Midwifery practice involves making clinical judgements that influence midwives' decision-making and the subsequent safe care of women and babies. Clinical judgements are shaped by midwives' knowledge and experiences, and form part of decision-making. Understanding how practitioners formulate decisions is an important aspect of both pre- and post-registration midwifery training, as midwives must be accountable and justify care decisions while working in partnership with women and their families (Nursing and Midwifery Council (NMC), 2018).
Clinical reasoning describes the cognitive processes underpinning decision-making and forms part of the broader philosophical domain of hypothetico-deductive theory (Newell and Simon, 1972; Jefford et al, 2011). This describes how the brain receives, stores and processes information from the environment (Elstein and Bordage, 1988; Mok and Stevens, 2005). Such models are rooted in rational and logical analysis of a situation where knowledge and judgement are made explicit.
Critical thinking is an essential requirement for effectual clinical reasoning and decision making, and a fundamental component of safe and effective midwifery practice (NMC, 2019). However, the concept of critical thinking is not always well understood. Students require strategies to understand and develop critical thinking skills to enhance decision-making within practice. The integration of the A-EQUIP model and restorative clinical supervision within pre-registration midwifery programmes is a means of supporting students to develop critical thinking skills.
What is critical thinking?
Critical thinking is the ability to engage in purposeful self-regulatory thinking and provides the impetus for knowledge development and clinical judgment (Facione and Facione, 2008; Abrami et al, 2015). Developing critical thinking skills can assist students with learning to be autonomous reflective practitioners as they embark upon a pathway of lifelong learning. Critical thinking can encourage insight and understanding and enhance engagement with professional behaviours necessary within practice. Through the development of critical thinking, students learn how to process, assess and assimilate information, developing clinical reasoning while reflecting upon thinking processes.
Carter et al (2018) have significantly contributed to the knowledge base for critical thinking in midwifery practice, including a literature review and the development of a conceptual model of critical thinking in midwifery practice. The model demonstrates a new understanding of critical thinking in midwifery practice that is embedded within a woman-centred philosophy of care that aligns well with the standards of midwifery (NMC, 2019) and framework for quality maternal and newborn care (Renfrew et al, 2014).
Thinking about what constitutes critical thinking can be helpful when exploring critical thinking (Box 1). Not thinking critically means automatically accepting what one is told or has read without asking whether it is accurate, true or reasonable (Chatfield, 2017). Asking meaningful questions is central to critical thinking.
Box 1.Overview of critical thinkingWhat it is:
- Enables analysis of all possibilities and reviews strengths and weaknesses
- Facilitates collection of appropriate information to inform analysis and consider possible solutions/alternatives
- Interprets information from a variety of sources and considers all viewpoints
- Is insightful and reflective, open to learning and improvement
What it is not:
- Being critical
- Making irrational judgements
- ‘Knee jerking’ when things go wrong or being so focused on a solution that you fail to see the bigger picture
- Refusing to accept criticism or that you may have made the wrong judgement
The ability to question and learn with an open mind involves considering various perspectives and the ability to explore beneath the surface of what is presented to identify the facts of a situation. Asking questions (Box 2) helps to break an issue or dilemma into parts to consider the relationship between each part and each part to the whole. This process helps develop more analytical answers and deeper thinking.
Box 2.Critical thinking questionsDescribe: what happened, when, where and why?
- What is this problem about?
- Who does it involve and affect?
- When and where is this happening?
Analysis: how, why and what if?
- What are the contributing factors?
- How might one factor impact another?
- What if one factor is removed or altered?
- Are there alternative options or factors to consider?
Evaluating: so what and what next?
- What does this mean?
- What actions do I need to take?
- How will I know that this is right?
Adapted from Learn Higher, 2021
Integral to critical thinking is the ability to analyse, evaluate and make judgements based on the outcomes of the evaluations. Reflection is important and closely intertwined with critical thinking, especially when used within a coaching framework (Fontien-Kuipers et al, 2018; Thoresen and Norbye, 2021). Reflective practice has been widely discussed within healthcare literature and encompasses the ability to reflect upon one's actions to engage in a process of continuous learning (Schon, 1991). Reflecting on practice supports the ability to self-regulate thoughts and behaviours as one considers their own judgements and beliefs while assessing them against the backdrop of new knowledge and skills development.
Within practice, critical thinking can improve the ability to recognise and adapt to changing situations, enhancing situational awareness and emotional intelligence when considering how a judgement might influence and be influenced by the presenting clinical picture. Rather than becoming fixated upon immediate assumptions, critical thinking encourages clinicians to actively seek to understand what is happening, evaluate the evidence and think carefully about the process of thinking itself (Chatfield, 2017).
The skills required for critical thinking are implicitly integrated into midwifery pre-registration programmes where students are required to use specific information with sufficient understanding and knowledge to explain the conceptual, contextual or methodological principles within practical situations (Abrami et al, 2015). Introducing students to skills of research appraisal develops critical thinking, confidence and self-efficacy. With motivation and effort, students can be encouraged to understand the multiple perspectives that may shape how information is presented and be able to negotiate information to draw conclusions, justify and articulate reasoning and advocate for women to promote informed choices.
The deployment of the A-EQUIP model (NHS England, 2017) and implementation of opportunities for restorative clinical supervision within pre-registration midwifery programmes can help students explicitly develop their critical thinking skills. As part of restorative clinical supervision, students can be supported to reflect upon practice experiences and examine their reactions and responses with a view to reviewing their knowledge, behaviour and learning.
Restorative clinical supervision provides opportunities for students to consider their motivation, check for possible bias or prejudice that may influence their clinical judgement and offers opportunities for self-development or improvement. Transparency is promoted, as students can be supported to reflect on errors or omissions that occurred and consider steps to address these. Restorative clinical supervision can be used to develop critical thinking and support effective clinical practice (Box 3).
Box 3.Restorative clinical supervision and critical thinkingDevelops analysis skills:Through sensitive prompting, facilitator can encourage students to identify actual/inferred meaning and impact of beliefs, judgements and opinions on a woman's experience or multi-professional working, eg verbal and non-verbal communicationAbility to classify information and make sense of its significance:By describing the incident, students can be supported to classify and clarify information, assisting with clear presentation of information in practice, eg use of situation, background, assessment, recommendationDevelops interpretational skills:Students can be supported to understand components of professional practice and meaningfully link them, eg physiological and clinical context for cardiotocography assessmentSupports practical application of midwifery skills:Midwifery skills include recognising and responding to physiological changes and providing information through effective communication to facilitate informed choiceSupports development of ideas:Supports development of blue sky thinking and ideas/innovation for improvement
Conclusion
Critical thinking skills are enhanced by the regular provision of constructive feedback and opportunities for supportive self-reflection, which can encourage self-regulation and reframing issues or difficulties experienced through critical thinking. The A-EQUIP model provides an excellent framework for supporting developing critical thinking as students are introduced to the benefits of critically thinking through restorative clinical supervision.