September 2002 / Volume 47 / Number 9 / Page 1007
It Hurts to Say “Hertz”
There is a new virus going around that affects only respiratory therapists. It seems to affect the brain’s speech center in a curious way. I have observed signs of it in my own department and in 3 abstracts I just reviewed for this year’s OPEN FORUM at the International Respiratory Congress. Like the herpes virus, this new strain seems to lie dormant for periods and then becomes active when the therapist starts talking about high-frequency ventilation (HFV). Therapists will start listing the ventilator settings and all of a sudden lapse into an incongruity. They will say something like this: “The mean airway pressure was 12,” meaning the average pressure was 12 centimeters of water. Then they will say, “The amplitude was 35,” meaning that the difference between the peak and trough airway pressure was 35 centimeters of water. Then all of a sudden they start to stutter, turn pale, diaphoretic, and say the most inane thing: “The hertz was 10.” Then they recover immediately and say something like “The oxygen concentration was 60%.” Fascinating! This virus causes them to momentarily confuse a unit of measurement (hertz) with a ventilation parameter (frequency). What could be the etiology of this new virus? This time we cannot blame the ventilator manufacturers, because they clearly label their controls as “Frequency” or “HFV rate.” Perhaps it is due to practicing unsafe ventilator checks. I fear this will become endemic and lead to even further lapses in awareness. I have a name for this new disease: parametometric inversosis.
Robert L Chatburn RRT FAARC
Respiratory Care Department
Department of Pediatrics
Case Western Reserve University
Clinician Perspective on Critical Thinking and Decision-Making
I have been a registered respiratory therapist for 18 years, with 14 of those in positions in which critical thinking (CT) and appropriate, accurate decision-making (DM) are of paramount importance. In those positions an individual either possessed CT and DM skills and survived or did not possess them and did not survive. After reading the editorial and original contribution on this subject in the May 2002 issue,1,2 I think some clinician views about CT and DM should be presented.
From my observations, CT and DM are skills. They must be practiced, tested, and refined in order to grow. I honestly believe they cannot be taught. Individuals can be exposed to them and then be placed in situations where they must be used. Depending on the individual, these situations will either make them or break them. All too often I have seen individuals graduate, work a little, pass the registry, and think they have arrived; they are now gone.
I am intrigued by Dr Mishoe’s statement regarding the luxury of assessment of CT proficiency as an acceptance criterion. Would this be prohibitive from a time or numbers standpoint? Isn’t the crux of CT and DM an improvement in quality?
I do not think the environment of health care as it exists today fosters the growth and use of CT and DM. Task orientation seems to be in the forefront. Facilities must return to placing a premium on CT and DM in order for them to be fully appreciated. Evidence showing that these 2 skills impact reducing costs and length of stay would be most beneficial.
Whatever the reasons, I am afraid CT and DM are becoming a lost art. But then again I may be wrong. If T-piece trials can come full circle to be acceptable, maybe other useful practices are not far behind.
Glenn A Roberts RRT
Respiratory Care Services
Medical Center of Central Georgia
- Mishoe SC. Educating respiratory care professionals: an emphasis on critical thinking. Respir Care 2002;47(5):568-569.
- Hill TV. The relationship between critical thinking and decision-making in respiratory care students. Respir Care 2002;47(5):571-577.
Is Critical Thinking a Luxury?
I wish to respond to Dr Thomas Hill’s study of critical thinking (CT) and decision-making (DM) in respiratory care students1 and Dr Shelley Mishoe’s related editorial, which
I applaud Dr Hill’s work and appreciate seeing research on respiratory care education appear in a professional journal, because this is such an important topic and there is so little research reported on it. I find Dr Hill’s report a credible, challenging study, which adds to what we know of training respiratory therapists (RTs). He thoroughly addresses many of the difficulties and limitations of this type of research. I agree with his suggestions for further research on the subject.
The article reports a statistical correlation between students’ CT capacity and their DM scores on the National Board for Respiratory Care Clinical Simulation Self-Assessment Examination, Dr Hill concludes that respiratory care educators should investigate and adopt strategies to develop CT in students and recommends CT assessment as part of the evaluation process for prospective students (and faculty). My response is in 3 parts.
Dr Hill’s study measures DM using the DM score of the National Board for Respiratory Care Clinical Simulation Self-Assessment Examination. I am doubtful that the DM score from that exam actually reflects DM capacity in the pure sense, and whether that exam score truly measures the student’s DM is not addressed in Dr Hill’s study. That is, the score is labeled decision-making, but probably reflects other factors.
A basic conclusion of Dr Hill’s study is that better CT proficiency is related to better DM and that respiratory care training programs are incorporating teaching strategies that promote CT. But data reported in the study seem to contradict the effectiveness of CT teaching strategies. I am skeptical that CT can be instilled in students who are not endowed with it on admission and doubtful that respiratory care instructors meaningfully improve CT in their students. Dr Hill’s Table 4 is, I believe, mislabeled as “Strategies Used by Programs to Develop Critical Thinking and Decision- Making.” More accurately, those are used to attempt to develop CT and DM, as it has not been established that any of them are effective or that there is a connection between them and student CT.
I do not share Dr Mishoe’s conviction that Socrates would be pleased with the efforts toward problem-based learning, particularly in the respiratory care training industry, but I agree with Dr Hill that CT assessment should be added to the evaluation procedure for student applicants.
1. The Decision-Making Measure
It was my pleasure to have served as a moderator of the American Association for Respiratory Care’s annual “Sputum Bowl” from 1982 through 1998. Early on it became clear that there is a startling fact about the subject content of respiratory care: there are a finite number of unique questions and that number is quite small. This means that credentialing exam questions, like Sputum Bowl questions, are variations and restatements of a limited number of items. Similarly, I believe that there are a limited number of possible decisions that can be used to construct branching-logic clinical simulations in respiratory care. This unsettling insight came from my experience writing, editing, and publishing computer-managed clinical simulations for the field of respiratory care. What is scored and reported as DM may be rote application of a small set of “IF THEN” rules. For example:
IF hypercapnia, THEN increase alveolar minute ventilation.
IF arterial resting PO2 is < XX mm Hg, THEN prescribe home oxygen.
IF forced expiratory volume in the first second improves X%, THEN administer bronchodilator.
Such “IF... THEN” rules can be memorized. Although I have not attempted to identify and count the unique DM elements in clinical simulations, I suspect that that number is small. The same items, rewritten and restated, appear again and again. The point is that there is reason to doubt that a high DM score on a clinical simulation exam authentically reflects DM capacity. It may, but it may also reflect simple familiarity with the topic, memorization of a few problem-solving rules, and mastery of the gamesmanship element of branching-logic simulations.
When simulations were adopted for respiratory care credentialing exams, they were promoted as instruments simulating the clinical environment, with opportunities to both make and rectify clinical decisions. Early exams were complex, with multiple true pathway branches. The current generation of simulations appears to be very nearly linear -- merely strings of multiple-choice questions. I wonder if there has been a degrading of the methodology over the years and whether any measurement of DM skill has been diluted. I would like to see the same study using a generic measure of DM capacity in addition to the Clinical Simulation Self-Assessment Examination scores. Would not DM capacity be evident in an unfamiliar context?
Dr Hill’s study attempts to address DM but does not recognize that the most any exam or simulation can do, necessarily removed from the clinic, is measure not clinical DM but the potential for clinical DM. Instruction designers and simulation developers know very well that there is a gap between exam performance and workplace performance.3 Clinical decision situations rarely present as carefully worded multiple-choice questions. Moreover, that a student has DM capacity, revealed by examination, does not indicate that the student will choose to apply it as a practitioner. Therefore I cannot agree with the exact wording of Dr Hill’s conclusion that, “students with strong CT proficiency make better clinical decisions.” They seem to make better simulated clinical decisions.
2. Teaching Critical Thinking
Dr Hill’s study surveyed respiratory care program directors to identify teaching strategies used to develop CT. The study lists as many as 9 such strategies used in various combinations and (I presume) to various degrees, in the 10 programs participating in the study. But, as Dr Hill states, those strategies are merely purported to improve CT. It has apparently not been established that any of them significantly improve CT. A study of baccalaureate nursing programs found no increase in student CT ability from sophomore to senior years, but did find CT improvement as a result of clinical experience after graduation.4 This perhaps suggests that respiratory care training programs might improve CT by redesigning and refining clinical instruction to authentically mirror the clinic and by concentrating on higher-level assessment and management skills rather than technical procedures. It would be useful to study CT among practicing RTs. The study by Maynard4 also questions the validity of the Watson-Glaser Critical Thinking Appraisal instrument (used in Dr Hill’s study) for the field of nursing and notes the difficulty of even defining CT so that it can be measured. No relationship was found between CT and nursing competence, leading the researcher to ask if nursing practice is too prescriptive to permit true, reflective, open-ended CT. The same question may be asked of respiratory care. Much of what we label CT and DM may be merely a sort of respiratory care catechism, tightly defined and finite.
Most troubling is Dr Hill’s report that, “No significant differences were found in the CT scores of students in different programs.” As there is wide variation in the CT strategies employed by the schools in Dr Hill’s study, should we not expect to see differences in the CT measurement in graduating students between the programs? Are all of these strategies, in any combination, equally potent? More likely, I suspect, they are equally impotent.
In the case of the respiratory care training industry, I cannot agree with Dr Mishoe’s perception that Socrates would be pleased with efforts toward incorporating problem-based learning. It is my perception that Dr Hill is correct in stating that “programs have experimented” with strategies to improve CT, such as problem-based learning. The dominant instruction method in respiratory care education is lecture. The statement that, “Educators today are well trained in the theories of instructional planning, delivery, and evaluation” does not agree with my experience or perception. My perception is that respiratory care educators teach as they were taught -- by talking. Dr Hill’s study reports only 4 of the 10 programs surveyed use problem-based learning, and those data are self-reported. I recall a program director who responded to the Dean’s plea for attention to CT by delivering a lecture on CT. Socrates might smile that as educators we believe that we have the capacity to improve CT in others by employing teacher-centered methods, without directly and aggressively addressing CT as an instructional goal.
Socrates is admired for tenaciously drilling to the truth, debunking unfounded assumptions, and rankling those in power by revealing their self-interest and collective ignorance (he included himself in this). He came to a bad end. I wonder how Socrates would fare were he reborn today as a respiratory care educator. I suspect his outcome might be the same. He might point out that the respiratory care training industry fails the field of respiratory care for reasons of self-interest. He would reveal our collective self-delusion when we devise a sophisticated testing method to verify clinical DM acumen, then sabotage it by shamefully spoon-feeding and drilling students so that they may pass credentialing exams. When we indulge in intensive exam preparation in our programs (sometimes as much as a semester of the course), we deceive ourselves that improved DM scores evidence CT.
In one personal respiratory care teaching experience, the Dean forbade us to “teach to the exam,” as this is patently unethical. Across the field of respiratory care, however, that proscription is the exception. Some educators point proudly to their program’s pass rates, ignoring that the statistical validation methodology the exams are based on does not include exhaustively drilling candidates, using mock and even retired exams, rendering the entire process suspect, if not corrupt. A program’s central goal ought to be generating safe and competent practitioners. An obsession with high program pass rates is a different goal and serves the self-interest of programs, institutions, and educators. I am convinced that an intelligent student can be schooled and drilled to pass our credentialing exams without substantive clinical experience. This is the dilemma public schools face when political pressure motivates them to teach students to score well on standardized tests rather than actually teaching the students. I am also convinced that drilling students in clinical simulation exam strategy is highly effective in improving DM scores, falsely improving CT and clinical DM.
Most troubling to me is something evoked by Dr Mishoe’s statement that, “I do not think we have the luxury at present of imposing additional acceptance criteria for admissions into our programs.” Is CT capacity a luxury in RTs? Should we take this to mean that it is in our power to instill CT thinking in students in whom it does not exist, or that CT isn’t really important? I disagree with both. There is perhaps reason to hope that CT can be nurtured and refined where it already exists but no evidence that CT can be taught to low-caliber students. Dr Hill’s study and Dr Mishoe’s editorial declare the vital importance of DM in RTs and identify CT as an essential element in DM. That double message is evocative of a frightful willingness in respiratory care programs to soften acceptance criteria so that classrooms may be filled. Lowering standards to fill the student ranks serves only the self-interest of programs. Worse, patients are unknowingly placed at risk by exposing them to clinical students who should not have been accepted. I believe that now, more than ever, respiratory care needs to hold to its standards. We don’t need just bodies in the classrooms and clinics; we need minds.
The crucial factor in generating competent and safe RTs is the quality of incoming students. Dr Hill’s study verifies exactly that, reporting a positive correlation between GPA and CT. Carpenters know that no degree of craftsmanship compensates for poor-quality materials. Filling the ranks with unqualified students may keep programs afloat but ultimately dishonors the field and delays resolving the essential obstacle to recruiting -- poor salaries. When the demand for skilled RTs is sufficient to increase wages, students of quality will be attracted. The current crisis in student recruitment, unlike previous downswings in the cycle, is not responding to a sluggish economy. This is alarming. Potential candidates seeking a career change are passing over respiratory care because, among other factors, it does not pay well. Dr Hill’s study suggests that the field is failing to attract or keep male students. Perhaps this should be examined. I agree with the suggestion that prospective faculty be tested for CT, but further recommend that current faculty be evaluated as well. I would not presuppose that respiratory care faculty are endowed with CT skill, and I suggest this as a starting point if CT is to be addressed in students. And the apparent gap between the best interests of the field and the schools deserves some critical thought.
Keith B Hopper PhD RRT
Technical Communication Program
Southern Polytechnic State University
- Hill TV. The relationship between critical thinking and decision-making in respiratory care students. Respir Care 2002;47(5):571-577.
- Mishoe SC. Educating respiratory care professionals: an emphasis on critical thinking (editorial). Respir Care 2002;47(5):568-569.
- Smith PL and Ragan TJ. Instructional design, 2nd ed. New York: John Wiley & Sons. 1999, xv, 399.
- Maynard CA. Relationship of critical thinking ability to professional nursing competence. J Nurs Educ 1996 35(12):12-18.
Dr Hill replies
I appreciate Dr Hopper taking the time to respond to the report of my research on critical thinking (CT) and decision-making (DM) in respiratory care students. My goal, as Dr Hopper points out, was to add some evidence to what we know about training respiratory therapists, by looking at the relationship between the CT and DM constructs, while recognizing the restrictions and limitations imposed by the study design. One of my doctoral professors always reminded us that we didn’t have to rediscover the atom but merely add a grain of sand to the mountain of knowledge. It is the constant addition of those mere grains that, when taken collectively, begin to reveal the important discoveries. Our best chance of improving the education of respiratory therapists will come from the summation of many such studies.
In attempting to measure a complex construct such as DM, the researcher seeks to identify an instrument that will capture the essence of that construct. Dr Hopper points out that the National Board for Respiratory Care Clinical Simulation Self-Assessment Examination may reflect factors other than DM, and that may be so. I chose to use that instrument as a measure of DM because the participating programs were already using it and it also allowed me to compare my data to that reported by other researchers. I agree with Dr Hopper’s suggestion that, “students with strong CT proficiency make better simulated clinical decisions,” since the study was performed using clinical simulation exams and not direct observation of clinical performance. Measurement of DM in the clinical setting is an excellent suggestion for further research.
Dr Hopper is skeptical that CT can be instilled in students who are not endowed with it upon admission to a program, and Mr Roberts makes the same point. I don’t disagree with their statements; however, I think educational programs nevertheless have an obligation to try to develop CT proficiency in students. By providing a learning environment in which CT is modeled, encouraged, and evaluated, students may have an opportunity to learn CT. I agree that not all students will be highly proficient in CT upon graduation, but we should still strive to encourage all students to develop this important skill.
I would also like to comment on Dr Hopper’s reduction of branching logic clinical simulations to a series of “IF THEN” rules. Consider Dr Hopper’s first example, that of increasing alveolar minute ventilation in the face of hypercapnia. There are several factors the practitioner must consider before changing the ventilator settings. Does the patient have chronic carbon dioxide retention secondary to chronic obstructive pulmonary disease? Is a small degree of hypercapnia tolerable (the permissive hypercapnia approach to ventilation)? Should minute ventilation be increased by changing the tidal volume, the frequency, or both? My experience with clinical simulation examinations has taught me that it is consideration of such additional factors that separates the successful test-taker from the unsuccessful one. Consideration of all those factors and a careful evaluation of the merits and perils of treatment options start to resemble the definition of CT.
Dr Hopper’s interest in this study and it’s implications for respiratory care education are much appreciated. It is through this type of dialog that we all learn how to do a better job of preparing future practitioners.
Thomas V Hill PhD RRT
Department of Respiratory Care
Kettering College of Medical Arts
Dr Mishoe replies
In response to the letters from Dr Hopper and Mr Roberts, I restate that I question whether any respiratory therapy program should require the Watson Glaser Critical Thinking Appraisal (WGCTA) as part of its application process and criteria for admission. I cannot justify the cost, the effort, or the consequences of adding more admissions criteria during a time of low applicant pools in respiratory care. My opinion that we do not have the luxury of adding additional admissions criteria such as the WGCTA in no way implies that critical thinking (CT) is a luxury we cannot afford. The prospective student pool is small enough, without restricting it further; that is my point, pure and simple, with no other agenda attached, as Dr Hopper suggests.
If someone does not agree with that opinion, then I would ask for reasons they might offer as to (1) why we should add the WGCTA as part of the admissions criteria, (2) how we would use WGCTA scores in our student selection process, and (3) how we would explain turning away a student with acceptable GPA and other admissions criteria but unacceptable WGCTA scores. I would seriously question Dr Hopper, Mr Roberts, or anyone involved in education today to turn away a qualified, prospective student with acceptable admissions criteria because of a WGCTA score. This is not to say that we should accept low-quality students or weaken our admission processes.
I will not respond to other questions in Dr Hopper’s letter (“Is CT capacity a luxury in [respiratory therapists] RTs? Should we take this to mean that it is in our power to instill CT thinking in students in whom it does not exist, or that CT isn’t really important?”), because both statements are his, not mine. It is an interesting tactic to make your own statements and then argue against them in an attempt to assign ownership to someone else. We know what Socrates would do when faced with similar circumstances; he would require the person to provide clarification and give reasons to support any conclusions. Therefore I ask Dr Hopper how he made the leap from “We do not have the luxury of adopting the WGCTA to our admissions criteria” to “CT isn’t really important.” I do not follow the logic in making such an association.
The most troubling part of Dr Hopper’s letter is the implication that Dr Hill or I would suggest that we should fill classes with low caliber students. He wrote: “Dr Hill’s study and Dr Mishoe’s editorial declare the vital importance of DM in RTs and identify CT as an essential element in DM. That double message is evocative of a frightful willingness in respiratory care programs to soften acceptance criteria so that classrooms may be filled.” Anyone who knows me or my work understands that I have been a strong advocate for facilitating CT in respiratory therapy students, faculty, and clinicians.1-4 I ask Dr Hopper to explain why he sees a double message and how he draws his conclusions. Again, I do not follow his logic and find no rationale to support how he came to such a conclusion.
I understand that editorials and letters to the editor allow for much more opinion than a discussion in an original study. However, I believe we should always strive to provide reasons and evidence to explain and support our opinions. I also teach students that, when they make statements that are not within conventional wisdom taken to be fact, theory, or common practice, they make it explicit that it is their opinion. Consequently, I am concerned with Dr Hopper’s comments about the changing nature of the clinical simulation exams (“Early exams were complex, with multiple true pathway branches. The current generation of simulations appears to be very nearly linear -- merely strings of multiple-choice questions. I wonder if there has been a degrading of the methodology over the years and whether any measurement of DM skill has been diluted.”) or any relationship to the Sputum Bowl. I object to someone stating that there has been a degrading of any standardized exam based on personal impressions that the nature of the exam is somehow different. Again, I would ask Dr Hopper to indicate that these are his own opinions and then to show the data to support his opinions.
Dr Hill’s paper is not intended as a validation of either the clinical simulation or the WGCTA; that was not the purpose of the study.5 Rather, the purpose was to determine if there is a relationship between decision-making in respiratory care (as measured by the clinical simulation exam) and general CT (as measured by the WGCTA). I believe Dr Hill chose appropriate instruments to test his hypothesis. Any instrument chosen to measure any variable has limitations, whether that instrument is the WGCTA or the decision-making section of the clinical simulation exam. To conduct research you must make a decision as to how you will measure something and then you must state and accept the method’s limitations, assumptions, and margins of error. There is quite a difference between choosing an instrument as a measurement tool and developing or validating an instrument. Dr Hill’s study did not assess either the methodology for development of the clinical simulation or any changes in the instrument from previous versions. Therefore I do not follow why Dr Hopper has offered his opinions about the clinical simulations.
I do not understand how the Sputum Bowl or its questions fit with Dr Hopper’s letter. Who ever claimed that the Sputum Bowl is a reflection of practice in respiratory care? When has any association been made between the Sputum Bowl and practice, the Sputum Bowl and credentialing exams, or the Sputum Bowl and CT? Factual, short answers such as those demonstrated in the Sputum Bowl are not a reflection of CT and do not fit with this discussion. In my opinion the Sputum Bowl is a chance to have some fun while flaunting RT trivia, facts, figures, and concepts; no more and no less.
I do agree with Dr Hopper on the point he makes about the differences between “teaching to a test” and facilitating CT. Novices need both. A responsible program in any discipline must prepare its students for practice, and that includes their ability to pass credentialing exams. However, we should not stop there. As Dr Hill states, further research is needed to determine which educational methods can best enhance CT.5 Dr Hill’s study describes the current strategies used by the programs in his study but lacks the data to draw any valid conclusions about those strategies. Therefore, no meaningful discussion is possible. Although Dr Hopper and perhaps Socrates would not be pleased with efforts to incorporate problem-based learning, I can offer some data that suggest that problem-based learning can enhance respiratory therapy students’ general CT, as measured by the WGCTA.6 The literature on problem-based learning offers many examples, some of them cited in my editorial, on the successful use of this method to improve students’ performance, including their CT.
I believe that the best way to facilitate CT in students and others is to role model it through a combination of skills, dispositions, and opportunities in the practice setting. Faculty and clinicians should serve as mentors to students and demonstrate the abilities to prioritize, anticipate, troubleshoot, decide, communicate, negotiate, and reflect.7-9 Some of these abilities can be facilitated and even measured by a test, but many occur in the practice setting. Faculty and practicing RTs can role model CT by showing an appreciation for multiple perspectives and being able to articulate how they derive their conclusions. I believe an evidenced-based approach to practice can enhance CT in respiratory practice as well as improve certain patient outcomes.10
I agree with Mr Roberts that CT must be practiced, tested, refined, and expected in order to grow. I agree that CT skills and attributes can be facilitated in educational programs, but it is in practice that these skills will further develop and can be enhanced. My own research supports Mr Roberts’ opinion that individuals can be exposed to CT skills and then must be placed in situations to use those skills for CT to flourish.7 I strongly agree with Mr Roberts that CT is a lost art if the practice setting does not expect it or support it. Research that I conducted indicates that practicing RTs who demonstrate high
Education programs and continuing education can enhance CT skills and traits, but ultimately it is where RTs work that will determine if CT is used by those capable of performing at the highest levels. I truly hope that CT in respiratory care practice will flourish rather than become a lost art, as Mr Roberts warns.
Shelley C Mishoe PhD RRT FAARC
School of Allied Health Sciences
Medical College of Georgia
- Mishoe SC. Critical thinking in respiratory care practice. In: Mishoe SC, Welch MA Jr. Critical thinking in respiratory care: a problem-based learning approach. New York: McGraw Hill, 2002.
- Mishoe SC, MacIntyre NR. Expanding professional roles for respiratory care practitioners. Respir Care 1997;42(1):71-91.
- Mishoe SC. Critical thinking and problem based learning. In: Hess DR, MacIntyre N, Mishoe SC, Galvin WF, Adams AB, Saposnick AB, editors. Respiratory care principles and practice. Philadelphia: WB Saunders, 2002.
- Mishoe SC, Hernlen K. Health care trends and the evolving role of the respiratory care professional. In: Hess DR, MacIntyre N, Mishoe SC, Galvin WF, Adams AB, Saposnick AB, editors. Respiratory care principles and practice. Philadelphia: WB Saunders, 2002.
- Hill TV. The relationship between critical thinking and decision-making in respiratory care students. Respir Care 2002;47(5):571-577.
- Mishoe SC, Dennison FH, Goodfellow LT. Can respiratory therapy education improve critical thinking? (abstract) Respir Care 1997;42(11):1078.
- Mishoe SC. Critical thinking in respiratory care practice. PhD diss, Department of Adult Education, University of Georgia, Athens, Georgia, 1994.
- Mishoe SC. Critical thinking in respiratory care practice. Proceedings of the 35th Annual Adult Education Research Conference. University of Tennessee, Knoxville, Tennessee. 1994:276-281.
- Mishoe SC. Critical thinking in respiratory care practice (abstract). Respir Care 1996;41(10):958.
- Montori VM, Guyatt GH. What is evidence-based medicine and why should it be practiced? Respir Care 2001;46(11):1201-1214.
- Mishoe SC. The effects of institutional context on critical thinking in the workplace. Proceedings of the 36th Annual Adult Education Research Conference. University of Alberta, Edmonton, Alberta, 1995:221-228.