.1016/j.pec.2012.08.005.

Sorensen K, Van den Broucke S, Fullam J, Doyle G, Pelikan J, Slonska Z, Brand H, European Health Literacy Project: Health Literacy and Public Health: a systematic review and integration of definitions and models. BMC Publ Health. 2012, 12: 80-10.1186/1471-2458-12-80.

Rubinelli S, Schulz P, Nakamoto K: Health literacy beyond knowledge and behavior: letting the patient be a patient. Int J Public Health. 2009, 54: 307-311. 10.1007/s00038-009-0052-8.

Peerson A, Saunders M: Health Literacy Revisited: what do we mean and why does it matter. Health Promot Int. 2009, 24 (3): 285-296. 10.1093/heapro/dap014.

Freedman D, Bess KD, Tucker HA, Boyd DL, Tuchman AM, Wallston K: Public health literacy defined. Am J Prev Med. 2009, 36 (5): 446-451. 10.1016/j.amepre.2009.02.001.

Chinn D: Critical health literacy: a review and critical analysis. Soc Sci Med. 2011, 73 (1): 60-67. 10.1016/j.socscimed.2011.04.004.

Dyess S: Faith: a concept analysis. J Adv Nurs. 2011, 67 (12): 2723-2731. 10.1111/j.1365-2648.2011.05734.x.

Hanna K, Decker C: A concept analysis: assuming responsibility for self care among adolescents with type 1 diabetes. Journal of Specialist Pediatric Nurses. 2010, 15 (2): 99-100. 10.1111/j.1744-6155.2009.00218.x.

Cowles K: Grief in a cultural context: expanding concept analysis beyond the professional literature. Concept development in nursing; foundations, techniques and applications. Edited by: Rodgers B, Knafl K. 2000, Philadelphia: WB Saunders Company, 2

Rodgers B: Concept analysis: an evolutionary view. Concept development in nursing: foundations, techniques and applications. Edited by: Rodgers B, Knafl K. 2000, Philadelphia: WB Saunders Company

McKenna H: Nursing theories and models. 2000, Oxford: Routledge

Walker LO, Avant KC: (3rd Edition) strategies for theory construction in nursing. 1994, Appleton and Lange: Connecticut

Egbert N, Nanna K: Health literacy: challenges and strategies. Online J Issues Nurs. 2010, 14 (3): [available at http://www.medscape.com/viewarticle/717465 ] last accessed Dec 30th 2011,

de Leeuw E: The Political Ecosystems of health literacies. Health Promot Int. 2012, 27 (1): 1-4.

Eunyoung E: The model of cultural competence through an evolutionary concept analysis. J Transcult Nurs. 2004, 15 (2): 93-102. 10.1177/1043659603262488.

Gibson C: (1991) A concept analysis of empowerment. In Journal of Advanced Nursing. 2006, 16: 354-361.

Hickey G, Kipping C: Exploring the concept of user involvement in mental health through a participation continuum. J Clin Nurs. 1998, 7 (1): 83-88. 10.1046/j.1365-2702.1998.00122.x.

Article   CAS   PubMed   Google Scholar  

Almond P: An analysis of the concept of equity and its application to health visiting. J Adv Nurs. 2002, 37 (6): 598-606. 10.1046/j.1365-2648.2002.02125.x.

Wharf Higgins J, Begoray D: Exploring the borderlands between media and health: conceptualising ‘critical media health literacy’. Journal of Media Literacy Education. 2012, 4 (2): 136-148.

Wilson J: Thinking with Concepts. 1963, London: Cambridge University Press

Haase J, Leidy N, Coward D, Britt T, Penn P: Simultaneous concept analysis: a strategy for developing multi related concepts. Concept development in nursing; foundations, techniques and applications. Edited by: Rodgers B, Knafl K. 2000, Philadelphia: WB Saunders Company, 2

Rodgers B: Concepts, analysis and the development of nursing knowledge: the evolutionary cycle. J Adv Nurs. 1989, 14: 330-335. 10.1111/j.1365-2648.1989.tb03420.x.

Risjord M: Rethinking concept analysis. J Adv Nurs. 2009, 65 (3): 684-691. 10.1111/j.1365-2648.2008.04903.x.

Risjord M: Nursing knowledge: science. 2010, West Sussex, Wiley-Blackwell: Practice and Philosophy

Wang R: Critical health literacy: a case study from China in schistosomiasis control. Health Promot Int. 2000, 15 (3): 269-274. 10.1093/heapro/15.3.269.

Kickbush I: Health Literacy: addressing the health and education divide. Health Promot Int. 2001, 16 (3): 289-297. 10.1093/heapro/16.3.289.

Levin-Zamir D, Peterburg Y: Health literacy in health systems: perspectives on patient self management in Israel. Health Promot Int. 2001, 16 (1): 87-94. 10.1093/heapro/16.1.87.

St Leger L: Schools, Health literacy and public health: possibilities and challenges. Health Promot Int. 2001, 16 (2): 197-205. 10.1093/heapro/16.2.197.

Gray N, Klein J, Noyce P, Sesselberg T, Cantrill J: The internet: a window on adolescent health literacy. J Adolesc Health. 2005, 37: 243.el-243.e7.

Steckelberg A, Hulfenhaus C, Kasper J, Mulhauser I: How to measure critical health competences; development and validation of the critical health competence test (CHC Test). Advances in Health Science Education. 2009, 14: 11-22. 10.1007/s10459-007-9083-1.

Porr C, Drummond L, Rishter S: Health literacy as an empowerment tool for low income mothers. Fam Community Health. 2006, 29 (4): 328-335. 10.1097/00003727-200610000-00011.

Gould L, Mogford E, DeVoght A: Successes and challenges of teaching the social determinants of health in secondary schools: case examples in Seattle, Washington. Health Promot Pract. 2010, 11 (3): 26s-33s. 10.1177/1524839909360172.

Mogford E, Gould L, DeVoght A: Teaching critical health literacy in the US as a means to action on the social determinants of health. Health Promot Int. 2011, 26 (1): 4-13. 10.1093/heapro/daq049.

Nutbeam D: The evolving concept of health literacy. Soc Sci Med. 2008, 67: 2072-2078. 10.1016/j.socscimed.2008.09.050.

Gillis D: Exploring dimensions of health literacy: a case study of interventions to promote and support breastfeeding. 2009, Nottingham University: PhD thesis

Ishikawa H, Yano E: Patient health literacy and participation in the health care process. Health Expect. 2008, 11 (2): 113-22. 10.1111/j.1369-7625.2008.00497.x.

Nebling T, Jochem M: Equipping and empowering patients: an examination of project work in critical health literacy. Journal of Communication in Healthcare. 2010, 3 (1): 37-47. 10.1179/175380610792016446.

Rodgers B, Knapfl K: Concept development in nursing: foundations, techniques and applications. 1993, Philadelphia: WB Saunders Company

Rodwell C: An analysis of the concept of empowerment. J Adv Nurs. 1996, 23 (2): 305-313. 10.1111/j.1365-2648.1996.tb02672.x.

Fingeld D: Empowerment of individuals with enduring mental health problems: results from concept analyses and qualitative investigations. Adv Nurs Sci. 2004, 27 (1): 44-52.

Freebody P, Luke A: ‘Literacies’ programs: debates and demands in cultural context. Prospect. 1990, 5: 7-16.

Long A: The potential of complimentary and alternative medicine in promoting well-being and critical health literacy: a perspective observational study of shiatsu. BMC Complement Altern Med. 2009, 9: 19-10.1186/1472-6882-9-19.

Article   PubMed   PubMed Central   Google Scholar  

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We would like to acknowledge the UK Health Literacy Group, Nicola Crichton, Lucy McDonald and Jo Newton for support and technical help. The research is part of a London South Bank University funded PhD scholarship in Health Literacy.

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SS conceived of the study, adapted the concept analysis research model, carried out the data collection and analysis and drafted the article. JW and GR contributed to the conception and design of the concept analysis and has been involved in the direction and content of the manuscript. KP participated in the supervision of the study and advised on drafts of the paper and approved the final manuscript. All authors read and approved the final manuscript.

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Sykes, S., Wills, J., Rowlands, G. et al. Understanding critical health literacy: a concept analysis. BMC Public Health 13 , 150 (2013). https://doi.org/10.1186/1471-2458-13-150

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Constructing critical thinking in health professional education

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Introduction

Calls for enabling ‘critical thinking’ are ubiquitous in health professional education. However, there is little agreement in the literature or in practice as to what this term means and efforts to generate a universal definition have found limited traction. Moreover, the variability observed might suggest that multiplicity has value that the quest for universal definitions has failed to capture. In this study, we sought to map the multiple conceptions of critical thinking in circulation in health professional education to understand the relationships and tensions between them.

We used an inductive, qualitative approach to explore conceptions of critical thinking with educators from four health professions: medicine, nursing, pharmacy, and social work. Four participants from each profession participated in two individual in-depth semi-structured interviews, the latter of which induced reflection on a visual depiction of results generated from the first set of interviews.

Three main conceptions of critical thinking were identified: biomedical, humanist, and social justice-oriented critical thinking. ‘Biomedical critical thinking’ was the dominant conception. While each conception had distinct features, the particular conceptions of critical thinking espoused by individual participants were not stable within or between interviews.

Multiple conceptions of critical thinking likely offer educators the ability to express diverse beliefs about what ‘good thinking’ means in variable contexts. The findings suggest that any single definition of critical thinking in the health professions will be inherently contentious and, we argue, should be. Such debates, when made visible to educators and trainees, can be highly productive.

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What this paper adds

‘Critical thinking’ is a term commonly used across health professional education, though there is little agreement on what this means in the literature or in practice. We depart from previous work, which most often attempts to create a common definition. Instead, we offer a description of the different conceptions of critical thinking held in health professional education, illustrate their dynamic use, and discuss the tensions and affordances that this diversity brings to the field. We argue that diversity in conceptions of critical thinking can allow educators to express unique and often divergent beliefs about what ‘good thinking’ means in their contexts.

Even though the term critical thinking is ubiquitous in educational settings, there is significant disagreement about what it means to ‘think critically’ [ 1 ]. Predominantly, authors have attempted to develop consensus definitions of critical thinking that would finally put these disagreements to rest (e. g. [ 2 , 3 , 4 , 5 ]). They define critical thinking variously, but tend to focus on a rational process involving (for example) ‘interpretation, analysis, evaluation, inference, explanation, and self-regulation’ [ 2 ]. Other authors have challenged this perspective by arguing that critical thinking is a more subjective process, emphasizing the role of emotion and relationships [ 6 , 7 , 8 , 9 ]. In the tradition of critical pedagogy, critical thinking has meant critiquing ideology [ 10 , 11 , 12 ]. Last, still others have argued that critical thinking is discipline or subject-specific, meaning that critical thinking is not universal, but does have a relatively stable meaning within different disciplines [ 13 , 14 , 15 , 16 , 17 , 18 ]. However, none of these attempts to clarify the ambiguity that surrounds critical thinking have led to agreement, suggesting that each of these perspectives offers, at best, a partial explanation for the persistence of disagreements.

This is problematic in health professional education (HPE) because professional programs are mandated to educate practitioners who have a defined knowledge base and skill set. When curriculum designers, educators, researchers, or policy-makers all agree that we should teach future professionals to ‘think critically’, resting on the assumption that they also agree on what that means, they may find themselves working at cross-purposes. Moreover, the focus on a stable meaning for critical thinking, whether within a discipline or across disciplines, cannot account for the potential value of the multiplicity of definitions that exist. That is, the availability of diverse conceptions of critical thinking likely enables educators to express diverse elements of and beliefs about their work, thereby suggesting a need to explore the conceptions of critical thinking held in HPE, and the contexts that inform those conceptions.

With the historical focus on developing broad definitions of critical thinking and delineating its component skills and dispositions, little has been done either to document the diverse conceptions of this term in circulation amongst active HPE practitioners or, perhaps more importantly, to illuminate the beliefs about what constitutes ‘good thinking’ that lie behind them and the relationships between them. Perhaps clarity in our understanding of critical thinking lies in the flexibility with which it is conceptualized. This study moves away from attempting to create universal definitions of critical thinking in order to explore the tensions that surround different, converging, and competing beliefs about what critical thinking means.

In doing so, we map out conceptions of critical thinking across four health professions along with the beliefs about professional practice that underpin those conceptions. Some of these beliefs may be tied to a profession’s socialization processes and many will be tied to beliefs about ‘good thinking’ that are shared across professions, since health professionals work within shared systems [ 19 ] toward the same ultimate task of providing patient care. It is the variety of ways in which critical thinking is considered by practitioners on the whole that we wanted to understand, not the formal pronouncements of what might be listed as competencies or components of critical thinking within any one profession.

Hence, with this study, we sought to ask:

How do educators in the health professions understand critical thinking?

What values or beliefs inform that understanding?

To explore these questions, we adopted a qualitative research approach that focuses on how people interpret and make meaning out of their experiences and actively construct their social worlds [ 20 ].

This study uses an emergent, inductive design in an effort to be responsive to the co-construction of new and unexpected meaning between participants and researchers. While techniques derived from constructivist grounded theory [ 21 ] were employed, methods like extensive theoretical sampling (that are common to that methodology) were not maintained because this study was intended to be broadly exploratory. This ‘borrowing’ of techniques offers the ability to capitalize on the open and broad approach offered by interpretive qualitative methodology [ 20 ] while engaging selectively with the more specific tools and techniques available from constructivist grounded theory [ 22 , 23 ].

The first author has a background in sociocultural and critical theory. Data collection and early analyses were carried out as part of her dissertation in Educational Policy Studies. As a result of her background in critical theory, there was a need for reflexivity focused on limiting predisposition toward participant interpretations of critical thinking that aligned with critical theory. The senior author was trained in cognitive psychology, and contributed to the questioning of results and discussion required to ensure this reflexivity. The first author’s dissertation supervisor also provided support in this way by questioning assumptions made during the initial stages of this work.

Participants were recruited through faculty or departmental listservs for educators. Senior administrators were consulted to ensure that they were aware of and comfortable with this research taking place in their unit. In some cases, administrators identified a few key individuals who were particularly interested in education. These educators were contacted directly by the first author to request participation.

The purposive sample includes four educators from each of four diverse health professional programs ( n  = 16 in total): medicine, nursing, pharmacy, and social work. All participants self-identified as being actively involved in teaching in their professional program and all were formally affiliated with either the University of Alberta (Medicine, Nursing, and Pharmacy) or the University of Calgary (Social Work). These four professions were selected to maximize diversity in approaches to critical thinking given that these professions have diverse perspectives and roles with respect to patient care. However, participants all worked in Alberta, Canada, within the same broad postsecondary education and healthcare contexts.

In addition, sampling priority was given to recruiting participants practising in a diverse range of specialties: primary care, geriatrics, paediatrics, mental health, critical care, and various consulting specialties. Specific specialties within each profession are not provided here in an effort to preserve participant anonymity. The goal was not to make conclusions about the perspective of any one group; rather, diversity in profession, practice context, gender, and years in practice was sought to increase the likelihood of illuminating diverse conceptions of critical thinking.

Data generation

Participants were invited to participate in two in-person semi-structured interviews conducted by the first author. All but one participant completed both interviews. Interviews were audio-recorded and interview guides are included in the online Electronic Supplementary Material. The first was about 1 hour in length and discussed how participants think about critical thinking in their teaching, professional practice, and other contexts. Participants were invited to bring a teaching artefact that represented how they teach critical thinking to the interview. Artefacts were used as a visual elicitation strategy to prompt discussion from a new angle [ 24 ]. Questions focused on what the participant thought about teaching critical thinking using the artefact and how they identified critical thinking (or lack thereof) in their students. Artefacts were not analyzed independently of the discussion they produced [ 25 ].

Interview 1 data were analyzed to produce a visual depiction of the aggregate terms, ideas, and relationships described by participants. The visual depiction took the form of a ‘mind map’ (see Appendix C of the Electronic Supplementary Material) that was generated using MindMup free online software [ 26 ]. In developing the mind map, we sought descriptions of participants’ views that remained as close to the data as possible, limiting interpretations and inferences. The ‘clusters’ that appear in the mind map (e. g., the cluster around ‘characteristics of the critical thinker’) represent relationships or categories commonly described when participants discussed those terms. Terms were not weighted or emphasized based on frequency of use (through font size or bolding) in an effort to allow individual participants to emphasize or deemphasize terms as they thought appropriate during the second interview.

Where there was no clear category or relationship, terms were left at the first level of the mind map, connected directly to ‘critical thinking’ at the centre. Including more connections and inferences would likely have improved the readability of the map for participants; however, we chose to include connections and exact language used by participants (even in cases where terms seemed similar) as often as possible, in an effort to limit researcher interpretation. That said, any attempt to aggregate data or to represent relationships is an act of interpretation and some inferences were made in the process, such as the distinction between descriptions about ‘characteristics’ of the critical thinker (the top left hand corner of the map) and ‘processes’ such as ‘reasoning’ or ‘examining assumptions’ (on the right side of the map). The second interview lasted approximately 45 minutes during which a visual elicitation approach invited participants to respond to the mind map.

Visual elicitation involves employing visual stimuli to generate verbal interview data. Participant-generated mind maps are often used in qualitative data collection [ 27 ], but the literature on using researcher-generated diagrams for visual elicitation is relatively thin [ 25 , 28 ]. In this study, using a researcher-generated mind map for visual elicitation offered several advantages. First, as with other forms of visual elicitation, diagrams of this kind can help participants develop candid responses and avoid rehearsed narratives [ 24 , 29 ]. For example, we used mind maps as one mechanism to reduce the tendency for participants who were familiar with the literature on critical thinking to get stuck on narrating seemingly rehearsed definitions of critical thinking. Second, we chose to use a mind map because it provided a social setting through which participants could react to language generated by others. Doing so does not allow the same degree of social negotiation inherent in focus groups, but it avoids the difficulty involved in attempts to disentangle individual from group views [ 30 ]. Third, the visual elicitation method was chosen because it offered a form of member check [ 31 ] that allowed researchers to understand the evolving nature of participants’ conceptions of critical thinking, rather than assuming that participants offer a single true conception during each and every discussion [ 32 ]. In other words, the mind map was used to prompt participants to elaborate their conception of critical thinking and locate it relative to other participants.

In interview 2, participants were asked to begin by discussing areas or terms on the mind map that resonated most with their own conception of critical thinking; they were then asked to discuss terms or concepts on the map that resonated less or with which they disagreed. They were also asked to comment on how relationships between ideas were represented through the map so that researchers could get a sense of the extent to which the relationships between the concepts depicted reflected the participants’ understanding of those relationships [ 28 ]. Participants were encouraged to disagree with portions of the map and most did actively disagree with some of the terms and relationships depicted, suggesting that the map did not come to dictate more than elicit individual interpretations [ 28 ]. Although participants were encouraged to ‘mark up’ the mind map, and the ‘marked up’ mind maps were treated as data, the primary data sources for this study were the audio-recorded interviews [ 25 ].

Participants were aware that the mind map represented aggregate data from the four health professions in the study, but were not initially told whether any of the responses came predominantly from any one profession; they did not generally seem to be attempting to associate terms with other professions. Nonetheless, interview 2 data are a mix of participants’ reactions to the ideas of others and their elaborations of their own understandings. Naturally, these data build on data generated in interview 1, and represent reactions to both the researcher interpretation of the data and to the conceptions of critical thinking offered by others. Interview 1 data tended to offer an initial, open impression of how participants think about critical thinking in their contexts. Because of these different approaches to data generation, quotes from interview 1 and 2 are labelled as ‘INT1’ or ‘INT2’, respectively.

Data analysis

Data were coded through an iterative cycle of initial and focused coding [ 33 ] with NVivo software. Initial line-by-line coding was used to develop codes that were close to the data, involving minimal abstraction. Initial codes were reviewed by the first author and dissertation supervisor to abstract categories (conceptions of critical thinking), sub-categories (features of those conceptions), and themes related to the relationships between those categories. Focused coding involved taking these categories and testing them against the data using constant comparison techniques derived from constructivist grounded theory [ 21 ]. Category development continued during the framing of this paper, and authors engaged in ongoing conversations to modify categories to better fit the data. In this process, we returned to the data to look for exceptions that did not fit any category, as well as contradictions and overlap between categories.

Interpretive sufficiency [ 34 ], in this study, occurred when no new features illustrating participants’ conceptions of critical thinking were identified. Memos were kept to track the development or elimination of initial insights or impressions. Institutional ethics approval was obtained from the University of Alberta.

Participant identities have been masked to preserve anonymity. The abbreviation ‘MD’ refers to educators in medical education, ‘NURS’ to nursing, ‘PHARM’ to pharmacy, and ‘SW’ to social work. Participants within each group were then assigned a number. For example, the code NURS3 is a unique identifier for a single participant.

Three main conceptions of critical thinking were identified, each of which will be elaborated in greater detail below: biomedical critical thinking, humanist critical thinking, and social justice-oriented critical thinking. It is important to note that these categories focus on the process and purpose of critical thinking, as defined by participants. Participant comments also spoke to the ‘characteristics’ or ‘dispositions’ of critical thinkers, such as ‘open-mindedness’ or ‘creativity’. The focus of this study, however, was on uncovering what critical thinking looks like as opposed to what a ‘critical thinker’ looks like.

The results below interweave responses from different professional groups in order to emphasize the way in which each of the three core conceptions that we have identified crosses professional boundaries. We then provide a brief discussion of the relationships between these three conceptions, emphasizing the limited extent to which these conceptions were profession-specific, and the tensions that we observed between these conceptions. In general, we also interweave results from both interviews because the discussion in interview 2 tended to reinforce the themes arising from interview 1, especially with respect to indications that different conceptions were used fluidly by individuals over time and dependent on the context being discussed. The interview from which data arose is marked after each quote and we have mentioned explicitly whenever a comment was made in specific response to the mind map presented during interview 2.

In this way, our data extend the literature on critical thinking by offering an appreciation of how each of these conceptions provide educators a different way of thinking, talking, and teaching about their work in HPE. We found that even individual participants’ conceptions of critical thinking shifted from time to time. That is, they often articulated more than one understanding of critical thinking over the course of an interview or between interviews 1 and 2. Some of these conceptions were shared by multiple participants but individual constellations of beliefs about what critical thinking means were unique and somewhat idiosyncratic. Thus, while participants’ conceptions of critical thinking were both idiosyncratic and common, they were also flexible and contextual; the meaning of critical thinking was continuously reconstructed and contested. In this way, critical thinking offered a window through which to explore how beliefs about what constitutes ‘good thinking’ in a profession are challenged in educational settings.

Biomedical critical thinking

Participants articulating a biomedical approach saw critical thinking and clinical reasoning as nearly synonymous. They emphasized a process that was rational, logical, and systematic. One participant articulated that critical thinking is ‘ to be able to reason logically’ (NURS4 INT1). Another related:

You have to kind of pull together data that’s relevant to the subject you’re dealing with. You have to interpret it, you have to analyse it, and you have to come up with some type of conclusions at the end as to how you deal with it. (PHARM3 INT1)

Participants discussing this approach agreed that critical thinking involved a systematic process of gathering and analyzing data: ‘I think [critical thinking and clinical reasoning] are the same. I think clinical reasoning is basically taking the data you have on a patient and interpreting it, and offering a treatment plan’ (MD1 INT1).

In keeping with an emphasis on the rational and logical, participants espousing this view often reacted negatively when they saw references to emotion on the mind map in interview 2: ‘as soon as you bring your emotions into the room, you’re no longer applying what I think is critical thinking’ (MD4 INT2). Participants also noted that decision-making was an important component of critical thinking: ‘ you have to make a decision. I think it’s a really important part of it’ (MD2 INT2).

For participants from pharmacy, in particular, critical thinking often meant departing from ‘rules’ that guide clinical practice in order to engage in reasoning and make situationally nuanced decisions. One pharmacist, describing a student not engaging in critical thinking, related that the student asked:

‘Have you ever seen Victoza given at 2.4   milligrams daily?’ … It’s very, you know, it’s very much yes or no. But at a deeper level, it’s actually missing things. … [There are] all these other factors that change the decision, right? … On paper there might be a regular set of values for the dose, … [but] without the rest of the background, that’s a very secondary thing. (PHARM4 INT1)

This perspective was identified as the dominant conception of critical thinking because the terms and concepts falling under this broad approach were most frequently discussed by participants; moreover, when participants discussed other conceptions of critical thinking, they were often explicitly drawing contrast to the biomedical view. While the biomedical perspective was dominant in all four groups (although primarily as a contrasting case for social workers), participants tended to occupy more than one perspective over the course of an interview. They might talk primarily about biomedical critical thinking, but also explicitly modify that perspective by drawing on the other two approaches identified: humanist critical and social justice-oriented critical thinking.

Humanist critical thinking

Participants, when adopting this view, described critical thinking as directed toward social good and oriented around positive human relationships. Humanist conceptions of critical thinking were often positioned as an alternative to the dominant biomedical perspective: ‘having to think of somebody else, at their most vulnerable, makes you know that knowledge alone, science alone, won’t get that patient to the place you want the patient to be. It won’t provide the best care’ (NURS1 INT1). In being so positioned, the humanist conception of critical thinking explicitly departed from the biomedical, which emphasized ‘setting aside’ emotion and de-emphasized the role of relationships in healthcare. In the humanist perspective, participants often discussed the purpose of critical thinking as:

Thinking about something for the betterment of yourself and the betterment of others. We’re social beings as human beings. … I think [critical thinking] has a higher purpose. … But I think that [if] critical thinking … [is] a human trait that we have or hope to have, then it has to have those components of what we are as humans. (NURS1 INT1)

Another participant emphasized that: ‘a great part of critical thinking is that human element and the consideration of ultimately what’s a good thing, a common good’ (NURS2 INT1).

In addressing the relational aspects of humanist critical thinking, participants argued that the focus on ‘hard’ sources of data, such as lab tests or imaging, in biomedical critical thinking was limiting. They were concerned that ‘hard data’ tend to be perceived as more objective and thus more important in biomedical critical thinking, compared with subjective patient narratives. They argued that the patient’s story is essential to critical thinking:

I think it doesn’t matter what kind of expert you are, you have to be able to think about patients in the context that they’re in and consider what the patient has to say, and really hear them. So I think that’s an important—that was a total lack of critical thinking in a totally, ‘I’m just going to get through this next patient to the next one’ . (MD1 INT1)

Taken together, these perspectives suggest that biomedical approaches to critical thinking fail to address the complex relational and psychosocial aspects of professional practice.

Social justice-oriented critical thinking

In social justice-oriented approaches to critical thinking participants articulated a process of examining the assumptions and biases embedded in their world. They often explicitly rejected biomedical conceptions of critical thinking as ‘ reductionistic ’ (SW3 INT1) because, in their view, these approaches fail to address the thinker’s own biases. Educators taking a social justice approach felt that: ‘critical thinking … is around things like … recognizing your own bias and recognizing the bias in the world’ (SW1 INT1). In this perspective, participants saw critical thinking as a process of analyzing and addressing the ways in which individual and societal assumptions limit possible actions and access to resources for individuals and social groups.

Unlike biomedical critical thinking and similar to the humanist view, participants articulating this conception tended to make the values and goals of critical thinking, as they conceived of it, explicit. They often contrasted their articulation of values in critical thinking with the ‘assumed’ and unarticulated values present in the biomedical perspective:

If you are not orientated in a social justice position, [critical thinking is] more about the mechanics, which is valuable as well, but … if we don’t understand the values associated with what we think, it seems to not be meaningless but there’s a piece missing or it’s assumed. The values are assumed. (SW3 INT1)

When taking this perspective, participants argued that it is necessary to understand social systems in order to think critically about individual patient cases. One educator questioned:

Why are there a disproportionate number of aboriginal inpatients than any other group? … When you start critically thinking about seeing the whole patient … there are issues related with all of society and that’s why people have more diabetes. (PHARM1 INT1)

Other participants had measured responses to this approach. One participant added to their primarily biomedical approach in order to accommodate perspectives encountered in the mind map, relating that behind their diagnostic work all physicians:

Certainly see a wide spectrum of social and economic status and cultures and things and recognizing that our system is kind of biased against certain groups as it is and knowing that but really not having a good sense of knowing even where to start deconstructing it. (MD2 INT2)

Relationships between conceptions of critical thinking

Results of this study suggest that critical thinking means a variety of things in different contexts and to different people. It might be tempting to see the three approaches outlined above as playing out along professional boundaries. Certainly, the social justice-oriented conception was more common among social work educators; the humanist approach was most common among participants from nursing; perspectives held by physician educators frequently aligned with dominant biomedical conceptions. In pharmacy, educators seemed to straddle all three perspectives, though they commonly emphasized a biomedical approach. Several participants suggested that their faculty or profession has a common understanding of critical thinking: ‘ critical thinking, for me and maybe for our faculty, is around things like … ’ (SW1 INT1).

However, while the disciplinary tendencies discussed above do appear in the data, these tendencies were not stable; participants often held more than one view on what critical thinking meant simultaneously, or shifted between perspectives. Participants also articulated approaches that were not common in their profession at certain moments, positioning themselves as ‘an outlier’, or positioning their specialty as having a different perspective than the profession as a whole, such that critical thinking might mean ‘thinking like a nurse’, or ‘thinking in geriatrics’. Further, participants’ perspectives shifted depending on the context in which they imagined critical thinking occurring.

This type of positioning and re-positioning occurred in both interviews, although they were particularly pronounced in interview 2, where participants were explicitly asked to react to different viewpoints by responding to the mind map. Examples of shifting perspectives in interview 1 occurred especially when participants from medicine shifted between biomedical and humanist conceptions. These shifts suggested a persistent tension and negotiation between characterizations of critical thinking as a rational process of data collection and analysis, and a more humanist approach that accounts for emotion and the relationship between professional and patient or family. Where participants sought to extend their notion of data beyond ‘hard data’ there is a sense of blending humanism with biomedical approaches to critical thinking. In the quote below, the participant brings together a call for a humanist relationship building with a need to gather and analyze all of the data, including important data about the patient’s experience:

I have colleagues who’ll say [to their patients]: ‘just say yes or no.’ … And it’s not very good and they’re missing stuff. So, critical thinking is—I guess it’s sort of dynamic in that you have to have time and you also have to have an interaction. (MD1 INT1)

While the participants described above negotiated between biomedical and humanist perspectives, participants primarily espousing a social justice-oriented conception of critical thinking responded to the ‘assumed’ values of the biomedical model. In talking about a problem solving-oriented biomedical approach, one participant argued that ‘ it’s important as well to have that, those foundational elements of how we think about what we think, but if we don’t understand the values associated … there’s a piece missing’ (SW3 INT1). Another stated that ‘critical thinking seems to be a neutral kind of process or—no, that can’t be true, can it?’ (SW1 INT2) with the mid-sentence shift indicating that two ways of conceptualizing critical thinking had come into conflict. This participant primarily discussed a social justice-oriented conception of critical thinking, which is not neutral, but at this moment also articulated a neutral, clinical reasoning-oriented or biomedical conception.

These relatively organic moments of negotiation certainly demonstrate a sense of conflicting values, of toggling between one perspective and another. However, they also suggest that there are ways in which these contradictions can be productively sustained. In negotiating between humanist and biomedical perspectives, educators effectively modify the dominant perspective.

In interview 2, when discussing the mind map, participants often encountered views that differed from their own. They responded either by making sense of and accommodating the new perspective, or by rejecting it. As an example of the former approach, one physician reacted to the ‘social justice-oriented’ corner of the mind map (specifically ‘examining assumptions’) by explaining how there are:

Assumptions in the background that come up for me all the time in terms of the different ways people live and want to live and how we run into it all the time … it’s always in the background and actually influencing you and until someone challenges the way you approached something, you don’t know what your assumptions are. (MD1 INT2)

As an example of a participant disagreeing with a perspective encountered in the mind map, one participant rejected social justice as an important component of critical thinking in medicine. They related that critical thinking has ‘got everything to do with reasoning, which makes sense. … Social justice has nothing to do with critical thinking’ (MD4 INT2). Interestingly, this participant also spoke at length about the link between social justice and critical thinking in the first interview, suggesting that a conception might seem ‘wrong’ when an individual is thinking and talking about it in one context, and entirely ‘right’ in another context.

Such results demonstrate that individual conceptions of critical thinking are multiple and flexible, not predetermined or stable. Educators bring certain values or perspectives into the foreground as they relate to the context under discussion, while others recede into the background. Though many participants seemed to have a primary perspective, multiple perspectives on critical thinking can co-exist and are actively negotiated by the individual.

In overview, the three broad conceptions of critical thinking offered here (biomedical, humanist, and social justice-oriented) echo approaches to critical thinking found in the critical thinking literature [ 11 , 35 , 36 , 37 ]. However, this study extends the literature in two key ways. First, our data point to ways in which different conceptions of critical thinking conflict and coalesce, within the field, within each profession, and even within individuals. Second, this tension offers an early empirical account of critical thinking in the health professions that suggests there may be benefits to maintaining flexibility in how one conceives of the concept.

The diverse conceptions of critical thinking identified all appear to have some value in HPE. It might be tempting to view each conception as a unique but stable perspective, reflecting thinking skills that are used within a particular context or value orientation. However, the multiplicity and flexibility of participants’ conceptions in this study offers some explanation as to why previous attempts to develop either generic (e. g. [ 2 , 3 , 5 ]) or discipline-specific [ 13 , 15 , 16 , 17 ] definitions and delineations of critical thinking have failed to stick.

Conceptions of critical thinking are not stable within a context or for a single educator. Educators’ conceptions of critical thinking shift within and between contexts as they navigate overlapping sets of values and beliefs. When educators take up different conceptions of critical thinking, the shifts they make are not just pragmatic; they actively negotiate the values and practices of the different communities in which they participate. Although we certainly saw hints of differences between professions, the strength of this study is that it captured the ways in which conceptions of critical thinking are not stably tied to any given profession. Critical thinking is connected to a broader idea of what ‘good thinking’—and, by extension, the ‘good professional’—looks like for each educator [ 38 ] within a given context or community.

These observations lead one to speculate about what purpose fluidity in conceptions of critical thinking might serve. Educators often have different values and goals for their profession, and, thus, it is not surprising that the meaning of critical thinking would be contested both within and across professions. Through their conceptions of critical thinking, participants contest ideas about what thinking is for in their profession—whether it should be focused on individual patient ‘problems’ or broader social issues, and the extent to which humanism is an important component of healthcare.

It is understandable that so much of the literature on critical thinking has sought to clarify a single ‘right’ definition; there is an argument for making a collective decision about what ‘good thinking’ means. Such a decision might offer clarity to interprofessional teaching and practice, or provide a foundation on which educational policy can be based. However, the critical thinking literature has long sought such a universal agreement and disagreements persist. Results of this study suggest a new approach, one that can account for multiple conceptions of critical thinking within and across health professions and practice contexts. The visual elicitation approach employed, asking participants to respond to the mind map, offered a unique perspective on the data that illuminated contradictions between conceptions held by individual participants, between participants, and between the conceptions themselves.

Such an approach offers a vehicle for thinking and talking about what kind of thinking is valued, both within and between professions. When conceptions of critical thinking are understood as flexible instead of stable, these acts of modification and contestation can be viewed as potential moments for critical self-reflection for individuals and for professional groups on the whole. Moreover, through their discussions of critical thinking, educators actively intervened to consider and assert what they value in their work.

These different conceptions might be complementary as often as they are incompatible. In fact, we would argue that ‘good thinking’ is inherently contentious (and should be) because it is such struggles over what ‘the good’ means in HPE that allow for challenges to the status quo. Advances at the heart of HPE and practice have been hard-won through deliberate reflection, discussion, action, and (often) conflict. For example, the ongoing movement toward relationship-oriented care has arguably occurred as a result of unexpected pushback regarding the limits of considering good healthcare as being entirely patient-centred. Thus, there is a need to bring unarticulated assumptions about important topics into the light so that the goals and values of educators and policy-makers can be openly discussed, even though they are unlikely to ever be fully resolved.

Strengths and limitations

This study offered a broad sample of educators from four different professions, who practised in a range of disciplinary contexts. Given that the sampling approach taken sought breadth rather than depth, the results explore a range of conceptions of critical thinking across HPE, rather than allowing strong claims about any one profession or context. The sample also focussed on conceptions of critical thinking within health professions education at specific institutions in Edmonton, Alberta. A multi-institutional study might build on these results to elaborate the extent to which each health profession has a core shared conception of critical thinking that translates across institutional settings. We expect that there may be significant differences between settings, given that what is meant by critical thinking seems to be highly contextual, even from moment to moment. Mapping aspects of context that impact how individuals and groups think about critical thinking would tell us much more about the values on which these conceptions are based.

Subsequent studies might also explore the extent to which conceptions of critical thinking among those identifying as ‘educators’ are comparable to those identifying as primarily ‘clinicians’. Although the boundary is definitely blurry, these groups engage in different kinds of work and participate in different communities, which we suspect may result in differences in how they conceive of critical thinking.

Conclusions

Rather than attempting to ‘solve’ the debate about what critical thinking should mean, this study maps the various conceptions of this term articulated by health professional educators. Educators took up biomedical, humanist, and social justice-oriented conceptions of critical thinking, and their conceptions often shifted from moment to moment or from context to context. The ‘mapping’ approach adopted to study this issue allowed for an appreciation of the ways in which educators actively modify and contest educational and professional values, even within their own thinking. Because critical thinking appears to be both value and context driven, arriving at a single right definition or taxonomy of critical thinking is unlikely to resolve deep tensions around what ‘good thinking’ in HPE means. Moreover, such an approach is unlikely to be productive. Such tensions produce challenges for shared understanding at the same time that they produce a productive space for discussion about core issues in HPE.

Abrami PC, Bernard RM, Borokhovski E, et al. Instructional interventions affecting critical thinking skills and dispositions: a stage 1 meta-analysis. Rev Educ Res. 2008;78:1102–34.

Article   Google Scholar  

Facione PA. Critical thinking: a statement of expert consensus for purposes of educational assessment and instruction. Millbrae: California Academic Press; 1990.

Google Scholar  

Black B. Critical thinking—a definition and taxonomy for Cambridge Assessment: supporting validity arguments about critical thinking assessments administered by Cambridge Assessment. 34 th IAEA Annual Conference; 09.9.2008; Cambridge; 2008.

Fischer SC, Spiker VA, Riedel SL. Critical thinking training for army officers volume two: a model of critical thinking. Arlington: US Army Research Institute; 2009.

Ennis RH. Critical thinking: a streamlined conception. In: Davies M, Barnett R, editors. The Palgrave handbook of critical thinking in higher education. New York: Palgrave MacMillan; 2015. pp. 31–47.

Chapter   Google Scholar  

Thayer-Bacon B. Transforming critical thinking: thinking constructively. New York: Teachers College Press; 2000.

Thayer-Bacon B. Caring and its relationship to critical thinking. Educ Theory. 1993;43:323–40.

Walters KS. Critical thinking, rationality, and the vulcanization of students. In: Walters KS, editor. Re-thinking reason: new perspectives on critical thinking. Albany: State University of New York Press; 1994. pp. 61–80.

Warren KJ. Critical thinking and feminism. In: Walters KS, editor. Re-thinking reason: new perspectives on critical thinking. Albany: State University of New York Press; 1994. pp. 199–204.

Brookfield SD. Speaking truth to power: teaching critical thinking in the critical theory tradition. In: Davies M, Barnett R, editors. The Palgrave handbook of critical thinking in higher education. New York: Palgrave MacMillan; 2015. pp. 529–43.

McLaren PL. Forward: critical thinking as a political project. In: Walters KS, editor. Re-thinking reason: new perspectives on critical thinking. Albany: State University of New York Press; 1994. pp. ix–xv.

Giroux H. Toward a pedagogy of critical thinking. In: Walters KS, editor. Re-thinking reason: new perspectives on critical thinking. Albany: State University of New York Press; 1994. pp. 199–204.

McPeck JE. Critical thinking and the ‘Trivial Pursuit’ theory of knowledge. In: Walters KS, editor. Re-thinking reason: new perspectives on critical thinking. Albany: State University of New York Press; 1994. pp. 101–18.

Chan ZC. A systematic review of critical thinking in nursing education. Nurse Educ Today. 2013;33:236–40.

Scheffer BK, Rubenfeld MG. A consensus statement on critical thinking in nursing. J Nurs Educ. 2000;39:352–9.

Krupat E, Sprague JM, Wolpaw D, Haidet P, Hatem D, O’Brien B. Thinking critically about critical thinking: ability, disposition or both? Med Educ. 2011;45:625–35.

Jones A. A disciplined approach to critical thinking. In: Davies M, Barnett R, editors. The Palgrave handbook of critical thinking in higher education. New York: Palgrave MacMillan; 2015. pp. 169–82.

Papp KK, Huang GC, Lauzon Clabo LM, et al. Milestones of critical thinking: a developmental model for medicine and nursing. Acad Med. 2014;89:715–20.

Grace S, Innes E, Joffe B, East L, Coutts R, Nancarrow S. Identifying common values among seven health professions: an interprofessional analysis. J Interprof Care. 2017;31(3):1–10. https://doi.org/10.1080/13561820.2017.1288091 .

Merriam SB. Qualitative research: a guide to design and implementation. San Francisco: Jossey-Bass; 2009.

Charmaz K. Constructing grounded theory. 2nd ed. Thousand Oaks: SAGE; 2014.

Kahlke RM. Generic qualitative approaches: pitfalls and benefits of methodological mixology. Int J Qual Methods. 2014;13:37–52.

Varpio L, Martimianakis MA, Mylopoulos M. Qualitative research methodologies: embracing methodological borrowing, shifting and importing. In: Cleland J, Durning SJ, editors. Researching medical education. Chichester: John Wiley & Sons; 2015. pp. 245–55. https://doi.org/10.1002/9781118838983.ch21 .

Wheeldon J. Is a picture worth a thousand words? Using mind maps to facilitate participant recall in qualitative research. Qual Rep. 2011;16:509–22.

Umoquit MJ, Tso P, Tünde V‑A, O’brien M, Wheeldon J. Diagrammatic elicitation: defining the use of diagrams in data collection. Qual Rep. 2013;18(60):1–12.

MindMup 2. Available from: https://www.mindmup.com/ . Accessed: 1 March 2018

Wheeldon J, Framing Experience FJ. Concept maps, mind maps, and data collection in qualitative research. Int J Qual Methods. 2009;8:68–83.

Crilly N, Blackwell A, Clarkson PJ. Graphic elicitation: using research diagrams as interview stimuli. Qual Res. 2006;6:341–66.

Hathaway AD, Atkinson M. Active interview techniques in research on public deviants: exploring the two-cop personas. Field methods. 2003;15:161–85.

Onwuegbuzie AJ, Dickinson WB, Leech NL, Zoran AG. A qualitative framework for collecting and analyzing data in focus group research. Int J Qual Methods. 2009;8:1–21.

Kinchin IM, Streatfield D, Hay DB. Using concept mapping to enhance the research interview. Int J Qual Methods. 2010;9:52–68.

Varpio L, Ajjawi R, Monrouxe L, O’Brien B, Rees C. Shedding the cobra effect: problematizing thematic emergence, triangulation, saturation and member checking. Med Educ. 2017;51:40–50.

Saldaña J. The coding manual for qualitative researchers. 2nd ed. Thousand Oaks: SAGE; 2013.

Christians CG. Ethics and politics in qualitative research. In: Denzin NK, Lincoln YS, editors. Handbook of qualitative research. 2nd ed. Thousand Oaks: SAGE; 2000. pp. 133–55.

Kahlke RM, White J. Critical thinking in health sciences education: considering ‘three waves’. Creat Educ. 2014;4:21–9.

Introduction WKS. beyond logicism in critical thinking. In: Walters KS, editor. Re-thinking reason: new perspectives on critical thinking. Albany: State University of New York Press; 1994. pp. 1–22.

Barnett R. A curriculum of critical being. In: Davies M, Barnett R, editors. The Palgrave handbook of critical thinking in higher education. New York: Palgrave MacMillan; 2015. pp. 63–76.

Pithers RT, Soden R. Critical thinking in education: a review. Educ Res. 2000;42:237–49.

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Acknowledgements

We thank Dr. Paul Newton for his contributions to the analysis of these data, in his role as supervisor of the dissertation work on which this manuscript is based. Thanks also to Dr. Dan Pratt for his help and support in developing this manuscript.

Support for this work was provided by the Government of Alberta (Queen Elizabeth II Graduate Scholarship), by the Social Sciences and Humanities Research Council (Doctoral Fellowship), and by the University of British Columbia (Postdoctoral Fellowship).

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Appendix a: interview guide for initial interview, appendix b: interview guide for second interview, appendix c: mind map, rights and permissions.

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Kahlke, R., Eva, K. Constructing critical thinking in health professional education. Perspect Med Educ 7 , 156–165 (2018). https://doi.org/10.1007/s40037-018-0415-z

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Critical Thinking: What It Is and Why It Matters

Defining critical thinking dispositions and why they’re crucial..

Posted September 23, 2024 | Reviewed by Devon Frye

• Another way to think about and measure critical thinking is to include aspects of motivational dispositions.
• Dispositions include open-mindedness and a willingness to be reflective when evaluating information.
• People scoring low in critical thinking dispositions tend to “keep it simple” when something is complex.
• Critical thinking dispositions help individuals avoid oversimplification and can facilitate awareness of bias.

Critical thinking springs from the notion of reflective thought proposed by Dewey (1933), who borrowed from the work of philosophers such as William James and Charles Peirce. Reflective thought was defined as the process of suspending judgment, remaining open-minded, maintaining a healthy skepticism, and taking responsibility for one’s own development (Gerber et al., 2005; Stoyanov & Kirshner, 2007).

Kurland (1995) suggested, “Critical thinking is concerned with reason, intellectual honesty, and open-mindedness, as opposed to emotionalism, intellectual laziness, and closed-mindedness. Thus, critical thinking involves… considering all possibilities… being precise; considering a variety of possible viewpoints and explanations; weighing the effects of motives and biases; being concerned more with finding the truth than with being right…being aware of one’s own prejudices and biases” (p. 3). Thus, being able to perspective-take and becoming conscious of one’s own biases are potential benefits of critical thinking capacities.

Reviews of the critical thinking literature (e.g., Bensley, 2023) suggest that the assessment of this construct ought to include aspects of motivational dispositions. Numerous frameworks of critical thinking dispositions have been proposed (e.g., Bensley, 2018; Butler & Halpern, 2019; Dwyer, 2017); some commonly identified dispositions are open-mindedness, intellectual engagement, and a proclivity to take a reflective stance or approach to evaluating information and the views and beliefs of both oneself and others. Demir (2022) posited that critical thinking dispositions reflect persons’ attitudes toward and routine ways of responding to new information and diverging ideas, willingness to engage in nuanced and complex rather than either/or reductionistic thinking, and perseverance in attempts to understand and resolve complex problems.

Other examples of dispositions are inquisitiveness, open-mindedness, tolerance for ambiguity, thinking about thinking, honesty in assessing or evaluating biases, and willingness to reconsider one’s own views and ways of doing things (Facione et al., 2001). Individual personality attributes associated with these proclivities include a need for cognition (a desire for intellectual stimulation), which is positively associated with critical thinking, and the need for closure (a motivated cognitive style in which individuals prefer predictability, firm answers, and rapid decision making ) and anti-intellectualism (a resentment of “the life of the mind” and those who represent it), both negatively associated with critical thinking.

Further, an ideological component that can impede critical thinking is dogmatism . In addition, rigid, dichotomous thinking impedes critical thinking in that it oversimplifies the complexity of social life in a pluralistic society (Bensley, 2023; Cheung et al., 2002; Halpern & Dunn, 2021) and tries to reduce complicated phenomena and resolve complex problems via “either/or” formulations and simplistic solutions.

In other words, folks with low critical thinking dispositions would tend to “keep it simple” when something is really quite complicated, and think it absolute terms and categories rather than seeing “the gray” in between the black and white extremes.

In sum, critical thinking dispositions are vitally important because they may help individuals avoid oversimplifying reality; they also permit perspective-taking and can facilitate their awareness of diversity and systematic biases, such as racial or gender bias . Some research has indicated that critical thinking dispositions uniquely contribute to academic performance beyond general cognition (Ren et al., 2020), and may help to reduce unsubstantiated claims and conspiracy beliefs (Bensley, 2023; Lantian et al., 2021).

But before we can study the potential impact of critical thinking dispositions, it is necessary to have a reliable, valid, and hopefully brief measure for this construct. I will discuss the development and validation of a measure of critical thinking dispositions in another post.

Bensley, D.A. ( 2023.) Critical thinking, intelligence, and unsubstantiated beliefs: An integrative review. Journal of Intelligence, 1 , 207. https://doi.org/10.3390/jintelligence11110207

Bensley, D.A. (2018). Critical thinking in psychology and everyday life: A guide to effective thinking . New York: Worth Publishers.

Butler, H.A., & Halpern, D.F. (2019). Is critical thinking a better model of intelligence? In Robert J. Sternberg (Ed.) The Nature of Intelligence (pp. 183–96). Cambridge: Cambridge University Press.

Cheung, C.-K, Rudowicz. E., Kwan, A., & Yue, X.. (2002). Assessing university students’ general and specific criticalthinking. College Student Journal, 36 , 504 – 25.

Demir, E. (2022). An examination of high school students’ critical thinking dispositions and analytical thinking skills. Journal of Pedagogical Research, 6 , 190–200. https://doi.org/10.33902/JPR.202217357

Dewey, J. (1933). How we think: A restatement of the relation of reflective thinking to the educative process . Lexington: Heath and Company.

Dwyer, C. P. (2017). Critical thinking: Conceptual perspectives and practical guidelines . Cambridge: CambridgeUniversity Press.

Facione, P., Facione, N,C,, & Giancarlo, C.A.F. (2001(. California Critical Disposition Inventory . Millbrae: California Academic Press.

Gerber, S., Scott, L., Clements, D.H., & Sarama, J. (2005). Instructor influence on reasoned argument in discussion boards. Educational Technology, Research & Development, 53 , 25–39. https://doi.org/10.1007/BF02504864

Halpern, D. F., & Dunn, D.S. (2021). Critical thinking: A model of intelligence for solving real-world problems. Journal of Intelligence, 9 , 22. https://doi.org/10.3390/jintelligence9020022

Kurland, D. (1995). I know what it says… What does it mean? Critical skills for critical reading . Belmont: Wadsworth.

Lantian, A., Bagneux, V., Delouvee, S., & Gauvrit, N. (2021). Maybe a free thinker but not a critical one: High conspiracybelief is associated with low critical thinking ability. Applied Cognitive Psychology, 35 , 674 – 84. https://doi.org/10.1002/acp.3790

Ren, X., Tong, Y., Peng, P. & Wang, T. (2020). Critical thinking predicts academic performance beyond general cognitiveability: Evidence from adults and children. Intelligence, 82 , 101487. https://doi.org/10.1016/j.intell.2020.101487

Stoyanov, S., & Kirschner, P. ( 2007). Effect of problem solving support and cognitive styles on idea generation:Implications for technology-enhanced learning. Journal of Research on Technology in Education, 40 , 49–63. https://doi.org/10.1080/15391523.2007.10782496

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Scoping Review of Critical Thinking Literature in Healthcare Education

Affiliation.

• 1 Program in Occupational Therapy, Washington University, St. Louis, MO, USA.
• PMID: 33571065
• DOI: 10.1080/07380577.2021.1879411

Critical thinking is the process of analyzing and evaluating thinking to make decisions. Critical thinking exposes assumptions, biases, and beliefs that influence clinical reasoning. This scoping review sought to explore instructional approaches for advancing students' critical thinking in healthcare education. Through analysis of 15 articles, no common definition of critical thinking emerged, nor consensus found on measurement or instructional methods. Some alternative instructional methods such as case-based learning, reflective guided questions, and multiple case exposures, when compared to lecture, did significantly impact learner critical thinking. To determine if critical thinking is an instructional method that would impact implicit biases and healthcare outcomes, five author recommendations are offered from gaps in the existing literature to provide a pathway for future research. To effectively prepare students for clinical practice, long term outcomes are necessary to assess if critical thinking skills can be taught and become part of a professional growth mindset.

Keywords: Critical thinking; healthcare education; scoping review.

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Defining Critical Thinking

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How Do Critical Thinking Ability and Critical Thinking Disposition Relate to the Mental Health of University Students?

Associated data.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Theories of psychotherapy suggest that human mental problems associate with deficiencies in critical thinking. However, it currently remains unclear whether both critical thinking skill and critical thinking disposition relate to individual differences in mental health. This study explored whether and how the critical thinking ability and critical thinking disposition of university students associate with individual differences in mental health in considering impulsivity that has been revealed to be closely related to both critical thinking and mental health. Regression and structural equation modeling analyses based on a Chinese university student sample ( N = 314, 198 females, M age = 18.65) revealed that critical thinking skill and disposition explained a unique variance of mental health after controlling for impulsivity. Furthermore, the relationship between critical thinking and mental health was mediated by motor impulsivity (acting on the spur of the moment) and non-planning impulsivity (making decisions without careful forethought). These findings provide a preliminary account of how human critical thinking associate with mental health. Practically, developing mental health promotion programs for university students is suggested to pay special attention to cultivating their critical thinking dispositions and enhancing their control over impulsive behavior.

Introduction

Although there is no consistent definition of critical thinking (CT), it is usually described as “purposeful, self-regulatory judgment that results in interpretation, analysis, evaluation, and inference, as well as explanations of the evidential, conceptual, methodological, criteriological, or contextual considerations that judgment is based upon” (Facione, 1990 , p. 2). This suggests that CT is a combination of skills and dispositions. The skill aspect mainly refers to higher-order cognitive skills such as inference, analysis, and evaluation, while the disposition aspect represents one's consistent motivation and willingness to use CT skills (Dwyer, 2017 ). An increasing number of studies have indicated that CT plays crucial roles in the activities of university students such as their academic performance (e.g., Ghanizadeh, 2017 ; Ren et al., 2020 ), professional work (e.g., Barry et al., 2020 ), and even the ability to cope with life events (e.g., Butler et al., 2017 ). An area that has received less attention is how critical thinking relates to impulsivity and mental health. This study aimed to clarify the relationship between CT (which included both CT skill and CT disposition), impulsivity, and mental health among university students.

Relationship Between Critical Thinking and Mental Health

Associating critical thinking with mental health is not without reason, since theories of psychotherapy have long stressed a linkage between mental problems and dysfunctional thinking (Gilbert, 2003 ; Gambrill, 2005 ; Cuijpers, 2019 ). Proponents of cognitive behavioral therapy suggest that the interpretation by people of a situation affects their emotional, behavioral, and physiological reactions. Those with mental problems are inclined to bias or heuristic thinking and are more likely to misinterpret neutral or even positive situations (Hollon and Beck, 2013 ). Therefore, a main goal of cognitive behavioral therapy is to overcome biased thinking and change maladaptive beliefs via cognitive modification skills such as objective understanding of one's cognitive distortions, analyzing evidence for and against one's automatic thinking, or testing the effect of an alternative way of thinking. Achieving these therapeutic goals requires the involvement of critical thinking, such as the willingness and ability to critically analyze one's thoughts and evaluate evidence and arguments independently of one's prior beliefs. In addition to theoretical underpinnings, characteristics of university students also suggest a relationship between CT and mental health. University students are a risky population in terms of mental health. They face many normative transitions (e.g., social and romantic relationships, important exams, financial pressures), which are stressful (Duffy et al., 2019 ). In particular, the risk increases when students experience academic failure (Lee et al., 2008 ; Mamun et al., 2021 ). Hong et al. ( 2010 ) found that the stress in Chinese college students was primarily related to academic, personal, and negative life events. However, university students are also a population with many resources to work on. Critical thinking can be considered one of the important resources that students are able to use (Stupple et al., 2017 ). Both CT skills and CT disposition are valuable qualities for college students to possess (Facione, 1990 ). There is evidence showing that students with a higher level of CT are more successful in terms of academic performance (Ghanizadeh, 2017 ; Ren et al., 2020 ), and that they are better at coping with stressful events (Butler et al., 2017 ). This suggests that that students with higher CT are less likely to suffer from mental problems.

Empirical research has reported an association between CT and mental health among college students (Suliman and Halabi, 2007 ; Kargar et al., 2013 ; Yoshinori and Marcus, 2013 ; Chen and Hwang, 2020 ; Ugwuozor et al., 2021 ). Most of these studies focused on the relationship between CT disposition and mental health. For example, Suliman and Halabi ( 2007 ) reported that the CT disposition of nursing students was positively correlated with their self-esteem, but was negatively correlated with their state anxiety. There is also a research study demonstrating that CT disposition influenced the intensity of worry in college students either by increasing their responsibility to continue thinking or by enhancing the detached awareness of negative thoughts (Yoshinori and Marcus, 2013 ). Regarding the relationship between CT ability and mental health, although there has been no direct evidence, there were educational programs examining the effect of teaching CT skills on the mental health of adolescents (Kargar et al., 2013 ). The results showed that teaching CT skills decreased somatic symptoms, anxiety, depression, and insomnia in adolescents. Another recent CT skill intervention also found a significant reduction in mental stress among university students, suggesting an association between CT skills and mental health (Ugwuozor et al., 2021 ).

The above research provides preliminary evidence in favor of the relationship between CT and mental health, in line with theories of CT and psychotherapy. However, previous studies have focused solely on the disposition aspect of CT, and its link with mental health. The ability aspect of CT has been largely overlooked in examining its relationship with mental health. Moreover, although the link between CT and mental health has been reported, it remains unknown how CT (including skill and disposition) is associated with mental health.

Impulsivity as a Potential Mediator Between Critical Thinking and Mental Health

One important factor suggested by previous research in accounting for the relationship between CT and mental health is impulsivity. Impulsivity is recognized as a pattern of action without regard to consequences. Patton et al. ( 1995 ) proposed that impulsivity is a multi-faceted construct that consists of three behavioral factors, namely, non-planning impulsiveness, referring to making a decision without careful forethought; motor impulsiveness, referring to acting on the spur of the moment; and attentional impulsiveness, referring to one's inability to focus on the task at hand. Impulsivity is prominent in clinical problems associated with psychiatric disorders (Fortgang et al., 2016 ). A number of mental problems are associated with increased impulsivity that is likely to aggravate clinical illnesses (Leclair et al., 2020 ). Moreover, a lack of CT is correlated with poor impulse control (Franco et al., 2017 ). Applications of CT may reduce impulsive behaviors caused by heuristic and biased thinking when one makes a decision (West et al., 2008 ). For example, Gregory ( 1991 ) suggested that CT skills enhance the ability of children to anticipate the health or safety consequences of a decision. Given this, those with high levels of CT are expected to take a rigorous attitude about the consequences of actions and are less likely to engage in impulsive behaviors, which may place them at a low risk of suffering mental problems. To the knowledge of the authors, no study has empirically tested whether impulsivity accounts for the relationship between CT and mental health.

This study examined whether CT skill and disposition are related to the mental health of university students; and if yes, how the relationship works. First, we examined the simultaneous effects of CT ability and CT disposition on mental health. Second, we further tested whether impulsivity mediated the effects of CT on mental health. To achieve the goals, we collected data on CT ability, CT disposition, mental health, and impulsivity from a sample of university students. The results are expected to shed light on the mechanism of the association between CT and mental health.

Participants and Procedure

A total of 314 university students (116 men) with an average age of 18.65 years ( SD = 0.67) participated in this study. They were recruited by advertisements from a local university in central China and majoring in statistics and mathematical finance. The study protocol was approved by the Human Subjects Review Committee of the Huazhong University of Science and Technology. Each participant signed a written informed consent describing the study purpose, procedure, and right of free. All the measures were administered in a computer room. The participants were tested in groups of 20–30 by two research assistants. The researchers and research assistants had no formal connections with the participants. The testing included two sections with an interval of 10 min, so that the participants had an opportunity to take a break. In the first section, the participants completed the syllogistic reasoning problems with belief bias (SRPBB), the Chinese version of the California Critical Thinking Skills Test (CCSTS-CV), and the Chinese Critical Thinking Disposition Inventory (CCTDI), respectively. In the second session, they completed the Barrett Impulsivity Scale (BIS-11), Depression Anxiety Stress Scale-21 (DASS-21), and University Personality Inventory (UPI) in the given order.

Measures of Critical Thinking Ability

The Chinese version of the California Critical Thinking Skills Test was employed to measure CT skills (Lin, 2018 ). The CCTST is currently the most cited tool for measuring CT skills and includes analysis, assessment, deduction, inductive reasoning, and inference reasoning. The Chinese version included 34 multiple choice items. The dependent variable was the number of correctly answered items. The internal consistency (Cronbach's α) of the CCTST is 0.56 (Jacobs, 1995 ). The test–retest reliability of CCTST-CV is 0.63 ( p < 0.01) (Luo and Yang, 2002 ), and correlations between scores of the subscales and the total score are larger than 0.5 (Lin, 2018 ), supporting the construct validity of the scale. In this study among the university students, the internal consistency (Cronbach's α) of the CCTST-CV was 0.5.

The second critical thinking test employed in this study was adapted from the belief bias paradigm (Li et al., 2021 ). This task paradigm measures the ability to evaluate evidence and arguments independently of one's prior beliefs (West et al., 2008 ), which is a strongly emphasized skill in CT literature. The current test included 20 syllogistic reasoning problems in which the logical conclusion was inconsistent with one's prior knowledge (e.g., “Premise 1: All fruits are sweet. Premise 2: Bananas are not sweet. Conclusion: Bananas are not fruits.” valid conclusion). In addition, four non-conflict items were included as the neutral condition in order to avoid a habitual response from the participants. They were instructed to suppose that all the premises are true and to decide whether the conclusion logically follows from the given premises. The measure showed good internal consistency (Cronbach's α = 0.83) in a Chinese sample (Li et al., 2021 ). In this study, the internal consistency (Cronbach's α) of the SRPBB was 0.94.

Measures of Critical Thinking Disposition

The Chinese Critical Thinking Disposition Inventory was employed to measure CT disposition (Peng et al., 2004 ). This scale has been developed in line with the conceptual framework of the California critical thinking disposition inventory. We measured five CT dispositions: truth-seeking (one's objectivity with findings even if this requires changing one's preconceived opinions, e.g., a person inclined toward being truth-seeking might disagree with “I believe what I want to believe.”), inquisitiveness (one's intellectual curiosity. e.g., “No matter what the topic, I am eager to know more about it”), analyticity (the tendency to use reasoning and evidence to solve problems, e.g., “It bothers me when people rely on weak arguments to defend good ideas”), systematically (the disposition of being organized and orderly in inquiry, e.g., “I always focus on the question before I attempt to answer it”), and CT self-confidence (the trust one places in one's own reasoning processes, e.g., “I appreciate my ability to think precisely”). Each disposition aspect contained 10 items, which the participants rated on a 6-point Likert-type scale. This measure has shown high internal consistency (overall Cronbach's α = 0.9) (Peng et al., 2004 ). In this study, the CCTDI scale was assessed at Cronbach's α = 0.89, indicating good reliability.

Measure of Impulsivity

The well-known Barrett Impulsivity Scale (Patton et al., 1995 ) was employed to assess three facets of impulsivity: non-planning impulsivity (e.g., “I plan tasks carefully”); motor impulsivity (e.g., “I act on the spur of the moment”); attentional impulsivity (e.g., “I concentrate easily”). The scale includes 30 statements, and each statement is rated on a 5-point scale. The subscales of non-planning impulsivity and attentional impulsivity were reversely scored. The BIS-11 has good internal consistency (Cronbach's α = 0.81, Velotti et al., 2016 ). This study showed that the Cronbach's α of the BIS-11 was 0.83.

Measures of Mental Health

The Depression Anxiety Stress Scale-21 was used to assess mental health problems such as depression (e.g., “I feel that life is meaningless”), anxiety (e.g., “I find myself getting agitated”), and stress (e.g., “I find it difficult to relax”). Each dimension included seven items, which the participants were asked to rate on a 4-point scale. The Chinese version of the DASS-21 has displayed a satisfactory factor structure and internal consistency (Cronbach's α = 0.92, Wang et al., 2016 ). In this study, the internal consistency (Cronbach's α) of the DASS-21 was 0.94.

The University Personality Inventory that has been commonly used to screen for mental problems of college students (Yoshida et al., 1998 ) was also used for measuring mental health. The 56 symptom-items assessed whether an individual has experienced the described symptom during the past year (e.g., “a lack of interest in anything”). The UPI showed good internal consistency (Cronbach's α = 0.92) in a Chinese sample (Zhang et al., 2015 ). This study showed that the Cronbach's α of the UPI was 0.85.

Statistical Analyses

We first performed analyses to detect outliers. Any observation exceeding three standard deviations from the means was replaced with a value that was three standard deviations. This procedure affected no more than 5‰ of observations. Hierarchical regression analysis was conducted to determine the extent to which facets of critical thinking were related to mental health. In addition, structural equation modeling with Amos 22.0 was performed to assess the latent relationship between CT, impulsivity, and mental health.

Descriptive Statistics and Bivariate Correlations

Table 1 presents descriptive statistics and bivariate correlations of all the variables. CT disposition such as truth-seeking, systematicity, self-confidence, and inquisitiveness was significantly correlated with DASS-21 and UPI, but neither CCTST-CV nor SRPBB was related to DASS-21 and UPI. Subscales of BIS-11 were positively correlated with DASS-21 and UPI, but were negatively associated with CT dispositions.

Descriptive results and correlations between all measured variables ( N = 314).

Regression Analyses

Hierarchical regression analyses were conducted to examine the effects of CT skill and disposition on mental health. Before conducting the analyses, scores in DASS-21 and UPI were reversed so that high scores reflected high levels of mental health. Table 2 presents the results of hierarchical regression. In model 1, the sum of the Z-score of DASS-21 and UPI served as the dependent variable. Scores in the CT ability tests and scores in the five dimensions of CCTDI served as predictors. CT skill and disposition explained 13% of the variance in mental health. CT skills did not significantly predict mental health. Two dimensions of dispositions (truth seeking and systematicity) exerted significantly positive effects on mental health. Model 2 examined whether CT predicted mental health after controlling for impulsivity. The model containing only impulsivity scores (see model-2 step 1 in Table 2 ) explained 15% of the variance in mental health. Non-planning impulsivity and motor impulsivity showed significantly negative effects on mental health. The CT variables on the second step explained a significantly unique variance (6%) of CT (see model-2 step 2). This suggests that CT skill and disposition together explained the unique variance in mental health after controlling for impulsivity. 1

Hierarchical regression models predicting mental health from critical thinking skills, critical thinking dispositions, and impulsivity ( N = 314).

CCTST-CV, The Chinese version of the California Critical Thinking Skills Test; SRPBB, Syllogistic Reasoning Problems with Belief Bias .

Structural equation modeling was performed to examine whether impulsivity mediated the relationship between CT disposition (CT ability was not included since it did not significantly predict mental health) and mental health. Since the regression results showed that only motor impulsivity and non-planning impulsivity significantly predicted mental health, we examined two mediation models with either motor impulsivity or non-planning impulsivity as the hypothesized mediator. The item scores in the motor impulsivity subscale were randomly divided into two indicators of motor impulsivity, as were the scores in the non-planning subscale. Scores of DASS-21 and UPI served as indicators of mental health and dimensions of CCTDI as indicators of CT disposition. In addition, a bootstrapping procedure with 5,000 resamples was established to test for direct and indirect effects. Amos 22.0 was used for the above analyses.

The mediation model that included motor impulsivity (see Figure 1 ) showed an acceptable fit, χ ( 23 ) 2 = 64.71, RMSEA = 0.076, CFI = 0.96, GFI = 0.96, NNFI = 0.93, SRMR = 0.073. Mediation analyses indicated that the 95% boot confidence intervals of the indirect effect and the direct effect were (0.07, 0.26) and (−0.08, 0.32), respectively. As Hayes ( 2009 ) indicates, an effect is significant if zero is not between the lower and upper bounds in the 95% confidence interval. Accordingly, the indirect effect between CT disposition and mental health was significant, while the direct effect was not significant. Thus, motor impulsivity completely mediated the relationship between CT disposition and mental health.

Illustration of the mediation model: Motor impulsivity as mediator variable between critical thinking dispositions and mental health. CTD-l = Truth seeking; CTD-2 = Analyticity; CTD-3 = Systematically; CTD-4 = Self-confidence; CTD-5 = Inquisitiveness. MI-I and MI-2 were sub-scores of motor impulsivity. Solid line represents significant links and dotted line non-significant links. ** p < 0.01.

The mediation model, which included non-planning impulsivity (see Figure 2 ), also showed an acceptable fit to the data, χ ( 23 ) 2 = 52.75, RMSEA = 0.064, CFI = 0.97, GFI = 0.97, NNFI = 0.95, SRMR = 0.06. The 95% boot confidence intervals of the indirect effect and the direct effect were (0.05, 0.33) and (−0.04, 0.38), respectively, indicating that non-planning impulsivity completely mediated the relationship between CT disposition and mental health.

Illustration of the mediation model: Non-planning impulsivity asmediator variable between critical thinking dispositions and mental health. CTD-l = Truth seeking; CTD-2 = Analyticity; CTD-3 = Systematically; CTD-4 = Self-confidence; CTD-5 = Inquisitiveness. NI-I and NI-2 were sub-scores of Non-planning impulsivity. Solid line represents significant links and dotted line non-significant links. ** p < 0.01.

This study examined how critical thinking skill and disposition are related to mental health. Theories of psychotherapy suggest that human mental problems are in part due to a lack of CT. However, empirical evidence for the hypothesized relationship between CT and mental health is relatively scarce. This study explored whether and how CT ability and disposition are associated with mental health. The results, based on a university student sample, indicated that CT skill and disposition explained a unique variance in mental health. Furthermore, the effect of CT disposition on mental health was mediated by motor impulsivity and non-planning impulsivity. The finding that CT exerted a significant effect on mental health was in accordance with previous studies reporting negative correlations between CT disposition and mental disorders such as anxiety (Suliman and Halabi, 2007 ). One reason lies in the assumption that CT disposition is usually referred to as personality traits or habits of mind that are a remarkable predictor of mental health (e.g., Benzi et al., 2019 ). This study further found that of the five CT dispositions, only truth-seeking and systematicity were associated with individual differences in mental health. This was not surprising, since the truth-seeking items mainly assess one's inclination to crave for the best knowledge in a given context and to reflect more about additional facts, reasons, or opinions, even if this requires changing one's mind about certain issues. The systematicity items target one's disposition to approach problems in an orderly and focused way. Individuals with high levels of truth-seeking and systematicity are more likely to adopt a comprehensive, reflective, and controlled way of thinking, which is what cognitive therapy aims to achieve by shifting from an automatic mode of processing to a more reflective and controlled mode.

Another important finding was that motor impulsivity and non-planning impulsivity mediated the effect of CT disposition on mental health. The reason may be that people lacking CT have less willingness to enter into a systematically analyzing process or deliberative decision-making process, resulting in more frequently rash behaviors or unplanned actions without regard for consequences (Billieux et al., 2010 ; Franco et al., 2017 ). Such responses can potentially have tangible negative consequences (e.g., conflict, aggression, addiction) that may lead to social maladjustment that is regarded as a symptom of mental illness. On the contrary, critical thinkers have a sense of deliberativeness and consider alternate consequences before acting, and this thinking-before-acting mode would logically lead to a decrease in impulsivity, which then decreases the likelihood of problematic behaviors and negative moods.

It should be noted that although the raw correlation between attentional impulsivity and mental health was significant, regression analyses with the three dimensions of impulsivity as predictors showed that attentional impulsivity no longer exerted a significant effect on mental effect after controlling for the other impulsivity dimensions. The insignificance of this effect suggests that the significant raw correlation between attentional impulsivity and mental health was due to the variance it shared with the other impulsivity dimensions (especially with the non-planning dimension, which showed a moderately high correlation with attentional impulsivity, r = 0.67).

Some limitations of this study need to be mentioned. First, the sample involved in this study is considered as a limited sample pool, since all the participants are university students enrolled in statistics and mathematical finance, limiting the generalization of the findings. Future studies are recommended to recruit a more representative sample of university students. A study on generalization to a clinical sample is also recommended. Second, as this study was cross-sectional in nature, caution must be taken in interpreting the findings as causal. Further studies using longitudinal, controlled designs are needed to assess the effectiveness of CT intervention on mental health.

In spite of the limitations mentioned above, the findings of this study have some implications for research and practice intervention. The result that CT contributed to individual differences in mental health provides empirical support for the theory of cognitive behavioral therapy, which focuses on changing irrational thoughts. The mediating role of impulsivity between CT and mental health gives a preliminary account of the mechanism of how CT is associated with mental health. Practically, although there is evidence that CT disposition of students improves because of teaching or training interventions (e.g., Profetto-Mcgrath, 2005 ; Sanja and Krstivoje, 2015 ; Chan, 2019 ), the results showing that two CT disposition dimensions, namely, truth-seeking and systematicity, are related to mental health further suggest that special attention should be paid to cultivating these specific CT dispositions so as to enhance the control of students over impulsive behaviors in their mental health promotions.

Conclusions

This study revealed that two CT dispositions, truth-seeking and systematicity, were associated with individual differences in mental health. Furthermore, the relationship between critical thinking and mental health was mediated by motor impulsivity and non-planning impulsivity. These findings provide a preliminary account of how human critical thinking is associated with mental health. Practically, developing mental health promotion programs for university students is suggested to pay special attention to cultivating their critical thinking dispositions (especially truth-seeking and systematicity) and enhancing the control of individuals over impulsive behaviors.

Data Availability Statement

Ethics statement.

The studies involving human participants were reviewed and approved by HUST Critical Thinking Research Center (Grant No. 2018CT012). The patients/participants provided their written informed consent to participate in this study.

Author Contributions

XR designed the study and revised the manuscript. ZL collected data and wrote the manuscript. SL assisted in analyzing the data. SS assisted in re-drafting and editing the manuscript. All the authors contributed to the article and approved the submitted version.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

1 We re-analyzed the data by controlling for age and gender of the participants in the regression analyses. The results were virtually the same as those reported in the study.

Funding. This work was supported by the Social Science Foundation of China (grant number: BBA200034).

• Barry A., Parvan K., Sarbakhsh P., Safa B., Allahbakhshian A. (2020). Critical thinking in nursing students and its relationship with professional self-concept and relevant factors . Res. Dev. Med. Educ. 9 , 7–7. 10.34172/rdme.2020.007 [ CrossRef ] [ Google Scholar ]
• Benzi I. M. A., Emanuele P., Rossella D. P., Clarkin J. F., Fabio M. (2019). Maladaptive personality traits and psychological distress in adolescence: the moderating role of personality functioning . Pers. Indiv. Diff. 140 , 33–40. 10.1016/j.paid.2018.06.026 [ CrossRef ] [ Google Scholar ]
• Billieux J., Gay P., Rochat L., Van der Linden M. (2010). The role of urgency and its underlying psychological mechanisms in problematic behaviours . Behav. Res. Ther. 48 , 1085–1096. 10.1016/j.brat.2010.07.008 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Butler H. A., Pentoney C., Bong M. P. (2017). Predicting real-world outcomes: Critical thinking ability is a better predictor of life decisions than intelligence . Think. Skills Creat. 25 , 38–46. 10.1016/j.tsc.2017.06.005 [ CrossRef ] [ Google Scholar ]
• Chan C. (2019). Using digital storytelling to facilitate critical thinking disposition in youth civic engagement: a randomized control trial . Child. Youth Serv. Rev. 107 :104522. 10.1016/j.childyouth.2019.104522 [ CrossRef ] [ Google Scholar ]
• Chen M. R. A., Hwang G. J. (2020). Effects of a concept mapping-based flipped learning approach on EFL students' English speaking performance, critical thinking awareness and speaking anxiety . Br. J. Educ. Technol. 51 , 817–834. 10.1111/bjet.12887 [ CrossRef ] [ Google Scholar ]
• Cuijpers P. (2019). Targets and outcomes of psychotherapies for mental disorders: anoverview . World Psychiatry. 18 , 276–285. 10.1002/wps.20661 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Duffy M. E., Twenge J. M., Joiner T. E. (2019). Trends in mood and anxiety symptoms and suicide-related outcomes among u.s. undergraduates, 2007–2018: evidence from two national surveys . J. Adolesc. Health. 65 , 590–598. 10.1016/j.jadohealth.2019.04.033 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Dwyer C. P. (2017). Critical Thinking: Conceptual Perspectives and Practical Guidelines . Cambridge: Cambridge University Press. [ Google Scholar ]
• Facione P. A. (1990). Critical Thinking: Astatement of Expert Consensus for Purposes of Educational Assessment and Instruction . Millibrae, CA: The California Academic Press. [ Google Scholar ]
• Fortgang R. G., Hultman C. M., van Erp T. G. M., Cannon T. D. (2016). Multidimensional assessment of impulsivity in schizophrenia, bipolar disorder, and major depressive disorder: testing for shared endophenotypes . Psychol. Med. 46 , 1497–1507. 10.1017/S0033291716000131 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Franco A. R., Costa P. S., Butler H. A., Almeida L. S. (2017). Assessment of undergraduates' real-world outcomes of critical thinking in everyday situations . Psychol. Rep. 120 , 707–720. 10.1177/0033294117701906 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Gambrill E. (2005). Critical thinking, evidence-based practice, and mental health, in Mental Disorders in the Social Environment: Critical Perspectives , ed Kirk S. A. (New York, NY: Columbia University Press; ), 247–269. [ Google Scholar ]
• Ghanizadeh A. (2017). The interplay between reflective thinking, critical thinking, self-monitoring, and academic achievement in higher education . Higher Educ. 74 . 101–114. 10.1007/s10734-016-0031-y [ CrossRef ] [ Google Scholar ]
• Gilbert T. (2003). Some reflections on critical thinking and mental health . Teach. Phil. 24 , 333–339. 10.5840/teachphil200326446 [ CrossRef ] [ Google Scholar ]
• Gregory R. (1991). Critical thinking for environmental health risk education . Health Educ. Q. 18 , 273–284. 10.1177/109019819101800302 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hayes A. F. (2009). Beyond Baron and Kenny: Statistical mediation analysis in the newmillennium . Commun. Monogr. 76 , 408–420. 10.1080/03637750903310360 [ CrossRef ] [ Google Scholar ]
• Hollon S. D., Beck A. T. (2013). Cognitive and cognitive-behavioral therapies, in Bergin and Garfield's Handbook of Psychotherapy and Behavior Change, Vol. 6 . ed Lambert M. J. (Hoboken, NJ: Wiley; ), 393–442. [ Google Scholar ]
• Hong L., Lin C. D., Bray M. A., Kehle T. J. (2010). The measurement of stressful events in chinese college students . Psychol. Sch. 42 , 315–323. 10.1002/pits.20082 [ CrossRef ] [ Google Scholar ]
• Jacobs S. S. (1995). Technical characteristics and some correlates of the california critical thinking skills test, forms a and b . Res. Higher Educ. 36 , 89–108. [ Google Scholar ]
• Kargar F. R., Ajilchi B., Goreyshi M. K., Noohi S. (2013). Effect of creative and critical thinking skills teaching on identity styles and general health in adolescents . Proc. Soc. Behav. Sci. 84 , 464–469. 10.1016/j.sbspro.2013.06.585 [ CrossRef ] [ Google Scholar ]
• Leclair M. C., Lemieux A. J., Roy L., Martin M. S., Latimer E. A., Crocker A. G. (2020). Pathways to recovery among homeless people with mental illness: Is impulsiveness getting in the way? Can. J. Psychiatry. 65 , 473–483. 10.1177/0706743719885477 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Lee H. S., Kim S., Choi I., Lee K. U. (2008). Prevalence and risk factors associated with suicide ideation and attempts in korean college students . Psychiatry Investig. 5 , 86–93. 10.4306/pi.2008.5.2.86 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Li S., Ren X., Schweizer K., Brinthaupt T. M., Wang T. (2021). Executive functions as predictors of critical thinking: behavioral and neural evidence . Learn. Instruct. 71 :101376. 10.1016/j.learninstruc.2020.101376 [ CrossRef ] [ Google Scholar ]
• Lin Y. (2018). Developing Critical Thinking in EFL Classes: An Infusion Approach . Singapore: Springer Publications. [ Google Scholar ]
• Luo Q. X., Yang X. H. (2002). Revising on Chinese version of California critical thinkingskillstest . Psychol. Sci. (Chinese). 25 , 740–741. [ Google Scholar ]
• Mamun M. A., Misti J. M., Hosen I., Mamun F. A. (2021). Suicidal behaviors and university entrance test-related factors: a bangladeshi exploratory study . Persp. Psychiatric Care. 4 , 1–10. 10.1111/ppc.12783 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Patton J. H., Stanford M. S., Barratt E. S. (1995). Factor structure of the Barratt impulsiveness scale . J Clin. Psychol. 51 , 768–774. 10.1002/1097-4679(199511)5 1 :63.0.CO;2-1 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Peng M. C., Wang G. C., Chen J. L., Chen M. H., Bai H. H., Li S. G., et al.. (2004). Validity and reliability of the Chinese critical thinking disposition inventory . J. Nurs. China (Zhong Hua Hu Li Za Zhi). 39 , 644–647. [ Google Scholar ]
• Profetto-Mcgrath J. (2005). Critical thinking and evidence-based practice . J. Prof. Nurs. 21 , 364–371. 10.1016/j.profnurs.2005.10.002 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Ren X., Tong Y., Peng P., Wang T. (2020). Critical thinking predicts academic performance beyond general cognitive ability: evidence from adults and children . Intelligence 82 :101487. 10.1016/j.intell.2020.101487 [ CrossRef ] [ Google Scholar ]
• Sanja M., Krstivoje S. (2015). Developing critical thinking in elementary mathematics education through a suitable selection of content and overall student performance . Proc. Soc. Behav. Sci. 180 , 653–659. 10.1016/j.sbspro.2015.02.174 [ CrossRef ] [ Google Scholar ]
• Stupple E., Maratos F. A., Elander J., Hunt T. E., Aubeeluck A. V. (2017). Development of the critical thinking toolkit (critt): a measure of student attitudes and beliefs about critical thinking . Think. Skills Creat. 23 , 91–100. 10.1016/j.tsc.2016.11.007 [ CrossRef ] [ Google Scholar ]
• Suliman W. A., Halabi J. (2007). Critical thinking, self-esteem, and state anxiety of nursing students . Nurse Educ. Today. 27 , 162–168. 10.1016/j.nedt.2006.04.008 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Ugwuozor F. O., Otu M. S., Mbaji I. N. (2021). Critical thinking intervention for stress reduction among undergraduates in the Nigerian Universities . Medicine 100 :25030. 10.1097/MD.0000000000025030 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Velotti P., Garofalo C., Petrocchi C., Cavallo F., Popolo R., Dimaggio G. (2016). Alexithymia, emotion dysregulation, impulsivity and aggression: a multiple mediation model . Psychiatry Res. 237 , 296–303. 10.1016/j.psychres.2016.01.025 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Wang K., Shi H. S., Geng F. L., Zou L. Q., Tan S. P., Wang Y., et al.. (2016). Cross-cultural validation of the depression anxiety stress scale−21 in China . Psychol. Assess. 28 :e88. 10.1037/pas0000207 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• West R. F., Toplak M. E., Stanovich K. E. (2008). Heuristics and biases as measures of critical thinking: associations with cognitive ability and thinking dispositions . J. Educ. Psychol. 100 , 930–941. 10.1037/a0012842 [ CrossRef ] [ Google Scholar ]
• Yoshida T., Ichikawa T., Ishikawa T., Hori M. (1998). Mental health of visually and hearing impaired students from the viewpoint of the University Personality Inventory . Psychiatry Clin. Neurosci. 52 , 413–418. [ PubMed ] [ Google Scholar ]
• Yoshinori S., Marcus G. (2013). The dual effects of critical thinking disposition on worry. PLoS ONE 8 :e79714. 10.1371/journal.pone.007971 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Zhang J., Lanza S., Zhang M., Su B. (2015). Structure of the University personality inventory for chinese college students . Psychol. Rep. 116 , 821–839. 10.2466/08.02.PR0.116k26w3 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]