The Science Journal of the American Association for Respiratory Care


May 2002 / Volume 47 / Number 5 / Page 568

Educating Respiratory Care Professionals: An Emphasis on Critical Thinking

It is not surprising that educators in any discipline desire to improve their students' thinking abilities to help them make better personal and professional decisions. The emphasis on critical thinking is nothing new and can be traced back to ancient times and accounts of how students were challenged to think about their knowledge, beliefs, and behaviors. For example, it is widely known that Socrates would press his students until they could provide reasons and evidence to support their arguments. He would dismiss those beliefs and decisions that could not be supported, causing dismay among his students and unrest among the politicians. The Socratic method has survived the test of time and has become an important educational tool to prepare doctors, lawyers, educators, respiratory therapists, and a variety of other professionals.

See the Original Study on Page 571

The difficulties in describing and improving critical thinking are well documented in numerous definitions, theories, and educational practices. Developing critical thinking in respiratory therapy students has been proposed as a method for improving clinical decision-making, based on the hypothesis and preliminary data that a positive relationship exists between decision-making and critical thinking.1-3 This issue of RESPIRATORY CARE provides additional evidence that there is a relationship between general critical thinking and decision-making in respiratory care.4 Dr Thomas V Hill's study supports the belief that students with strong critical thinking abilities make better clinical decisions, using the Watson Glaser Critical Thinking Appraisal (WGCTA, Psychological Corporation, San Antonio, Texas) to measure critical thinking and the Clinical Simulation Self Assessment Examinations (CSSAE, developed by the National Board for Respiratory Care) to measure decision-making. In addition, the study describes current educational practices in respiratory care, reporting the predominant use of role modeling, case studies, clinical simulation, computer-assisted instruction, and small group discussion.4

Dr Hill's study also illustrates common difficulties in educational research and social sciences research in general, which frequently result in small sample sizes and the use of nonexperimental designs, since randomization is often not possible. Therefore, although we have enough data to document that a positive relationship exists between critical thinking and decision-making, we cannot determine cause and effect.2-4 We are left to ponder which educational methods can improve our students' decision-making and critical thinking, although there are some data that support the use of problem-based learning in respiratory care.5,6 I cannot help but smile and believe that Socrates would look favorably on the successful uses of problem-based learning,7-10 while reminding us we need additional evidence to support its use in respiratory care.

Since most respiratory therapy programs are struggling with limited pools of qualified students, I would caution against Dr Hill's suggestion that assessment of critical thinking proficiency could be used as part of a process for evaluating prospective students.4 I do not think we have the luxury at present of imposing additional acceptance criteria for admissions into our programs. However, I think his suggestion that we consider using the WGCTA to assess prospective faculty is an interesting proposition and deserves additional consideration.4 I also believe that we can do a lot more to promote critical thinking among our practicing respiratory therapists. For example, the issues on Evidence-Based Medicine in Respiratory Care could be incorporated into continuing education and in-service programs to facilitate critical thinking and an evidence-based approach to practice among respiratory therapists.11,12 We should also investigate which educational methods can improve the critical thinking of our practicing respiratory therapists.

In conclusion, we need further study of the effectiveness of educational strategies to promote the development of critical thinking and decision-making. As a means to evaluate program effectiveness, I encourage educational programs to use the WGCTA to assess their students' abilities on admission and prior to graduation to determine whether there are any changes in their students' critical thinking.5 To those conducting educational research, I challenge you in the spirit of Socrates to work with other colleagues to design and implement a prospective, randomized study with sufficient power to add to our knowledge base of those strategies that can improve critical thinking and decision-making in respiratory care.

Shelley C Mishoe PhD RRT FAARC
Office of the Dean
School of Allied Health Sciences
Medical College of Georgia
Augusta, Georgia


  1. Mishoe SC. Critical thinking, educational preparation, and development of respiratory care practitioners. Distinguished Papers Monograph 1993;2:29-43.
  2. Mishoe SC, Dennison FH, Thomas-Goodfellow L. A comparison of respiratory therapy students' critical thinking abilities with performance on the clinical simulation examinations (abstract). Respir Care 1997;42(11):1078.
  3. Shelledy DC, Valley MA, Murphy DE, Carpenter ME. Effects of content, process computer-assisted instruction, and critical thinking abilities on students' performance on written clinical simulations. Respir Care Educ Annu 1997;6:11-29.
  4. Hill TV. The relationship between critical thinking and decision making in respiratory care students. Respir Care 2002;47(5):571-577.
  5. Mishoe SC, Dennison FH, Thomas-Goodfellow L. Can respiratory therapy education improve critical thinking? (abstract) Respir Care 1997;42(11):1078.
  6. O'pt Holt TB. A first year experience with problem-based learning in a baccalaureate cardiorespiratory care program. Respir Care Educ Annu 2000;9:47-58.
  7. Benjamin EM, Schneider MS, Hinchey KT. Implementing practice guidelines for diabetes care using problem-based learning: a prospective controlled trial using firm systems. Diabetes Care 1999;22(10):1672-1678.
  8. Teshima DY. Outcome measurement of problem-based learning. Clin Lab Sci 2001;14:68-69.
  9. Curtis JA, Indyk D, Taylor B. Successful use of problem-based learning in a third-year pediatric clerkship. Ambulatory Pediatr 2001;1(3):132-135.
  10. Antepohl W, Herzig S. Problem-based learning versus lecture-based learning in a course of basic pharmacology: a controlled randomized study. Med Educ 1999:33(2):106-113.
  11. Conference on evidence-based medicine in respiratory care. Part I. Respir Care 2001;46(11):1200-1303.
  12. Conference on evidence-based medicine in respiratory care. Part II. Respir Care 2001;46(12):1368-1449.

Correspondence: Shelley C Mishoe PhD RRT FAARC, Office of the Dean, School of Allied Health Sciences AA2028, Medical College of Georgia, Augusta, GA 20912-0010. E-mail:

The entire text of this article is available in the printed version of the May 2002 RESPIRATORY CARE.

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