CRITICAL THINKING (CT) is vital in developing. Critical Thinking and Evidence-Based Practice JOANNE PROFETTO-MCGRATH, PHD, MED, BSCN, BA PSYCH, RN*

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1 Critical Thinking and Evidence-Based Practice JOANNE PROFETTO-MCGRATH, PHD, MED, BSCN, BA PSYCH, RN* Critical thinking (CT) is vital to evidence-based nursing practice. Evidence-based practice (EBP) supports nursing care and can contribute positively to patient outcomes across a variety of settings and geographic locations. The nature of EBP, its relevance to nursing, and the skills needed to support it should be required components of baccalaureate education and must be introduced early in students development as independent, self-directed learners and as professional nurses. Among the knowledge, skills, and processes needed to support EBP, CT is paramount. The development of CT can prepare nurses with the necessary skills and dispositions (habits of mind, attitudes, and traits) to support EBP. The intents of this study were to explore the importance of CT as an essential skill to support EBP and to describe some of the strategies and processes considered key to the ongoing development of CT. (Index words: Critical thinking; Critical thinking dispositions; Habits of mind; Nursing education; Evidence-based practice; Nursing practice; Research utilization) J Prof Nurs 21: , A 2005 Elsevier Inc. All rights reserved. Critical Thinking and Evidence-Based Nursing Practice CRITICAL THINKING (CT) is vital in developing evidence-based nursing practice. Evidence-based practice (EBP) supports nursing care that can be bindividualized to patients and their families, is more effective, streamlined, and dynamic, and maximizes effects of clinical judgmentq (Youngblut & Brooten, 2001, p. 468). Evidence-based *Associate Professor, Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada; Senior Research Fellow, Knowledge Utilization Studies Program, University of Alberta, Edmonton, Alberta, Canada; and Associate, Center for Knowledge Transfer, University of Alberta, Edmonton, Alberta, Canada. Address correspondence and reprint requests to Dr. Profetto- McGrath: Associate Professor, Faculty of Nursing, Clinical Sciences Building, University of Alberta, Edmonton, Alberta, Canada T6G 2G3. joanne.profetto-mcgrath@ualberta.ca /$ - see front matter n 2005 Elsevier Inc. All rights reserved. doi: /j.profnurs practice can contribute positively to patient outcomes across a variety of settings and geographic locations. The nature of EBP, its relevance to nursing, and the skills needed to support it should be required components of baccalaureate education and must be introduced early in students development as independent, self-directed learners and as professional nurses. Among the skills and processes needed to support EBP, CT is paramount (Profetto- McGrath, 2003; Tanner, 1999). The development of CT can prepare nurses with the necessary skills and dispositions (habits of mind, attitudes, and traits) to support EBP. The intents of this study were to explore the importance of CT as an essential skill needed to support EBP and to describe some of the strategies and processes that are considered key to the ongoing development of CT. Evidence-based practice is defined and its importance/value in nursing is highlighted to fulfill these aims. Second, CT is defined and its elements are described while pointing out how these relate to EBP. Specific attention is placed on examples of required skills and dispositions for CT. Lastly, key strategies and processes that scholars purport to contribute to the development of CT are described. DEFINING EBP AND ITS IMPORTANCE TO NURSING Since the establishment of evidence-based medicine at McMaster University in the 1980s, several authors have offered definitions for EBP (French, 2002). Despite the varied definitions used for EBP, the core components of evidence, clinical expertise, and patient values deemed important by these authors are included. For example, the definition by Sackett, Straus, Richardson, Rosenberg, and Hynes (2000, p. 1), bas the integration of best research evidence with clinical expertise and patient valuesq to facilitate clinical decision making, has been used as the basis of the work of several researchers and clinicians (DiCenso, Guyatt, & Ciliska, 2005; Jeniceck & Hitchcock, 2005). The Sigma Theta Tau International [STTI] (2003) defines evidence-based nursing 364 Journal of Professional Nursing, Vol 21, No 6 (November/December), 2005: pp

2 CT AND EBP 365 as ban integration of the best evidence available, nursing expertise, and the values and preferences of the individuals, families and communities who are served.q The STTI identifies some conditions for this to occur: nurses have to access the latest research and consensus of expert opinions and must be skilled to use their judgment in planning and providing care in consideration of cultural and personal values and preferences. The Canadian Nurses Association (2002, p. 1) defines EBP as ba continuous interactive process involving the explicit [precise], conscientious [careful, thorough] and judicious [well thought-out, well judged] consideration of the best available evidence to provide care.q As is evident from these pragmatic definitions, the focus is primarily on the best ways to find and apply research evidence. For the purpose of this article, EBP refers to the integration of the best research evidence with clinical expertise and patient values (Jeniceck & Hitchcock, 2005) within the context of local environments and available resources. Patient values refer to each individual s unique preferences, concerns, and expectations related to clinical decisions (Sackett et al., 2000). Evidence-based practice has been deemed important and valuable for nursing in many levels. First, it advances the quality of care provided by nurses and increases the satisfaction of patients as recipients of that care (Glanville, Schirm, & Wineman, 2000). Evidence-based practice refocuses nursing practice from routines, tasks, and opinion-driven decisions based on tradition or habit to practices that have been subjected to critical appraisal and substantiated by evidence, in particular, research evidence (Gagan & Hewitt-Taylor, 2004; Sams, Penn, & Facteau, 2004; Shapiro & Driever, 2004; Zeitz & McCutcheon, 2003). Youngblut and Brooten (2001) suggest that EBP provides opportunities for individualized, more effective, streamlined, and dynamic nursing care and that it augments effective clinical judgment. In addition, EBP is viewed as a way to reduce the research practice gap (Cobban, 2004; Hutchinson & Johnston, 2004), which has been identified as an ongoing issue in nursing. SUPPORTING EBP Sackett et al. (2000) view EBP as a two-stage process. First, they assert that there is the question of generating evidence, which relies heavily on science. Second, there is the issue of using the evidence, the art of nursing. According to these authors, both involve logic and CT. Jeniceck and Hitchcock (2005, p. 62) also assert that bgood evidence is not everything. It s also essential to know how you use it. Good uses of evidence is everything.q Phrases within this definition, how to use it and good uses, imply that evidence has to be effectively implemented in practice for it to be helpful. To do so, professional nurses need specific skills. According to DiCenso et al. (2005, p. 6), the necessary skills required for EBP consist of the capacity to... define a patient problem precisely and ascertain what information is required to resolve the problem, to conduct an efficient search of the literature, to select the best of the relevant studies, to apply rules of evidence to determine their validity, to extract the clinical message, to determine how the patient s values affect the balance between advantages and disadvantages of the available management options, to involve the patient appropriately in the decision, and to implement and evaluate the management plan. Jeniceck and Hitchcock (2005) point to similar components and suggest that locating the best research evidence needed for EBP (i.e., discriminating high-quality studies from unsound ones) is often a challenge for nurses. DiCenso (2003) remarked that achieving and maintaining these skills require intensive and frequent study and time. Inherent in the activities already outlined are several skills including the use of questions, critical appraisal, application, and evaluation skills that are influenced by and necessary for CT. A closer look into one of these skills, questioning, reveals the reciprocal relationship it shares with CT. Jeniceck and Hitchcock (2005) believe that effectively framed questions can serve nurses well when faced with these challenges. This claim is shared by Udod and Care (2004), Profetto-McGrath, Bulmer Smith, Day, & Yonge (2004), and Young (2003). Questioning is a skill that can be learned and serves to activate CT and to be an indicator of its use (Browne & Keeley, 1994; Loy, Gelula, & Vontver, 2004). Questions can be used to challenge what is heard, observed, read, and experienced by students and nurses in practice (Profetto-McGrath et al., 2004). Well-articulated questions are important in facilitating EBP in that they direct nurses to necessary evidence, reveal gaps in the present evidence, and assist nurses in gathering the evidence necessary to solve a patient problem or to support best practices (Foster, 2004; Kee & Bickle, 2004; Twibell, Ryan, & Hermiz, 2005). Young (p. 11) stresses that, bnurses must become confident enough in their role to question whether common practice is best practice.q

3 366 Young and Profetto-McGrath also believe that nurses need nurturing to be curious or inquisitive. It is this curiosity that partly fuels nurses search for best practices; this is best reflected in the questions they ask. Curiosity is congruent with CT and can only thrive within a questioning culture that fosters rather than stifles curiosity. A questioning culture, whereby nurses are encouraged to question their practice and thus confirm whether their activities are indeed supported by evidence, is needed in organizations (Cullen, Greiner, Greiner, Bombei, & Comried, 2005; Profetto-McGrath et al., 2004; Tanner, 1999; Udod & Care, 2004). The importance of CT in EBP has been introduced in the above discussion. The ensuing discussion focuses on answering the following questions so that this relationship could be further understood and appreciated: What is CT? How does CT support EBP? What key strategies serve to develop, facilitate, and sustain CT? CRITICAL THINKING Although CT can be traced back to the work of ancient philosophers such as Aristotle, renewed interest has been given to CT since the 1980s as evidenced by the hundreds of new publications across health care disciplines, the offering of courses at colleges and universities, and the presentation at conferences related to this topic. The focus on CT has been fueled by the voices of several prominent philosophers, researchers, and educators in the field (e.g., Alfaro-LeFevre, Brookfield, Ennis, N. Facione, P. Facione, Fisher, Glaser, Norris, Paul, and Scriven) who have focused on developing it from an abstract concept to an exceedingly practical and relevant aspect of everyday life encompassing academia and practice (Jeniceck & Hitchcock, 2005). Various definitions, goals, and components of CT have been stated by experts over the years based on divergent world views and perspectives (Jeniceck & Hitchcock, 2005; Profetto-McGrath, 2003). However, across the varied conceptualizations of CT offered by authors, many commonalities exist. Critical thinking involves reflection and, at times, suspension of judgement. It also involves evaluation and critical appraisal. It engages the skills of analysis and interpretation. The process of CT is oriented toward making judgments about many situations encountered on a daily basis. Critical thinking integrates JOANNE PROFETTO-MCGRATH knowledge and skills. It includes such skills as analysis, evaluation, and inference. However, knowledge and skills are insufficient for CT. To be effective, critical thinkers must also have the necessary dispositions (attributes, habits of mind, attitudes) to use knowledge and complement the skills. The ideal critical thinker is characterized as (APA, 1990, p. 3): Habitually inquisitive, well-informed, trustful of reason, open-minded, flexible, fair-minded in evaluation, honest in facing personal biases, prudent in making judgements, willing to reconsider, clear about issues, orderly in complex matters, diligent in seeking relevant information, reasonable in the selection of criteria, focused on inquiry, and persistent in seeking results which are as precise as the subject and the circumstances of inquiry permit. I believe that CT skills and dispositions are congruent with and needed for EBP and that both can be taught and fostered in baccalaureate nursing education programs as well as in practice settings. The ability to think critically builds the foundation for clinical decision making and assists students and nurses in thinking beyond routines and protocols (Erickson-Owens & Powell Kennedy, 2001). Critical thinking allows nurses to be reflective and critical in their daily practice and provides them with the confidence to be prudent in differentiating good practice from ineffective practice (Kim, 1999). In this light, the skill of analysis and the disposition of open-mindedness as components of CT should be considered. Analysis, one of the skills associated with CT, reveals an individual s comprehension and expression relative to the importance of various elements, situations, and meanings. First, an individual is able to achieve this comprehension by categorizing, decoding, and clarifying information. Second, analysis reflects the individual s ability to bidentify the intended and actual inferential relationship among statements, questions, concepts, and judgementsq (Facione & Facione, 1994, p. 9). Analysis includes the subskills of exploring ideas, discriminating claims, and examining arguments (Facione & Facione, 1994). Open-mindedness is defined as tolerance of divergent views and willingness to seriously entertain alternatives (Colucciello, 1997; Facione, 1997). An open-minded individual bis able and willing to form an opinion, or revise it, in the light of evidence and argumentq (Hare, 1985, p. 123). Sellman (2003) considers open-mindedness as a virtue for professional practice. He believes that the open-minded nurse

4 CT AND EBP 367 bis an educational aspiration and a practical imperativeq (p. 23). In opposition, he suggests that a closed-minded nurse will hold firm to a position or idea regardless of what the evidence indicates and discusses the notion that he or she may be incorrect. Furthermore, Sellman contends that nurses who are closed-minded oppose change based on the perception that current practice, even if outdated, has served them well in the past and will continue to serve them well in the future. For example, when using a specific protocol, a nurse who is open-minded will be open to the currency of the protocol as well as its suitability in the provision of care to a specific patient. Being so disposed, the nurse is likely to consider a number of options. Alternatively, a closed-minded nurse will be quick to follow the protocol despite its questionable validity and individual patient care needs (Sellman, 2003). In the study by Profetto-McGrath (2003) in which the relationship between the research utilization (RU) and the CT of 141 nurses across four hospitals was investigated, she found that open-mindedness was significantly correlated with overall, instrumental, and conceptual RU. In this study, overall RU referred to the use of any kind of research findings in any kind of way and in any aspect of the nurse s work. Instrumental RU was defined as the use of research findings in giving patient care or as part of interventions. To illustrate, a nurse may give pain medication every 3 4 hours for the first 24 hours postoperatively even if the patient does not request the medication this frequently. Also, conceptual RU was described as the use of research findings to change one s thinking or opinions about how patient care or situations should be approached (Estabrooks, 1997; 1999a, 1999b). Strategies and Approaches to Develop and Support CT Over the years, several strategies and approaches to develop and support CT have been reported in the literature. Based on an extensive review of unpublished and published work, Profetto-McGrath (1999) identified several categories of strategies and approaches important to CT. Staib (2003) also conducted a literature review between 1996 and 2002 using the CINAHL database and retrieved 17 articles related to CT strategies. Generally, the categories reported by both Profetto-McGrath and Staib included the following: (1) a variety of writing strategies such as scholarly papers, reflective journals, and critiques; (2) role modeling and questioning; (3) verbal strategies such as structured controversies and debates, clinical rounds, and simulations; (4) computer-assisted instruction; (5) concept maps; and (6) problem-based learning (PBL), to name a few. Although additional research is needed to build the evidence base in support of these strategies effectiveness in developing CT, there is sufficient evidence supporting the use of some of these strategies and approaches to warrant their inclusion in the discussion that follows. The following discussion focuses on several of the most prevalent of these strategies, including PBL, reflective journals as an example of a written strategy, role modeling, and journal clubs, featured given their promise alone or in combination. Problem-Based Learning Problem-based learning is a teaching-and-learning strategy first developed and implemented in 1965 by the Faculty of Medicine at McMaster University (Neufeld, Woodward, & MacLeod, 1989). Students enrolled in PBL programs encounter real practice situations in the form of scenarios (case studies) that stimulate their learning (Williams, 2004). Using these real life scenarios, students learn how to formulate relevant questions, become adept at finding information from a variety of sources including peerreviewed journals, become skilled at appraising the quality and relevance of information related to the question or problem of interest or need, and are taught to fit this new information into their expanding knowledge (Lusardi, Levangie, & Fein, 2002). Problem-based learning as a process fosters the development and growth of CT, selfdirected learning, critical reflection, and cohesion between the discipline and the practice of nursing (Williams, 2004). A PBL approach in baccalaureate education can successfully support students development of CT skills necessary for effective EBP. Lusardi et al. (2002) and Williams (2004) believe that there are striking similarities between the goals and processes of PBL and those of EBP. These similarities readily facilitate the transition from the classroom to the practice setting relatively easily. Williams, an advocate and researcher of PBL, outlined how PBL can serve to develop critical reflection for professional practice that is congruent with CT skills and dispositions. Price and Price (2000) reported on how they used PBL within a maternal child health practice setting to enhance nurses professional development and CT.

5 368 Reflective Journals Reflection traditionally encompasses nurses buse [of] narrative[s] about care, specifically of their own experiences which enable them to appreciate episodes in a sensitive wayq (Price, 2004, p. 46). The most common form of reflection among nursing students and those in practice alike is the use of reflective journals. These journals take on a wide variety of forms, from daily writings to notes focusing on critical incidents in an attempt to personalize and reflect on experiences (Craft, 2005). It is hoped that, through these writings, nurses or students will borganize their thoughts;...set weekly goals;...communicate thoughts, fears, and skills; and experience an opportunity to think critically by connecting theory to practiceq (Ruthman et al., 2004). This exploration can be further enhanced by using technical reflection to link these experiences to developments in practice or the literature (Taylor, 2002). The effectiveness of reflective journals in increasing CT in nursing students has been studied by Fonteyn and Cahill (1998). Using the theoretical framework of Schon (1982), they studied the logs of third-year baccalaureate nursing students assigned to a variety of units in an acute care setting during one semester. Fonteyn and Cahill concluded that the students overall CT had improved. In particular, the students improved in the areas of pattern recognition, forming relationships, generating hypothesis and explanations, and drawing conclusions. The multiple benefits of reflective journals or logs have been supported by other authors (e.g., Baker, 1996; Brown & Sorrell, 1993; Sedlak, 1997). Role Modeling Role modeling is a source of learning for nursing students. Important role models include nurse educators because they spend a great deal of time with students in classes, seminars, laboratories, and clinical practice. They also work in collaboration with nurses in the field. Therefore, nurse educators need to be critical thinkers themselves and be able to create a learning environment that fosters CT, self-reliance and independence, and questioning (Dickerson, 2005). They should be competent in teaching in the academic and/or clinical setting (Erickson-Owen & Powell Kennedy, 2001; Profetto-McGrath, 2003). To role model and in so doing nurture CT, nurse educators need to assess their own CT abilities, reflect on their own teaching style, be willing to reconsider their teaching approaches, and demonstrate lifelong learning. In addition, educators must be aware of the most current best evidence supporting practice regardless of the setting where they work and, thus, be able to support and teach EBP to their students (Erickson-Owen & Powell Kennedy, 2001). Journal Clubs JOANNE PROFETTO-MCGRATH The development of CT and critical appraisal deemed important to EBP should not be restricted to academic endeavors. This goal can also be achieved with practitioners in a variety of practice settings through the establishment of journal clubs. Despite some challenges associated with the use of journal clubs (e.g., time and resources), several authors (Kessenich, Guyatt, & DiCenso, 1997; Koziol- McLain & Tanabe, 1996; Seymour, Kinn, & Sutherland, 2003; Tibbles & Sanford, 1994) espouse the importance of these clubs to develop CT and critical appraisal skills. At their most basic, journal clubs are bdiscussions between like-minded colleagues with a desire and enthusiasm to develop local practiceq by looking at current literature (Grant, 2003, p. 72). Journal clubs tend to have an informal style and focus on critical appraisals and discussion (Mazuryk, Daeninck, Neuman, & Bruera, 2002). Usually, an individual will serve as a moderator and provide a brief analysis of an article and then lead a discussion of its meaning and implication. Many journal clubs have developed in such a way that any number of professionals may present research from their field to a wider team of health care providers (Khan, Dwarakanath, Pakkal, Brace, & Awonuga, 1999). Journal clubs have also been formed specifically among groups of nurses. Generally, journal clubs sponsor EBP and CT by introducing nurses to new developments and a wider perspective on health care. This increases their ability to critically review and interpret research (Goodfellow, 2004). Wright (2004, p. 10) believes that they add bcontext and a purpose for...information,q often rekindling scientific curiosity. Several authors also suggest that journal clubs increase reading habits among nurses, build critical appraisal skills, and lead to increased mentoring among colleagues (Grant, 2003; Khan et al., 1999; Mazuryk et al., 2002). They facilitate bprofessional development and lifelong learningq by broadening outlook and providing a safe forum for the expression of ideas (Grant, 2003, p. 73). Although not widely reported in the literature, journal clubs could be formed to bring educators, students, and nurses together in practice settings as a way to bridge academia and practice.

6 CT AND EBP 369 Conclusion For all of the voices calling for EBP, the bnursing literature is relatively silent on the issue of how best to teach and evaluate the skills required for EBPQ (Fineout-Overholt & Johnston, 2005, p. 38). Although a number of components are needed to support EBP, the importance of CT in supporting EBP was explored in this article, along with those strategies and processes considered key to the ongoing development of CT. Critical thinking encompasses skills and dispositions that are needed regardless of the nature of the evidence used by nurses, the sources from which such evidence are drawn, and the settings for its application. As Fineout-Overholt and Johnston (pp ) point out: One starting place for the paradigm shift from evidence generators to evidence users is for educators to consider how they think about research and other evidence, as this highly influences how they communicate EBP concepts to nurses. Educators can foster excitement about research and communicate its applicability, or they can foster indifference to, and even dislike for, the subject. Student nurses and nurses who are critical thinkers constitute an effective aspect of the overall movement toward effectively implementing EBP. Critical thinking skills must be taught, supported, and nurtured in undergraduate nursing education programs and in all settings where nurses practice. Critical thinking and EBP must be explicitly connected and implicitly integrated for nurses starting in their basic nursing education programs, built upon in their continuing education programs, and fostered throughout their lifetime. Acknowledgment I thank Michael Taylor (RA) for his assistance with the literature searches and the editorial work. References American Philosophical Association. (1990). Critical thinking: A statement of expert consensus for purposes of educational assessment and instrument. The Delphi Report: Research findings and recommendations prepared for the committee on pre-college philosophy. Newark, DL: Author. Baker, C. R. (1996). Reflective learning: A teaching strategy for critical thinking. Journal of Nursing Education, 35, Brown, H. N., & Sorrell, J. M. (1993). Use of clinical journals to enhance critical thinking. Nurse Educator, 18, Browne, M. N., & Keeley, S. M. (1994). Asking the right questions A guide to critical thinking. 4th ed. New Jersey: Prentice Hall. Canadian Nurses Association. (2002). Evidence-based decision making and nursing practice. Ottawa: Author. Cobban, S. J. (2004). Evidence-based practice and the professionalization of dental hygiene. International Journal of Dental Hygiene, 2, Colucciello, M. L. (1997). Critical thinking skills and dispositions of baccalaureate nursing students A conceptual model for evaluation. Journal of Professional Nursing, 13, Craft, M. (2005). Reflective writing and nursing education. Journal of Nursing Education, 44, Cullen, L., Greiner, J., Greiner, J., Bombei, C., & Comried, L. (2005). Excellence in evidence-based practice: Organizational and unit exemplars. Critical Care Nursing Clinics of North America, 17, DiCenso, A. (2003). Evidence-based nursing practice: How to get there from here. Nursing Leadership, 16, DiCenso, A., Guyatt, G., & Ciliska, D. (2005). Evidence-based nursing. A guide to clinical practice. St. Louis, MO: Elsevier Mosby. Dickerson, P. S. (2005). Nurturing critical thinkers. Journal of Continuing Education in Nursing, 36, Erickson-Owens, D. A., & Powell Kennedy, H. (2001). Fostering evidence-based care in clinical teaching. Journal of Midwifery & Women s Health, 46, Estabrooks, C. A. (1997). Research utilization in nursing: An examination of formal structure and influencing factors. Unpublished doctoral dissertation. University of Alberta, Edmonton, Canada. Estabrooks, C. A. (1999a). The conceptual structure of research utilization. Research in Nursing & Health, 22, Estabrooks, C. A. (1999b). Modeling the individual determinants of research utilization. Western Journal of Nursing Research, 21, Facione, N. C. (1997). Critical thinking assessment in nursing education programs: An aggregate data analysis. Millbrae: The California Academic Press. Facione, N. C., & Facione, P. A. (1994). The California Critical Thinking Skills Test and the National League for Nursing. A resource paper. Millbrae, CA: California Academic Press. Fineout-Overholt, E., & Johnston, L. (2005). Teaching EBP: A challenge for educators in the 21st century. Worldviews on Evidence-Based Nursing, 2, Fonteyn, M. E., & Cahill, M. (1998). The use of clinical logs to improve nursing students metacognition: A pilot study. Journal of Advanced Nursing, 28,

7 370 Foster, R. L. (2004). Challenges in teaching evidencebased practice. Journal for Specialists in Pediatric Nursing, 9, French, P. (2002). What is the evidence on evidencebased nursing? An epistemological concern. Journal of Advanced Nursing, 37, Gagan, M., & Hewitt-Taylor, J. (2004). The issues for nurses involved in implementing evidence in practice. British Journal of Nursing, 13, Glanville, I., Schirm, V., & Wineman, N. M. (2000). Using evidence-based practice for managing clinical outcomes in advanced practice nursing. Journal of Nursing Care Quality, 15, Goodfellow, L. M. (2004). Can a journal club bridge the gap between research and practice? Nurse Educator, 29, Grant, M. J. (2003). Using research in practice: Journal clubs for continued professional development. Health Information and Libraries Journal, 20, Hare, W. (1985). In defense of open-mindedness. Montreal: McGill University Press. Hutchinson, A. M., & Johnston, L. (2004). Bridging the divide: A survey of nurses opinions regarding barriers to, and facilitators of, research utilization in the practice setting. Journal of Clinical Nursing, 13, Jeniceck, M., & Hitchcock, D. L. (2005). Evidence-based practice. Logic and critical thinking in medicine. Chicago: AMA Press. Kee, F., & Bickle, I. (2004). Critical thinking and critical appraisal: The chicken and the egg? Quarterly Journal of Medicine, 97, Kessenich, C. R., Guyatt, G. H., & DiCenso, A. (1997). Teaching nursing students evidence-based nursing. Nurse Educator, 22, Khan, K. S., Dwarakanath, L. S., Pakkal, M., Brace, V., & Awonuga, A. (1999). Postgraduate journal club as a means of promoting evidence-based obstetrics and gynaecology. Journal of Obstetrics and Gynecology, 19, Kim, H. S. (1999). Critical reflective inquiry for knowledge development in nursing practice. Journal of Advanced Nursing, 2, Koziol-McLain, J., & Tanabe, P. (1996). Reviewing the research literature: You don t have to do it alone. Journal of Emergency Nursing, 22, Loy, G. L., Gelula, M. H., & Vontver, L. A. (2004). Teaching students to question. American Journal of Obstetrics and Gynecology, 191, Lusardi, M., Levangie, P. K., & Fein, B. (2002). A problem-based learning approach to facilitate evidencebased practice in entry-level health professional education. Journal of Prosthetics and Orthotics, 14, Mazuryk, M., Daeninck, P., Neuman, C. M., & Bruera, E. (2002). Daily journal club: An education tool in palliative care. Palliative Medicine, 16, Neufeld, V. R., Woodward, C. A., & MacLeod, S. M. (1989). The McMaster MD program: A case study in renewal in medical education. Academic Medicine, 64, Price, A. (2004). Encouraging reflection and critical thinking in practice. Nursing Standard, 18, JOANNE PROFETTO-MCGRATH Price, A., & Price, B. (2000). Problem-based learning in clinical practice facilitating critical thinking. Journal of Nurses in Staff Development, 16, Profetto-McGrath, J. (1999). Critical thinking skills and critical thinking dispositions of baccalaureate nursing students. Unpublished doctoral dissertation, University of Alberta, Edmonton, Canada. Profetto-McGrath, J. (2003). The relationship of critical thinking skills and critical thinking dispositions of baccalaureate nursing students. Journal of Advanced Nursing, 43, Profetto-McGrath, J., Bulmer Smith, K., Day, R. A., & Yonge, O. (2004). The questioning skills of tutors and students in a context based baccalaureate nursing program. Nurse Education Today, 24, Ruthman, J., Jackson, J., Cluskey, M., Flannigan, P., Folse, V. N., & Bunten, J. (2004). Using clinical journaling to capture critical thinking across the curriculum. Nursing Education Perspectives, 25, Sackett, D. L., Straus, S. E., Richardson, W. S., Rosenberg, W., & Hynes, R.B. (2000). Evidence-based medicine: How to practice and teach EBM (2nd ed.). Edinburgh, Scotland: Churchill Livingstone. Sams, L., Penn, B. K., & Facteau, L. (2004). The challenge of using evidence-based practice. Journal of Nursing Administration, 34, Schon, D. (1982). The reflective practitioner. San Francisco: Jossey-Bass. Sedlak, C. A. (1997). Critical thinking of beginning baccalaureate nursing students during the first clinical course. Journal of Nursing Education, 36, Sellman, D. (2003). Open-mindedness: A virtue for professional practice. Nursing Philosophy, 4, Seymour, B., Kinn, S., & Sutherland, N. (2003). Valuing both critical and creative thinking in clinical practice: Narrowing the research practice gap? Journal of Advanced Nursing, 42, Shapiro, S. E., & Driever, M. J. (2004). Clinical decision rules as tools for evidence-based nursing. Western Journal of Nursing Research, 26, Sigma Theta Tau International. (2003). Sigma Theta Tau International s position statement on evidence-based nursing. Retrieved May 10, 2005, from nursingsociety.org/research/main.html#ebp. Staib, S. (2003). Teaching and measuring critical thinking. Journal of Nursing Education, 42, Tanner, C. A. (1999). Evidence-based practice: Research and critical thinking. Journal of Nursing Education, 38, 99. Taylor, B. (2002). Technical reflection for improving nursing and midwifery procedures using critical thinking in evidence based practice. Contemporary Nurse, 13, Tibbles, L., & Sanford, R. (1994). The research journal club: A mechanism for research utilization. Clinical Nurse Specialist, 8, Twibell, R., Ryan, M., & Hermiz, M. (2005). Faculty perceptions of critical thinking in student clinical experiences. Journal of Nursing Education, 44, Udod, S. A., & Care, D. W. (2004). Setting the climate for evidence-based nursing practice: What is the leader s role? Nursing Leadership, 17,

8 CT AND EBP 371 Williams, B. (2004). Creating cohesion between the discipline and practice of nursing using problem based learning. International Journal of Nursing Education Scholarship, 1, Wright, J. (2004). Journal clubs Science as conversation. New England Journal of Medicine, 351, Young, K. M. (2003). Where s the evidence? American Journal of Nursing, 103, 11. Youngblut, J. M., & Brooten, D. (2001). Evidencebased nursing practice: Why is it important? AACN Clinical Issues, 12, Zeitz, K., & McCutcheon, H. (2003). Evidence-based practice: To be or not to be, this is the question! International Journal of Nursing Practice, 9,