evidence-based approaches to promoting critical thinking · evidence-based approaches to promoting...
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Evidence-based Approaches to Promoting Critical Thinking
Rosalinda Alfaro- LeFevre, RN, MSN
www.AlfaroTeachSmart.com
© 2008 www.AlfaroTeachSmart.com 1
The illiterate of the twenty-first century will not be those who cannot read and write, but those who cannot learn, unlearn, and relearn.
—Alvin Toffler, author of Future Shock
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—Alvin Toffler, author of Future Shock
You can download handouts, tools and this powerpoint (for the next
two weeks) from:
www.AlfaroTeachSmart.com
© 2008 www.AlfaroTeachSmart.com 5
Another Great Resource for Tools
STAFFEDNET LISTSERV
Subscribe info: https://lists.hsc.utah.edu/wws/info/staffednet
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https://lists.hsc.utah.edu/wws/info/staffednet
CT Book (2008)CT Book (2008)
Saunders/ElsevierSaunders/Elsevier
USA: 800USA: 800--325325--41774177www.us.elsevierhealth.comwww.us.elsevierhealth.com
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CANADA: 866CANADA: 866--896896--33313331www.elsevier.cawww.elsevier.ca
NP BookNP Book (2006)(2006)LippincottLippincottwww.lww.comwww.lww.com
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USA: 800USA: 800--638638--3030 3030
CANADA: 800CANADA: 800--223223--23002300
GroundGround RulesRulesFeel free
Tell us about problems.
OK to Parallel Process
Have fun! (Keep it down.)
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Have fun! (Keep it down.)
Stay on Task
We’re all experts / We’re Both Responsible
Check cell phones & egos at the door.
Who’s Here?
Staff nurses?
Managers - Administers?
Staff Development?
School of Nursing Faculty?
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School of Nursing Faculty?
Nursing Home Administtraters?
Social Workers?
Other?
Progress Worksheet
80/20 Rule
Pre-course Assessment
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Pre-course Assessment
Expected OutcomesExpected Outcomes
1. Explain why there must be agreement among faculty on how the terms evidence-based approaches, critical thinking, and nursing process are defined.
2. Describe how to use evidence-based critical
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2. Describe how to use evidence-based critical thinking indicators (CTIs) to promote and evaluate critical thinking (CT).
Expected OutcomesExpected Outcomes
3. Identify ways to prioritize what you teach, rather than trying to “teach it all”.
4. Use evidence-based strategies to promote
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4. Use evidence-based strategies to promote critical thinking in students.
Expected OutcomesExpected Outcomes
1. Explain why there must be agreement among faculty on how the terms evidence-based approaches, critical thinking, and nursing process are defined.
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BrainBrain--based Learningbased Learning
� Your brain can think faster than I can talk
� You can read faster than I can talk
� Looking at the same thing from various
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� Looking at the same thing from various perspectives = increased learning & insight
BrainBrain--based Learning*based Learning*
� Active participation = retention
� Humor reduces stress and helps you learn. (Funderstanding)
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learn. (Funderstanding)
*Hart, L. (2002) Human Brain, Human Learning, 3rd Ed. Covington, WA: Books for Educators, Inc.
*On Purpose Associates. Brain-based Learning. Retrieved May 8, 2006: http://www.funderstanding.com/brain_based_learning.cfm
*www.Funderstanding.com
Think, Pair, Share*
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* Developed by Professor Frank Lyman at the University of Maryland in 1981. Read more at:
http://www.eazhull.org.uk/nlc/think,_pair,_share.htm
Code of Conduct
People think better when they
like & trust one another.
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like & trust one another.
Problem-specific
Critical Thinking
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Problem-specific
Prevention &
Management
(PPM)
General Principles
& CT Skills (CTIs)
What’s The Big Deal?
• Bush Goals 2000 (number of people who
can think critically will increase). (Scans, 1992)
• Break the mold schools (students aren’t prepared to function in the real world).
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prepared to function in the real world).
• To survive, we must learn very specific skills and strategies to get the results we need.
• MOST of brain research & CT research has happened in the past 5-10 years
• Few teachers are familiar with the research & continue to teach in old ways.
• Learning and using new strategies takes
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• Learning and using new strategies takes time, but eventually your lives (and your students’ lives) will be easier --- you’ll be amazed at your results.
Gap Between Education & PracticeGap Between Education & Practice__________________Growing Rapidly_________Growing Rapidly_________
� I am dragging my faculty along…. I feel like we
need to BLAST some faculty into the future
� “Practice is going ahead in a speed boat, and
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� “Practice is going ahead in a speed boat, and
we’re coming along in a canoe” (D. Iggy)
� We need tools to help them assess, diagnose, and predict those at risk efficiently.
PRACTICING NURSES’ QUOTES
� We have “chain of command” problems
� Nursing models are important, but not
enough…our approaches are multidisciplinary.
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multidisciplinary.
� Most of us know nothing of NANDA, NIC, NOC.”
� We tell new grads to leave nursing diagnosis at the door.
EDUCATOR QUOTES
“ We’re at war over what goes on the left & side of the statement”
“ Medical diagnoses can’t be listed after the related to part of the statement. It has to be only what the nurse can do independently”
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nurse can do independently”
“We’re at war over replacing assessment tools and care plans with maps.
“We’re required to map in every course….but we don’t know why”
Bus is Leaving the Station & Now it’s an Airplane
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Will you be on it?
Expected OutcomesExpected Outcomes
1. Explain why there must be agreement among faculty on how the terms evidence-based approaches, critical thinking, and
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approaches, critical thinking, and nursing process are defined.
Getting on the Same Page
� Is CT the same as NP?
� Does NP mean NANDA, NIC, NOC?
� Too much time wasted arguing over meaning
� Student - faculty thinking is blocked by “no”
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� Student - faculty thinking is blocked by “no”
� Makes the difference between frustration & meaningful learning
What Does “Evidence-Based” Mean?
� Many reliable valid studies?
� Expert consensus?
� Expert opinion?
� Support from publications?
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� Support from publications?
� Real time studies?
� Systematic reviews?
� All of the above?
Evidence-Based Practice EBP
� Recognize that no one knows it all
� Students, nurses, and faculty must be comfortable answering questions like, “based on what evidence?”…How do you know?...Is there enough evidence for this for this situation?
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� EBP is still in its infancy. No official org identifying teaching-evaluation strategies that are EBP.
� Educator’s EBP Workshop® is done byhttp://www.acestar.uthscsa.edu/ (see star model in appendix). NLN doing more too.
Evidence-Based Practice (EBP) *
� Bridges the gap between scientific evidence and its practical use in the clinical setting.
� Integrates the following into clinical practice:
1. The best research evidence
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1. The best research evidence
2. Opinions from clinical experts
3. Patient values and preferences
• Sackett, D.,et al (2000). Evidence-based medicine: How to practice and teach
EBM. Edinburgh, Scotland: Churchill, Livingstone.
Evidenced-Based Nursing Education
Evidence Based Nursing Education (EBNE) is integration of Evidence Based Practice (EBP) with educator expertise and learner needs and
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with educator expertise and learner needs and values. (Alfaro-LeFevre, 2008)
Evidence-Based Practice
An approach to health care (or teaching) practices in which the nurse, student or or teacher is aware of:
1. The evidence that bears on her clinical or
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1. The evidence that bears on her clinical or educational practices
2. The strength of that evidence.
“To the best of our knowledge….”*
Evidence-Based Practice
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*Academic Center for Evidence-Based Nursing (ACE) Web site. Available at: http://www.acestar.uthscsa.edu.
Recommended
NURSE EDUCATOR COMPETENCIES: CREATING AN EVIDENCE-BASED PRACTICE FOR NURSE EDUCATORS
AUTHOR: Judith A. Halstead, DNS, RN, ANEF,
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AUTHOR: Judith A. Halstead, DNS, RN, ANEF, Editor
PRICE: NLN Members $49.95 Non-NLN Members $59.95
Common CT Descriptions
• A composite of knowledge, skills, & attitudes (Watson and Glaser, 1980).
• Knowing how to learn, reason, think creatively, generate and evaluate ideas,
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creatively, generate and evaluate ideas, see things in the mind's eye, make decisions and solve problems (SCANS, 1992).
• Reasonable, reflective thinking that focuses on what to believe or do. (Ennis, 1987)
• The ability to solve problems by making sense of information using creative, intuitive, logical and analytical mental processes…and
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logical and analytical mental processes…and the process is continual (Snyder, 1993).
• The art of thinking about your thinking, while you're thinking, to make it better, more clear, accurate, & defensible. (Paul, 1995)
• The process of purposeful, self-regulatory judgment... the cognitive engine that drives problem solving & decision-making. (Facione & Facione, 1994)
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(Facione & Facione, 1994)
• Knowing how to focus your thinking to get the results you need (includes intuitive, logical, and creative thinking). (Alfaro-LeFevre, 2004)
Hartman’s Color Code®
Red = Power
Blue = Intimacy
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Yellow = FunYellow = Fun
White = Peace
Critical Thinking Indicators (CTIs)*
• Definition: Behaviors that evidence suggests promote critical thinking in clinical practice.
• Give concrete descriptions and examples.
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• Give concrete descriptions and examples.
• Listed in context of what’s likely to be observed when a nurse is thinking critically in the clinical setting.
*Alfaro-LeFevre, 2004, 2006
CTI USE
� Self improvement / Evaluation
� Curriculum/Course Evaluation
� Organizational impact
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� Risk management
� Clinical preparation/reflection
… When I see you skipping assessments and making assumptions I know you’re not thinking critically because a first priority in CT is identifying assumptions
Example
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priority in CT is identifying assumptions and verifying the facts….
… When you are able to explain reasons behind procedures I know you are more likely to be thinking critically because critical thinking requires you to understand
Example
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critical thinking requires you to understand underlying reasons and principles so that you can adapt as needed.
What Does “Evidence-Based” Mean?
In context of nursing process:
� Facts supporting judgments
� Patient assessment data
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� Logic applied to intuition
� References/Research/ Expert opinion supporting interventions
ANA (2004) Standard Related to Diagnosis
Standard II: Diagnosis. The registered nurse analyzes the assessment data to determine the
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assessment data to determine the diagnoses or issues (ANA, 2004)
ANA (2004) Standard Related ____________to Language__________
““Must use standard or recognized terms..”Must use standard or recognized terms..”
� This means most common language, not
only NANDA, NIC, NOC
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only NANDA, NIC, NOC
� JCAHO “Do Not Use Lists” growing
� Use the language of the facilties you use and NCLEX---don’t “rename”.
____Check the Evidence___
Examples:
� What’s the evidence that shows that Fluid Volume Deficit is different from Dehydration?
� How often do problems fall neatly into a two
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� How often do problems fall neatly into a two part statement?
Old vs New ThinkingOld vs New Thinking
Old Thinking
� We must use NNN
� Right & Left Side of
New Thinking
� Discriminate, prioritize, use the most common terms.
� Mapping frees the brain
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� Right & Left Side of Statement
� We must be creative
� Tools are crutches
� Mapping frees the brain
� We need more evidence
� We ALL need tools
WHY WE NEED TOOLS
Cognitive function is often compromised with increasing levels of stress and fatigue---often the norm in complex, high-intensity fields of work. Aviation, aeronautics, and product manufacturing rely heavily on checklists to reduce human error.
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heavily on checklists to reduce human error. Checklists are important tools in error management. They contribute significantly to reductions in the risk of costly mistakes and improving overall outcomes.”*
*Hales, B. and Pronovost, P. (2006) The checklist—a tool for error management and performance improvement, Journal of Critical Care,21(3) 231-235
CLINICAL WORKSHEET
Name______________ Room_____
Age____ Religion___ Culture____
Diet____ Activity_______________
Medical Dx_____________________
Dr.____________________________
Allergies_______________________
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Neuro:
Resp: Oxygen:
Cardiac:
Circ:
Skin:
GI:
Medications/IV’s:
Potential Complications:
Nursing DX/problems:
CLINICAL WORKSHEET
Name George S. Room 232
Age 82 Religion Cath Culture Hisp
Diet Lo Na Activity: Bedrest
Neuro:
Medical Dx CHF
Dr. O’Hara
Allergies Lidocaine
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Neuro:
Resp: Oxygen: 2 L
Cardiac:
Circ: all pulses strong
Skin:
GI:
GU: Foley draining clear yellow
Medications/IV’s: HL right hand
Potential Complications: Pulm Edema
Nursing DX/problems:
Digoxin 0.25 mg po OD 1000CIPRO 500 mg po BID 1000
2000KCl Elixir 20 mEq po OD 1000
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KCl Elixir 20 mEq po OD 1000 Multivitamin po OD 1000Ambien 5 mg po hs 2000MOM 30 cc po hs 2000
Digoxin 0.25 mg po OD 1000CIPRO 500 mg po BID 1000
2000KCl Elixir 20 mEq po OD 1000
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KCl Elixir 20 mEq po OD 1000Multivitamin po OD 1000Ambien 5 mg po hs 2000MOM 30 cc po hs 2000
Digoxin 0.25 mg po OD 1000CIPRO 500 mg po BID 1000
2000KCl Elixir 20 mEq po OD 1000
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KCl Elixir 20 mEq po OD 1000Multivitamin po OD 1000Ambien 5 mg po hs 2000MOM 30 cc po hs 2000
TACIT“Preventing Adverse Drug Events
T= Therapeutic Effect?
A = Allergy or Adverse Reactions?
C = Contraindications?
I = Interactions?
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I = Interactions?
T = Toxicity / Overdose?
Rule: 90% of med errors are due to med side effects
Use Tools for Consistency
1. Promotes systematicity
2. Avoids omissions—develops habits
3. Adopt and adapt as much as possible
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3. Adopt and adapt as much as possible
4. Remember the FAA
We MUST Start Thinking in New Ways
80/20 RULE:80/20 RULE:
� Match reality more closely
� Match state boards
� What knowledge, experiences, &
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� What knowledge, experiences, &
practice will help them achieve in
the above contexts?
Can’t Throw Out Nsg Dx
� 40 State practice acts include the term Diagnosis* Check the law.
� Prioritize & take a broader look at what your dealing with (behavior, side effect, complication, outcome, etc.)
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outcome, etc.)
� Becoming more of a generic term (any problem a nurse identifies)
*Lavin, M.A., Meyer, G., & Carlson, J.H. (1999). A review of the use of nursing
diagnosis in U.S. nurse practice acts. Nursing Diagnosis, 10, 57-64.
Prioritizing Diagnoses
• How do you assess for it?
• What do you do about it?
• Is it a priority?
• Is it a concept, rather than a diagnosis?
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• Is it a concept, rather than a diagnosis?
• Does it simplify communication?
(Is there already a term for it that most
healthcare professionals know?)
____Diagnosis Mapping Worksheet__
In-depth problem solving/ prevention through systematic, analysis of both the problem and the contributing factors.
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The problem may be listed as a diagnosis, a behavior, a side effect, or a potential problem or complication.
4 Elements For Learner Success*
1. Clear outcomes & competencies up front
2. Continual feedback as to positives & negatives
3. Consistent application of the same criteria
4. Ability to give reasons behind the judgments
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4. Ability to give reasons behind the judgments you make about performance (to avoid the idea of being arbitrary or capricious, etc).
* Christianson, L (2005)
Requirements For ______Meaningful Learning______
� Teacher must give clear instructions, find
out prior knowledge, & explain relevancy
� Learner must choose to learn it in
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� Learner must choose to learn it in
a meaningful way
Meaningful Learning (continued)
� Learner must be involved in following progress & keeping a “paper trail” (portfolio)
� Start with self-assessment (pre-
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� Start with self-assessment (pre-course assessment tool)
____Crucial to Success_______Crucial to Success___
Lots of FORMATIVE evaluation and STUDENT INVOLVEMENT in monitoring
their own progress toward
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competencies/outcomes through specific tools and strategies.
Precourse Assessment
� Helps learner get focused and identify learning needs.
� Helps you do the same and also identify “stars” in the group
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identify “stars” in the group
� Saves time
� Promotes meaningful learning
Prioritizing What
You Teach
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Preparing
for NCLEX®
Preparing for
Clinical Practice
Let’s Start With StrategiesLet’s Start With StrategiesThat are a MUST for BOTH That are a MUST for BOTH Practice & NCLEX®Practice & NCLEX®
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____Remember TPE_____Remember TPE___
T= Teach
P= Practice
E= Evaluate
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E= Evaluate
Focus on Safe Effective CareFocus on Safe Effective Care
Stress:���� Active, not passive, communication���� Communication (Report/Record)���� Advocating for patients (chain of command)
Be sure they know what MUST be charted:
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Be sure they know what MUST be charted:
���� Assessments & re-assessments,���� Changes in status ���� Importance of following policies/procedures
Be Sure They Know Management
CHF
COPD
Wounds
Diabetes
Arthritis
Depression
Kidney Disease
Shock
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Diabetes
Asthma
Head Injury
Shock
Dehydration
Blood transfusion
Preparing for Both
Stress:
� Setting priorities: What will you do first?
� Planning ahead: What will you do if….?
�Managing risks: What will you monitor?
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�Managing risks: What will you monitor?
Preparing for Clinical Practice
� Stress safety & infection control
� Plan collaborative experiences.
� Discuss eval tool on day one
� Be explicit about what you expect / clarify
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� Be explicit about what you expect / clarify that clinical is a LEARNING experience
� Give tools to guide their day
Prioritizing For NCLEX®Prioritizing For NCLEX®
Focus on setting priorities and delegation/teamwork from early courses and in the skills lab.
Be sure they learn pharmacology and IV drugs (focus on nursing implications---do a summary class).
Stress assessment & monitoring (safe effective care)
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Stress assessment & monitoring (safe effective care)���� Pre-intra-post procedure assessment���� Pre-intra-post drug administration assessment���� WHO can you delegate WHAT to WHOM, WHEN?���� Evaluating, prioritizing
NCLEX ® Test PlanNCLEX ® Test Plan
1. Terminology*
“Allude to NANDA”
“Don’t use NIC and NOC”
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2. Math: Must use drop-down calculator
3. Physiological integrity ~ 50%!
*Personal phone call to NCSBN July, 2005
____More NCLEX® Strategies___
Encourage them to get Review Books day 1
Assign several faculty to be experts
Match your course and against test plan
Get test banks
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Get test banks
Questions should be analysis/application
Don’t write from scratch yourself
Get students to write questions
Evidence-based Strategies
� Mapping
� Simulation
� NCLEX practice
� Be able to explain reasoning behind methods
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� Be able to explain reasoning behind methods
� No one knows it all
� GET STUDENTS INVOLVED
� EBT is still in its infancy
4 Elements For Learner Success*
1. Clear outcomes & competencies up front
2. Continual feedback as to positives & negatives
3. Consistent application of the same criteria
4. Ability to give reasons behind the judgments
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4. Ability to give reasons behind the judgments you make about performance (to avoid the idea of being arbitrary or capricious, etc).
* Christianson, L (2005)
RewardsRewards
Improved Confidence
Good Habits
Ability to change based on
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Ability to change based on
context & evidence
Results
Bibliography
Alfaro-LeFevre, R. (2006). Applying nursing process: A tool for critical thinking (6th ed.). Philadelphia: Lippincott- Williams & Wilkins
Alfaro-LeFevre, R. (2008). Critical Thinking and Clinical Judgment: A practical approach (4th ed.). Philadelphia: Elsevier - Saunders
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Philadelphia: Elsevier - SaundersAlfaro-LeFevre, R. (2008). Evidence-based Critical Thinking Indicators. Available at: www.AlfaroTeachSmart.com.
ANA (2004). Nursing scope & standards of performance and standards of clinical practice . Washington, DC: American Nurses Publishing
ANA (2001). Code of ethics for nurses with interpretive statements. Washington, DC: American Nurses Publishing.
Christensen, L. (2005). Email communication.
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Christensen, L. (2005). Email communication.
Ennis, R. (1987). A taxonomy of critical thinking dispositions and abilities. In J.B. Baron, J.J. Sternberg (Eds.), Teaching thinking skills: Theory and practice. New York, New York: Freeman.
Facione, N., Facione, P., Sanchez, C. (1994). Critical thinking disposition as a measure of competent clinical judgment: The development of the California Critical Thinking Disposition Inventory.
Journal of Nursing Education, 33(8), 345–351.Gardner, H. (1993). Multiple intelligences. New
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Gardner, H. (1993). Multiple intelligences. New York, NY: Basic Books
Goleman, D. (1995). Emotional intelligence. New York, NY: Bantam Books.
Oermann, M. & Gaberson, K. (2006). Evaluation and testing in nursing education. 2nd Ed. New York: Springer.
Oermann, M. (2005). Keynote Speech at NLN-Villanova University Faculty Development Institute. Villanova, PA.
Paul, R. and Elder, L (2001). Critical thinking: Tools
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Paul, R. and Elder, L (2001). Critical thinking: Tools for taking charge of your learning and your life. Upper Saddle River, NJ: Prentice Hall
Snyder, M. (1993). Critical Thinking: A Foundation for Consumer-Focused Care. The Journal of Continuing Education in Nursing, 24(5): 206-210.