The Science Journal of the American Association for Respiratory Care

Original Contributions

May 2002 / Volume 47 / Number 5 / Page 571

The Relationship Between Critical Thinking and Decision-Making in Respiratory Care Students

Thomas V Hill PhD RRT

INTRODUCTION: Respiratory therapists evaluate the condition of their patients, make decisions about the appropriateness of the treatment plan, provide care, and evaluate the outcomes of their decisions. To practice effectively they must think critically and make appropriate decisions. As educators make curriculum changes to improve students' decision-making (DM) skills, strategies to develop critical thinking (CT) have been proposed as one method of achieving that goal. This approach is based on the hypothesis that a positive relationship exists between DM and CT. The present study examines the relationship between CT and DM in respiratory care students. If there is a positive relationship between CT and DM, respiratory care training programs might improve the DM skills of future practitioners by providing instruction that improves CT. METHODS: Using a correlational research design, DM scores from the Clinical Simulation Self-Assessment Examination (CSSAE) were compared with scores from the Watson-Glaser Critical Thinking Appraisal for 143 graduating respiratory care students from 10 programs. Program directors completed a questionnaire and were then interviewed about the methods they employ to develop CT and DM in their students. RESULTS: A significant correlation between CT and DM was found for 110 students completing the Secure Form of the CSSAE (r = 0.32, p < 0.01). All programs used case studies and clinical simulations, and most used role modeling, computer-assisted instruction, patient rounds, small group discussion, and study skills courses. No differences were identified in the use of the CT and DM development strategies by different programs. CONCLUSIONS: The findings support the belief that students with strong CT proficiency make better clinical decisions. Assessment of CT proficiency could be used as one part of a process for evaluating prospective students and faculty for respiratory care programs. Program directors and faculty felt that case studies and clinical simulations are important strategies.
Key words: critical thinking, decision-making, respiratory therapists, training, education.
[Respir Care 2002;47(5):571–577]

The practice of respiratory care has changed tremendously during its 50-year development. When the first inhalation technician positions were created in the 1940s, those practitioners were primarily responsible for delivering oxygen cylinders to the patient's bedside, where a physician or nurse would administer the oxygen to the patient by tent or mask. Since that time the profession has evolved and respiratory therapists now assume much more responsibility for initiating, monitoring, and modifying the care they provide. With the introduction of therapist-driven protocols, respiratory therapists have been empowered to independently evaluate the patient's condition and make decisions regarding the need for treatment. That level of practice requires the practitioner to process a great deal of information about the patient's condition, to make decisions about which treatments to initiate, to assess the effectiveness of the treatments, and to implement necessary changes to the treatment plan. To effectively complete that process, practitioners must possess the proficiency to think critically and to make appropriate decisions.

See the Related Editorial on Page 568

As the practice of respiratory care evolved, the techniques for training prospective practitioners also developed. Early training programs were based in hospitals, and the length of training ranged from several weeks to a year. Most teachers were physicians and practitioners with experience in practice but not necessarily a foundation in education. Currently most training occurs in colleges and universities, within formally accredited programs of 1-4 years. Educators today are well trained not only in the techniques for delivering patient care, but also in the theories of instructional planning, delivery, and evaluation.

Respiratory care programs have become quite proficient in teaching future practitioners appropriate command of the knowledge and technical skills necessary to function in the current clinical setting. Yet as health care becomes more concerned with documentation of quality outcomes, cost containment, and the effectiveness of care, respiratory therapists must be able to do more than follow the physician's instructions. They must be able to independently evaluate the patient's condition, make decisions about how to treat the patient, implement the treatment plan, and evaluate the outcomes of their decisions. Participants in a National Consensus Conference on Respiratory Care Education gave high rankings to the ability of future practitioners to analyze, assess, and problem-solve. Educational programs are thus charged with teaching and evaluating students' ability to make appropriate decisions.

Ennis defined critical thinking (CT) as reasonable, reflective thinking focused on what to believe or do. As educational programs make curriculum changes to improve students' decision-making (DM) skills, the introduction of processes to develop CT proficiency has been proposed as one method of achieving that goal. The rationale for focusing on improving DM by teaching CT is based on the hypothesis that a positive relationship exists between DM and CT. This relationship has been described in both nursing and respiratory care students, but warrants further study.

The traditional lecture mode of instruction employed by many programs presents obstacles to the development of the student's CT proficiency. In the lecture format, students are presented with information and concepts and then left on their own to analyze, prioritize, and structure their new knowledge. Lecture is a generally passive style of education for the students, in which CT is not taught. Programs face the challenge of teaching the vast amounts of information and concepts deemed necessary for competent practice while also developing the student's CT proficiency, sometimes within the short time frame of a 2-year program.

Several strategies have been proposed for developing CT in students, including achieving a balance between lecture and interaction, increasing student participation in learning, introducing students to poorly-structured problems within their discipline, and employing problem-based learning. Though educational programs have experimented with some of those strategies to improve CT, their effectiveness has not been widely reported. A description of strategies used by programs whose students score higher in CT would benefit educators as they seek to improve these important abilities in their students.

The nature of the relationship between CT and DM has been the subject of much discussion and has been investigated by several researchers. Ennis's definition implies that the individual uses the process of CT to arrive at an appropriate decision. A consensus definition from the American Philosophical Association focuses on CT as a process of purposeful judgment that places emphasis on DM in the context of an identified problem, goal, desired outcome, or purpose. This notion of CT as the process to the outcome of DM is supported by others. Brookfield claims that if the individual thinks critically he or she will make good clinical decisions that are grounded in an accurate understanding of contexts for practice. Case claims that CT improves the quality of professional and personal decisions. In a proposed model of CT for nursing judgment, discipline-specific clinical DM is defined as the outcome of CT.

Several studies have attempted to test for the existence of a relationship between CT and DM. Earlier studies found no significant correlation between CT and DM, but later studies found a significant positive correlation. Mishoe et al and Shelledy et al reported significant relationships between CT and DM in respiratory care students and suggested that additional research is needed on the nature of the relationship between CT and DM.

The present study examines the relationship between DM and CT in respiratory care students and describes strategies used by respiratory care training programs to develop CT and DM. The research questions include: (1) Do statistically significant relationships exist between CT and DM in respiratory care students? and (2) What methods do respiratory care training programs use to develop CT and DM in their students?

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

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