REFLECTION AND CRITICAL THINKING OF

HUMANISTIC CARE IN MEDICAL EDUCATION

Shu-Jen Shiau1,2 and Chung-Hey Chen3
1
School of Nursing, National Taipei College of Nursing, and 2Division of Nursing Education,
Medical Education Committee, Ministry of Education, Taipei, and 3College of Nursing,
Kaohsiung Medical University, Kaohsiung, Taiwan.

The purpose of this paper is to stress the importance and learning issues of humanistic care in
medical education. This article will elaborate on the following issues: (1) introduction; (2) reflection and critical thinking; (3) humanistic care; (4) core values and teaching strategies in medical
education; and (5) learning of life cultivation. Focusing on a specific approach used in humanistic
care, it does so for the purpose of allowing the health professional to understand and apply the
concepts of humanistic value in their services.

Key Words: critical thinking, humanistic care, medical education, reflection

(Kaohsiung J Med Sci 2008;24:36772)

INTRODUCTION
Humanistic care in the twenty-first century requires
reflective maturity, global perspectives, interdisciplinary, technical information, and comfort with ambiguity. Health professionals face challenges everyday
when offering their services to people. They know
what they know and do not know, and have alternative methods to make clinical decisions. Health
professionals also need to be reflective in the context
of patients, families, and communities. It is very
important that health professionals are enabled to
be reflective, critical, flexible, and comfortable with
humanistic care [1]. In 1992, Carper regarded the various patterns of knowing as not mutually exclusive, as interrelated and interdependent [2]. By
focusing on the concept of humanistic care, health

Received: Apr 29, 2008

Accepted: Jul 30, 2008
Address correspondence and reprint requests to:
Dr Shu-Jen Shiau, 365, Ming Te Road, Peitou
112, Taipei, Taiwan.
E-mail: Shiau6@gmail.com

Kaohsiung J Med Sci July 2008 Vol 24 No 7

2008 Elsevier. All rights reserved.

professionals will be able to understand the core values

in their services.
From the significance of the reflective, multidimensional approach to humanistic care, we realize that
the health care arena is an extremely complex and
dynamic process. Therefore, there are many ways in
which humanistic care can be implemented in the care
of individuals, families, and communities. In addition, health professionals need humanistic care to
provide their services as a multidimensional reflective experience. Self-reflection, history, legal and ethical issues, spirituality, culture, family, media, group,
evidenced-based practice, economics, and health policy
can all affect humanistic care, and need to be critically thought about as an important process to consider throughout humanistic care [1]. Being aware of
the possibilities allows for fluidity and flexibility in
thinking that the health professional needs. Health
professionals touch the lives of people in every situation from birth to death, in health and illness. Care is
a human response to a particular situation. To allow
for diversity of ideas, health professionals write from
their own experience, use their own case studies, and
develop their own thoughts on the caring situation.
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S.J. Shiau and C.H. Chen

How do people respond to issues surrounding

sickness and health? As a teacher thinking about how
to teach in the 21st century, it is wise to understand
the changes in approaches to education. With regard
to health care education from the 20th to 21st century
[3], here are some strategies: (1) the dreaded lecture;
(2) small group learning; (3) problem-based learning;
(4) case study; (5) reflecting on reflection; (6) role
playa stage of learning; (7) creative activities; (8)
simulationtransforming technology into teaching;
(9) experience learning exercises; (10) blended and
e-learning; (11) self-directed study; and (12) applying
strategies to practice.
This article will elaborate on the following issues:
reflection and critical thinking; humanistic care; core
values and teaching strategies in medical education;
and learning of life cultivation.

REFLECTION AND CRITICAL THINKING

ODonnell et al defined self-reflection as an examination of ones own thoughts and feelings, and requires
maturity and a desire to know who you are [4]. The
genesis for humanistic care began when we taught
education; self-reflection was used to develop a nature
of knowledge needed for medical practice. Knowledge
lies embedded within everyday life experiences, and
how to transform daily experience to the answer we
need is self-reflection. Self-reflection asks that we look
at ourselves and transform our everyday life experience
to knowledge that can then be applied in humanistic
care [1]. As a result, those intellectual and affective
activities in which individuals engage to experience
will lead to new understandings and appreciations [5].
When expressing care, health professionals need
to understand that the process requires looking inward
at ones own self, then outward at the world around
them, and then back in again. We describe who we
are, where we are from, our education, and relate
how these experiences have shaped our philosophy
and care for others. During the period of reflection,
we can share and recognize that reflection is the process
of looking back at an experience or situation and analyzing it. It is an opportunity to question our values,
beliefs, and assumptions [6]. We each draw from our
intra- and interperceptual experiences; however, it is
better to have adequate action with self-reflection and
awareness of what the self brings to the humanistic
368

care process. Reflection can facilitate the development

of encouraging inquiry and autonomy, acknowledging
feelings, increasing self-awareness and understanding, and enhancing professional practice. Witmer
described these steps in reflection: (1) look back; (2)
elaborate and describe; (3) analyze outcomes; (4)
revise approach; and (5) new trial [7].
Critical thinking was defined by Campbell as
open-minded reasoning; use of intellectual standards
of reasoning including, clarity, depth and breadth of
understanding and relevance of information to a situation, and questioning of assumptions and biases
[8]. In addition, critical thinking gives us a way to
look at the world and, thus, support the work we do.
According to Paul and Nosichs theory, critical thinking is the intellectually disciplined process of actively
and skillfully conceptualizing, applying, analyzing,
synthesizing, and evaluating information gathered
from, or generated by, observation, experience, reflection, reasoning, and communication, as a guide to
belief and action [9].
There are five elements to critical thinking: thought;
macro-abilities; traits of the mind; affective dimensions; and intellectual standards. Further, there are
six processes that can improve critical thinking ability:
experiential learning; reflection; advanced questioning technique; computer assisted instruction; concept
mapping; and case method. Combining nursing theoretical work with critical thinking, we can find that
critical thinking is essential in this era of theory utilization because theory provides the basis for nurses
knowledge as well as a structure to guide caring
actions [10].

HUMANISTIC CARE
In the 21st century, health professionals are expected
to provide more than medical care, going more in the
direction of holistic care. Medicine can be not only a
science but can also be more humanistic by assisting
people to seek their own value of life and achieve
self-actualization and self-healing. Maslows hierarchy of human needs (Figure 1) provides the profound
map to understand humanistic desires.
Looking into Watsons theory [11], humanistic
caring is a fundamental belief in the internal power
of the care process to produce growth and change for
people. Watson believed that faithhope can facilitate
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Humanistic care in medical education

Self-transcendent
Selfactualization
Esteem and self-esteem
Love and belonging
Safety and security

Physiological needs: air, food, water, sleep, sex, etc.

Figure 1. Maslows hierarchy of human needs.

the promotion of holistic nursing and positive health.

Watsons 10 care factors are: (1) formation of a
humanisticaltruistic system of values; (2) instillation
of faithhope; (3) cultivation of sensitivity to ones
self and to others; (4) development of a helpingtrust
relationship; (5) promotion and acceptance of the
expression of positive and negative feelings; (6) systematic use of the scientific problem-solving method
for decision-making; (7) promotion of interpersonal
teachinglearning; (8) provision of a supportive, protective, and/or corrective mental, physical, sociocultural, and spiritual environment; (9) assistance with
gratification of human needs; and (10) allowance for
existentialphenomenological forces. Watson defined
each of these care factors and gave examples of what
nurses can ask themselves critically with regard to each
factor. For example, for: (1) formation of a humanistic
altruistic system of values: practice of loving-kindness
and equanimity in the context of caring-consciousness.
The questions you can ask yourself are: Who is this
person? Am I open to participate in his/her personal
story? How am I being called to care? How ought I
to behave in this situation? For: (2) instillation of
faithhope: being authentically present and enabling
and sustaining the deep belief system and subjective
life world of self and the one-being-cared-for. The
questions you can ask yourself are: What does this
relationship mean to this patient? What health event
brought this person to the health facility? What information do I need to nurse this person? Can I imagine
what this experience is like? Can I encourage this
person to find faith/hope?
Applying Watsons perspective, when working
with others during times of despair, vulnerability
Kaohsiung J Med Sci July 2008 Vol 24 No 7

and the unknown, we are challenged to learn again,

to reexamine our own meaning of life and death [11].
A human-to-human act of caring within a given
moment becomes a basic foundation for facing our
humanity, uniting us and the cosmic energy of love.
Caring and compassionate acts of love beget healing
for self and others [12]. For Christians, humanism
means valuing life over material things, and to encourage ethics and moral values [13]. The sacrament of
reconciliation is considered: in relation to God, in
relation to my neighbor, in relation to myself [14].
Watsons human care theory projects a reverence for
the mysteries of life and an acknowledgment of lifes
spiritual dimensions. A health care professional who
is tuned in to lifes spiritual dimensions can express
care and help patients do the same by taking into
account patients spiritual needs; they have the ability
to understand their own spirituality and that of the
patient, family, and community. Chen addresses values, religious beliefs, and what is meant by spirituality and humanistic care in nursing [13].

CORE VALUES AND TEACHING STRATEGIES

IN MEDICAL EDUCATION
In Lewis Excellence Without a Soul: How a Great
University Forgot Education, the core value of education was emphasized [15]. The World Federation for
Medical Education has listed the core areas in the
medical curriculum as: (1) basic biomedical sciences;
(2) basic behavioral and social sciences; (3) humanities;
(4) general clinical skills; (5) clinical decision-making
skills; (6) communication abilities; and (7) medical
ethics. Global Minimum Essential Requirements offer
seven educational outcomecompetence domains: (1)
professional values, attitudes, behavior and ethics; (2)
scientific foundation of medicine; (3) communication
skills; (4) clinical skills; (5) population health and
health systems; (6) management of information; and
(7) critical thinking and research [16]. The Taiwan
Medical Accreditation Council also emphasizes these
core values of medical education and practice.
The philosophy of the School of Nursing,
McMaster University, is our favorite: nursing is a scientific and humanistic activity of professional caring.
The McMaster model of nursing education defines
the learner and facilitator as persons made up of body,
mind and spirit, influenced by life meaning, values
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S.J. Shiau and C.H. Chen

and beliefs [17]. The Taiwan Nursing Accreditation

Council identified different professional core values of universities and colleges. For universities, they
are: (1) critical thinking and reasoning; (2) general
clinical skills; (3) basic biomedical science; (4) communication and team work capability; (5) caring; (6)
ethics; (7) accountability; and (8) life-long learning.
For colleges, they are: (1) general nursing skills; (2)
basic medical sciences; (3) respecting life and caring;
(4) identifying and solving problems; (5) professional conduct and teamwork capability; and (6) selfdevelopment [18].
There has been a great growth in knowledge and
research with regard to education, resulting in many
theories of how to learn. Some of them have been
grouped under schools of thought as follows:
Behaviorist. This theory presents transactional
analysis theory and considers that positive and
negative strokes to self-esteem have great impact
on learning.
Cognitivist. Here are many theorists who consider
that in terms of skills acquisition, a learner moves
from being a novice to being a potential expert.
Humanist. Learners are people; we learn from
each other and have different driving forces and
life problems.
Reflectionist. Focus is on what goes on inside an
individuals head, their thinking. Due regard is
given to the idea that we can use this to identify
learning, in a reflective way [3].
In relation to learning styles, there are several models:
Kolbs model. Kolb, who considered the different
processes of concrete and abstract thinking,
together with experimentation and observation.
There are four categories of learner; a learner will
have a preferred leaning towards one of the categories: diverger, converger, assimilator, accommodator.
Honey and Mumfords model. In this theory, students are categorized as activists, pragmatists,
reflectors or theorists.
VARK model. These models consider the cognitive processes (visual, auditory, reading/writing,
kinesthetic); students will have a preference for
one to enhance learning.
Neurolinguistic programming. Helps provide reference to individuals who think with pictures, sound
and feeling. Also, the other senses of taste, touch
and smell are connected with memories; therefore,
370

learning may be improved if these aspects are also

incorporated into the teaching sessions.
In relation to teaching styles, there are also several
models:
Robins and Greenwood. They describe two different teaching stylesconservative and progressive.
Gilmartins model. There are four styles. Type 1 is
a didactic style, type 2 is similar to type 1 but
includes experiential activities, type 3 favors
student-centered facilitation, and type 4 focuses
on creative approaches.
Grashas model. This reflects the activity pursued
by the person at the front of the class. There are
five categories: expert, formal authority, personal
model, facilitator, delegator.

LEARNING OF LIFE CULTIVATION

Caring concern is the core of nursing. Quality medical care is patient-centered and based on safety,
effectiveness, adequacy, efficiency, and equality. The
incorporation of care, concern and compassion (3Cs)
into nursing education is the major subject we would
like to discuss [19]. The 3Cs are the mission of the
School of Nursing, Catholic Fu-Jen University in
Taiwan. In research into the 3Cs applied in nursing
education, Shiau demonstrated that the relevant concept and strategies embracing the 3Cs of nursing
education can develop into the learning of life cultivation through which are included three elements:
growing experience; lifes meaning and value; and
professional services (Figure 2) [20].

Lifes meaning
and value

3Cs
Professional
services

Growing
experience

Figure 2. Learning of life cultivation.

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Humanistic care in medical education

Shiau et al reported on the phenomena of offering

and receiving 3C experiences of life, based on emphasizing the cultivation of life education in nursing
education. Their findings demonstrated that utilization of the 3Cs to offer and receive experiences
of bitter events can transform the bitterness into a
learning mechanism of love and wisdom. Their results provide important references for the continued
development of the fundamental theory and strategies of life education in nursing, and the enhancement of in-depth self understanding and service to
others [21]. In another report, Shiau et al studied
one teacher and 11 students on a Leadership and
Management course. They participated in weekly
discussions of the learning experience associated
with the clinical practicum. Content analysis revealed four main problems: individual characteristics of
patients and families and their stress adaptation on
bio-psycho-spirits; humanity-centered procedures
and equipment; suffering related to nursing working context; and nurse growth to be a whole person. The following problem resolutions were found:
offering care in respecting the individual characteristics of patients and their families, and stressing
care in stress adaptation of bio-psycho-spirits; formulating and planning humanity-centered nursing
procedures and equipment; cultivating an understanding and supportive nursing administration culture; and constructing a developing program of
knowledge, attitude and behavior for self and professional development [22].
A 3Cs Learning Group was developed to promote
nursing leaders adoption of the concepts and competencies of the 3Cs in nursing administration in
order to more firmly root nursing care in care for the
human being [23]. The findings demonstrated the
effectiveness of the mentors facilitation concepts
and skills, and the dynamic operation of the group
process (Figure 3). The results can provide information and suggest techniques to assist nursing leaders
in 3Cs learning groups to promote self growth and
encourage nursing staff to enhance service advocacy
and quality [24].
The results of this series of research studies with
the incorporation of 3Cs will develop a humanitarian
perspective, focused on patients, nurses, and the
working environment perspective, which will more
closely meet the core values of caring concern and
medical quality.
Kaohsiung J Med Sci July 2008 Vol 24 No 7

Work

Individual

Group

Figure 3. Dynamic operation of the group process.

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