Critical Thinking at the Bedside

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Ruth R. Robert, MSN, RN, FNP-C, CMSRN, PCCN, is Director of Education and Research, Baylor Medical Center at Garland, Garland, TX.

Sandra Petersen, DNP, APRN, FNP-BC, GNP-BC, PMHNP, is Associate Professor, University of Texas, Tyler, TX.

Critical Thinking at the Bedside: Providing Safe Passage to Patients

B etween the categories of logi-cal and illogical opinions liesreasoned opinion. This pro - cess has dominion over emotion and focuses equally on process and out- come; it is called critical thinking (Paul & Elder, 2008). Critical thinking skills are widely sought in modern society. They can play an important role in various types of decision mak- ing: making a judgment about educa- tion, choosing a career, evaluating a job, deciding how to organize at work, and choosing a life partner (Paul & Elder, 2006).

The word critical derives etymo- logically from two Greek roots: kriti- cos (discerning judgment) and kriteri- on (standards). Etymologically, the word implies the development of “ discerning judgment based on stan- dards” (Online Etymology Dictionary, n.d., para 1). The intellectual roots of critical thinking applied to the practice of teaching were planted by Socrates 2,500 years ago. Socrates’ practice was followed by the critical thinking of Plato, Aristotle, and the Greek skeptics (Knight, 2007).

The concept of critical thinking has become widespread in literature and has been studied in various set- tings. In general, U.S. corporations focus on applying creative organiza- tional structures and information systems to promote critical thinking. In the 1980s, critical thinking gained widespread recognition as a behav- ioral science construct in the educa- tion system. In 1988, the nation’s governors adopted the National Educational Goals, identifying criti- cal thinking as a core skill. In 1990, the Secretary’s Commission to Achieve Necessary Skills and the publication of America’s Choice: High

Skills or Low Wages focused national attention on the importance of criti- cal thinking. Critical thinking skills and the study of behaviors are also woven into economic models of business productivity and policy- making across the globes (Thaler, 2012).

In an updated discussion, Ennis (2011) defined critical thinking as, “Reasonable reflective thinking focused on deciding what to believe or do” (para 1). Critical thinking “explicitly aims at well-founded judg- ment and hence utilizes appropriate evaluative standards in the attempt to determine the true worth, merit, or value of something” (Merriam Webster Dictionary On line, n.d., para. 1). Watson and Glaser (1980) viewed critical thinking not only as cognitive skills, but also as a compos- ite of skills, knowledge, and atti-

tudes. Glaser first published on criti- cal thinking in the 1940s. His ideas, now considered the cornerstones of dialog about critical thinking, were developed as early as 1925. In 1964, he and colleague Watson developed the Watson-Glaser Critical Thinking Appraisal (WGCTA), a multiple choice critical thinking test designed to measure the critical thinking sub- skills: inference, recognition of as - sumptions, deduction, interpretation, and evaluation of arguments (Adams, Whitlow, Stover, & Johnson, 1996; Watson & Glaser, 1991).

McPeck (1981), whose definition revolves around two critical thinking components (the context of discov- ery and justification), was often at odds with Watson and Glaser in his opinions, arguing that skill and propensity in a realm of reflective skepticism rather than knowledge,

Ruth R. Robert Sandra Petersen

The critical thinking ability of health care professionals can affect patient safety directly (Buerhaus, Donelan, Ulrich, Norman, & Dittus, 2005). The National League for Nursing (NLN, 2006) expects nursing graduates to be able to demonstrate critical think- ing. Nursing programs are required to measure critical thinking as an outcome criterion for accreditation. This process of program accreditation is considered an indicator that a professional program offers a quality product. Based on NLN expectations, health care disciplines should diligently seek opportunities to enhance critical thinking by promoting qualitative and quantitative research that focuses on curriculum evaluation, enhancing educators’ and facul- ty knowledge, and improving patient care outcomes.

Instructions for Continuing Nursing Education Contact Hours appear on page 92.

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attitudes, and skills define the boundaries of critical thinking. Kurfiss (1988), in a radically different premise, sought to establish the notion that critical thinking is asso- ciated with the justification of beliefs. Others, such as Beyer (1990), Bell (1991), and Brookfield (1987), suggested variations on the themes proposed by Watson and Glaser, and McPeck.

Perhaps most familiar to educators is Bloom’s Taxonomy. Bloom described major areas in the cogni- tive domain. This information was drawn from the Taxonomy of Educational Objectives, Handbook 1: Cognitive Domain (Bloom, 1956). The taxonomy begins by defining knowledge as the remembering of pre- viously learned material. Knowledge, according to Bloom, represents the lowest level of learning outcomes in the cognitive domain. Knowledge is

followed by comprehension, the ability to grasp the meaning of material and exceeds the knowledge level. Comprehen sion is the lowest level of understanding. Application is the next area in the hierarchy and refers to the ability to use learned material in new and concrete principles and theories. Application requires a higher level of understanding than comprehension.

Meyer Vigilance in Nursing Model: Critical Thinking in Nursing

Jones (2010) proposed critical thinking extends beyond problem solving; it reflects a wider perspec- tive, focused on increasing efficiency and efficacy in practice. The Meyer (2002) Vigilance in Nursing Model similarly uncovered the meaning of critical thinking in nursing practice (see Figure 1) by describing the men-

tal processes, or vigilance, nurses use to differentiate the significant from the non-significant observations made with regard to patients.

In a grounded theory study of women with migraine headaches, for example, vigilance was conceptual- ized as “the art of watching out,” predicated on a particularized knowl- edge of the condition in each respon- dent (Meyer, 2002). Vigilance result- ed in a decision to intervene or not. Vigilance was not seen, felt, or heard by others. It was only through the action that resulted from watching out that others could infer vigilance had occurred. The elements of vigi- lance derived in the migraine study have proved to have relevance in nursing: attaching meaning to what is, anticipating what might be, calcu- lating risks, readiness to intervene, and monitoring the results of inter- vention.

FIGURE 1. Professional Nursing Vigilance Model of Critical Thinking in Nursing Practice

Source: Adapted from Meyer & Lavin (2005)

Nursing Knowledge Base

Assessment Diagnosis Intervention

Attaching meaning to what it is

Calculating the risk

Saying ready to

act

Monitoring results/

outcomeAnticipating what it is

Professional Nursing Vigilance

Informed Nursing Action

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Nurses continually use logical rea- soning to project and monitor the achievement of patient outcomes (Rew & Barrow, 2007). Because nurs- es are with patients around the clock, they are charged with moni- toring the results of their own inter- ventions as well as the interventions of others. A common example is seen in a physician’s request for information about a patient’s response to interventions for digox- in-related cardiac arrhythmias. In order to answer, a nurse must have followed a process that includes monitoring the effectiveness of actions and making judgments about what interventions work or do not work in specific situations. By doing so, the nurse can promote safe patient care and build the multifac- eted knowledge base described by Benner (1984) as critical thinking, a characteristic of expertise in nursing (Meyer, 2002; Rew & Barrow, 2007).

Purpose and Methods The purpose of this review is to

provide an analysis of the concept of critical thinking and identify its importance to nurses as they attempt to make sound clinical deci- sions in their provision of patient care. A compilation of literature from nursing, medicine, public health, and education as well as a formal def- inition from Merriam Webster’s Dictionary were used to define criti- cal thinking. A literature review across multiple disciplines was con- ducted from 1940 to 2012 to explore and convey knowledge and ideas regarding critical thinking since the beginning of its popularity in the 1940s. Although the concept of criti- cal thinking dates over 2,500 years to Socrates, effort was made to define guiding concepts and examine the evolution that represents the con- cept’s more recent history. In addi- tion, inquiries were made for sources published 1940-2012 through data bases such as CINAHL (Cumulative Index to Nursing and Allied Health Literature), Ovid, Medline, and PubMed. Key words and phrases included the following: critical think- ing, nursing curriculum, critical think-

ing evaluation instruments, skills, nurs- ing care, strategies, and nursing and concept analysis. The key words and references were chosen specifically to present the reader with a picture of the state of knowledge and the major questions regarding the con- cept of critical thinking.

The method used for the concept analysis was taken from Walker and Avant (2005). The eight-step process provides a structured way to analyze the concept of critical thinking. Adhering to Walker and Avant’s model, uses of the concept were iden- tified, defining attributes, antece - dents, and consequences. Various cases were constructed, and empirical referents for nursing were defined.

Synonyms for Critical Thinking

The synonyms that can be used interchangeably with critical include afflictive, crucial, decisive, essential, urgent, vital, analytical, diagnostic, penetrating, reproachful, acute, conclu- sive, consequential, exceptive, high-pri- ority, integral, momentous, pivotal, pressing, risky, significant, and strategic (Online Etymology Dictionary, n.d.).

Synonyms for Thinking The synonyms for thinking

include introspective, meditating, cog- nition, contemplation, idea, introspec- tion, judgment, logic, musing, opinion, rationalization, reasoning, meditative, philosophical, intellectualize, brains, reflect, resolve, and revolve (Thesaurus Online, n.d.).

Attributes Defining attributes are character-

istics of a concept that appear repeat- edly in the literature, and they should be grouped to create a clear picture of what composes the con- cept (Walker & Avant, 2005). From a review of literature and the various definitions of critical thinking, 10 defining attributes were identified: (a) recognizing a unique situation that needs further evaluation; (b) defining a set of criteria for analyzing ideas; (c) using reasoned judgment to evaluate a situation; (d) recogniz- ing personal assumptions and biases; (e) remaining open-minded and flexible; (f) purposefully viewing the

situation from all possible angles; (g) selecting the best solution based on personal knowledge and level of experience; (h) having the willingness to take a risk and implement a deci- sion; (i) displaying self-confidence in implementing the selected solution; and (j) being willing to alter opinions when new facts are presented and committed to excelling for better out- comes (Petress, 2004).

Background of the Concept

Improving patient safety through the integration of critical thinking in education and practice has always been important within the profes- sion of nursing, so much so the National League of Nursing mandat- ed its measurement as an outcome criterion for accreditation in 2006. Turner (2005) identified the evolu- tion of the concept of critical think- ing through a review of the literature from 1981 to 2001, finding hun- dreds of definitions and attributes related to the concept. Literature published 1981-1991 for this analy- sis only contained seven articles about critical thinking in nursing. These articles addressed 36 critical thinking attributes and five surro- gate terms. Over the next 10 years (1992-2002), the number of pub- lished articles grew to 401. These ref- erenced 162 attributes and 43 surro- gate terms.

The critical thinking ability of health care professionals can have a direct effect on patient safety (Buerhaus, Donelan, Ulrich, Norman, & Dittus, 2005). Critical thinking is influential in almost all health care disciplines, including physical thera- py (Vendrely, 2005), occupational therapy (Velde, Wittman, & Vos, 2006), nursing education (Romeo, 2010; Zygmont & Schaefer, 2006), and nursing practice (Raterink, 2008). In evidence-based nursing, a lack of conceptual clarity surrounds the concept of critical thinking in both education and practice. A survey of 11 deans or directors of nursing pro- grams, 82 nurse administrators, 117 nurse educators, and 23 new and 96 experienced baccalaureate nursing

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graduates showed critical thinking was listed consistently among the most important competencies but was ranked as the lowest observed competency (King, Smith, & Glenn, 2003).

The need for a clear understand- ing of the construct of critical think- ing across disciplines led a commit- tee of the American Philosophical Association (APA) to undertake a project in 1987 to achieve a consen- sus definition of critical thinking. The APA Delphi Report focused on the conceptualization of critical thinking by a consensus of 46 experts, composed of theorists, edu- cators, and specialists in critical thinking assessment, over a 22- month period (Facione, 1990a).

The consensus definition of criti- cal thinking, as defined by the APA Delphi report, confirmed in 1994 by a replication study commissioned by the U.S. Department of Education Office of Educational Research and Instruction and conducted by Pennsylvania State University’s National Center on Post-Secondary Teaching, Learning, and Assessment, was endorsed strongly in terms of its descriptions of both the skills and disposition of critical thinkers (Jones & Radcliff, 1994). The APA Delphi consensus definition, along with the U.S. Department of Education Office of Educational Research and Instruction replication study, has at least established some agreement on a definition of critical thinking. A consensus needed to be achieved to identify the constructs of the term adequately and develop appropriate measures for evaluating the con- structs in the educational arena.

Critical thinking (CT), as defined by the APA Delphi Report, was expressed in the following state- ment:

We understand critical thinking to be purposeful, self-regulatory judgment which results in inter- pretation, analysis, evaluation, and inference, as well as explana- tion of the evidential, conceptu- al, methodological, criteriologi- cal, or contextual consideration upon which that judgment is based. CT is essential as a tool of inquiry. As such, CT is a liberat-

ing force in education and a pow- erful resource in one’s personal and civic life. While not synony- mous with good thinking, CT is a pervasive and self-rectifying human phenomenon. The ideal critical thinker is habitually inquisitive, well-informed, trust- ful of reason, open-minded, flex- ible, fair-minded in evaluation, honest in facing personal biases, prudent in making judgments, willing to reconsider, clear about issues, orderly in complex mat- ters, diligent in seeking relevant information, reasonable in selec- tion of criteria, focused in inquiry, and persistent in seeking results which are as precise as the subject and the circumstances of inquiry permit. Thus, educating good critical thinkers means working toward this ideal. It combines developing CT skills with nurturing those dispositions which consistently yield useful insights and which are the basis of a rational and democratic soci- ety. (Facione, 1990b, p. 2)

In spite of these earlier efforts to solidify thought, a consensus defini- tion of critical thinking has remained elusive. Katoaka-Yahiro and Saylor (1994), Daly (1998), and Petress (2004) suggested critical thinking is a pervasive term that seldom is defined clearly or comprehensively. A num- ber of authors have contributed to the abundance of definitions and interpretations of critical thinking (Brookfield, 1987; Ennis, 2011; McPeck, 1981; Paul, 1990; Perry, 1970; Watson & Glaser, 1964). It has been viewed as an examination of assumptions (Brookfield, 1987; Meyers, 1986); as a composite of knowledge, attitudes, and applica- tion skills (Meyers, 1986; Paul, 1993; Watson & Glaser, 1980); as a reflec- tive thinking process (Dewey, 1933; Ennis, 2011; Mezirow, 1991); and as cognitive skills and dispositions (Facione, 1991).

Various definitions reflect some unique elements, but some common themes exist. The definitions estab- lish the connectivity between critical thinking and knowledge, cognitive skills, complex reasoning, argumen- tation, beliefs, action, problem iden-

tification, evidence, and the recogni- tion of alternative frames of refer- ence and possibilities (Daly, 1998). Early proponents of critical thinking reflected a skills perspective with associated lists of cognitive skills, while opponents to the skills per- spective advocated a skills and dispo- sitions approach (Brookfield, 1987; Paul 1993). McPeck (1990), in appo- sition to both approaches, claimed critical thinking was not transferable across domains and was associated with appropriate knowledge about the field along with disposition toward critical thinking. Health care leaders have subsequently employed a number of measures to assess criti- cal thinking and further define the term by incorporating critical think- ing skills in models illustrating the ideal health care practitioner (Velde et al., 2006; Vendrely, 2005).

Despite evolution in the defini- tion of critical thinking, ambiguity still exists about the meaning of the term and confusion remains about appropriate synonyms for discussion, including critical inquiry, clinical rea- soning, clinical judgment, problem- based learning, and nursing process (Myrick, 2002). Varied critical think- ing definitions and perspectives have been proposed, with some authors including cognitive skills and atti- tudes in their description (Profetto- McGrath, 2003). Other writers have posited that critical thinking includes investigation and reflection on all aspects of clinical problems to decide appropriate interventions (Bowles, 2000). Morrison and Free (2001) asserted that critical thinking encom- passes assessment and multi-logical thinking as inherent in the ability to relate to patients and effectively apply concepts to clinical scenarios. Giancarlo, Blohm, and Urdan (2004) noted, “Critical thinking is widely recognized as an essential compo- nent of education and a powerful and vital resource in one’s personal and civic life” (p. 347). According to Case (2005), “Every curriculum doc- ument mentions critical thinking, and there is universal agreement about the need to make thoughtful judgments in virtually every aspect of our lives – from who and what to believe to how and when to act”

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(p. 45). Facione (2006) suggested crit- ical thinking skills include the ability to analyze, synthesize, infer, and evaluate situations. Critical thinking is viewed most importantly as a process rather than an endpoint or objective (Petress, 2004).

Nursing professionals are increas- ingly exhorted to demonstrate mas- tery of critical thinking skills. Shirrell (2008) noted critical thinking has been considered an essential nursing competency since 1997, yet the abil- ity to teach critical thinking has remained a controversial issue. As a case in point, Facione (2006) argued critical thinking skills can be taught and learned. On the other hand, Case (2005) stated he “is disheart- ened by the failures to teach critical thinking” (p. 45). Results of Tanner’s (2005) research about teaching stu- dents to think critically were incon- clusive, revealing no consistent rela- tionship between teacher critical thinking and student critical think- ing. It is important for nurses to develop critical thinking, problem solving, and reflective practice tech- niques to expand their clinical decision-making skills (Hoffman, Donoghue, & Duffield, 2004). Schol - ars have studied various strategies, techniques, and tools utilized to enhance the learning experience and engagement in critical thinking processes. Facione (2006) found existing tools measure critical think- ing in general but do not capture the context-dependent aspects of critical thinking in health care disciplines.

A more recent exploration of crit- ical thinking assessment in nursing began with a pilot in 2008 of the California Critical Thinking Dispo - sition (CCTD) with nursing students in Taiwan (Tao & Cui, 2007; Zhang & Lambert, 2008). Twenty-nine Likert items were developed initially through literature review and focus group interview. Subjects of this study consisted of 135 nursing stu- dents at the largest nursing universi- ty in Taiwan. Four of these items with item total correlation less than 0.3 were deleted. Remaining items were grouped into the following fac- tors: clarification of problem, ration- al action, and critical evaluation. Results showed this instrument pos-

sesses acceptable expert content validity. Concurrent validity was shown by positive correlation with CCTD (r=0.617, p<0.01). Internal reliability was shown by Cronbach’s alpha 0.75 for total instrument and 0.75, 0.77, 0.76 for three factors accordingly. This measurement of critical thinking ability in nursing process with 25 items and three fac- tors has acceptable validity and relia- bility. Further testing with more het- erogeneous subjects is needed, how- ever, to explore the impact of critical thinking ability in nursing practice and the patient care environment.

Cases of a Critical Thinking Focus in Practice

A Model Case A model case provides an exam-

ple of the concept and demonstrates its defining attributes (Walker & Avant, 2005). The following example offers a model case of critical think- ing in nursing practice. A nurse is reviewing the cardiac monitors for 30-year-old Jacob, admitted to the telemetry floor for cellulitis of the leg. Jacob had a peripherally inserted central catheter (PICC) in place to allow infusion of broad-spectrum antibiotics. He had no previous his- tory of cardiac problems, but the nurse noticed frequent runs (4-5 beats) of ventricular tachycardia. The nurse entered the room and assessed the patient. He told the nurse that since his PICC was inserted, he felt fluttering in his chest with any movement. In reflecting on this finding, the nurse reviewed the radi- ologist’s report after the PICC inser- tion. The X-ray showed a PICC in the right ventricle rather than in the superior vena cava, so the nurse immediately called a doctor and explained the concerns. The physi- cian arrived quickly and adjusted the PICC catheter, and the patient’s ven- tricular tachycardia resolved. Two days after completing his course of antibiotics, the patient was dis- charged to his home in stable condi- tion.

This model case contains all the defining attributes of critical think- ing. The nurse demonstrated knowl-

edge of the case as a whole by con- sidering all the signs and symptoms. The antecedents of a search for understanding truth and the recep- tivity of critical thinking that feel safe are evident in the safe passage of the patient from the hospital setting to home. The consequences of verifi- cation of critical thinking through reasoning are seen in the nurse’s final diagnosis and intervention on behalf of the patient (Lunney, 2009).

A Borderline Case A borderline case is an example

that “contains most of the defining attributes of the concept being examined but not all of them” (Walker & Avant, 2005, p. 70). Reba, a pulmonary unit nurse, was assigned to take care of Ms. Brown. Reba knew Ms. Brown, whom she had transferred from the pulmonary unit to the medical-surgical unit the previous day. Ms. Brown was being treated for acute exacerbation of chronic obstructive pulmonary dis- ease. She was glad to see a familiar face and was able to build rapport with Reba, even though she was wearing a bivalve intermittent posi- tive airway pressure (BiPAP) device. Ms. Brown suffered from shortness of breath if the BiPAP had to be removed to feed or bathe her, and her color became dusky. According to Reba, this was not a new experi- ence for the patient, and she always improved after taking deep breaths. During this episode, Reba thought that Ms. Brown was not looking good, but a check of her vital signs showed they were normal, so she felt comfortable with Ms. Brown’s condi- tion. Near the end of the shift, how- ever, the patient became very anx- ious and began complaining of increased restlessness and shortness of breath. Reba recalled that when Ms. Brown was in the pulmonary unit, she frequently had heightened anxiety episodes with increased shortness of breath and hypoxia. Reba, using knowledge gained when working in a specialized unit, inter- preted the patient’s behavior to be consistent with the theory that patients with chronic lung disease often need a hypoxic drive to sustain respiration. Following the physi-

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cian’s orders, the nurse treated the patient’s discomfort with intra- venous morphine 5 mg. The medica- tion order indicated the patient could receive 2-5 mg every 4 hours as needed for pain; no attempt was made to administer the lowest incre- ment ordered. From her previous experience, Reba was sure the extra sedation would ease Ms. Brown’s apprehension, thereby improving her breathing pattern. Unfortunately, at the change of shift, a patient techni- cian found Ms. Brown not breathing well, and the rapid response team call was initiated. The patient was trans- ferred to the intensive care unit.

This borderline case has some of the defining attributes of the con- cept of critical thinking but not all. Unfortunately, the nurse did not take the time to view the situation from all possible angles. She was able to grasp knowledge of the case as a whole by considering all the signs presented to her.

A Related Case Related cases contain ideas very

similar to the main concept, but they differ when examined closely (Walker & Avant, 2005). A novice nurse received Mr. Jones from the emergency department (ED) at 1:00 a.m. with a diagnosis of high blood pressure; the patient had a history of hypertension and chronic alco- holism. Mr. Jones was found in his apartment, semi-comatose with alcohol intoxication, and transport- ed to the ED. He lives alone and is a heavy drinker who is admitted fre- quently to the hospital. A physical assessment revealed the patient was alert and oriented in all three spheres, had stable vital signs (pulse 102 beats/minute, blood pressure 159/93 mm Hg, and temperature 98° F). His pupils were equal and reactive to light. However, the nurse believed something was wrong with the patient. He was very talkative, but his speech was slurred. The nurse did not believe this was related to his drinking. The nurse monitored him closely throughout the shift until he could be examined by the primary physician, a resident. Due to Mr. Jones’ inebriation, the examining doctor believed the behavior was

due to his alcohol consumption and determined the patient could be dis- charged. The nurse disagreed and discussed her concerns about Mr. Jones’ speech with the examining physician. The physician could not see any basis for her concerns and insisted Mr. Jones be discharged. Because Mr. Jones had been seen by a resident, the nurse then took the concern to the resident’s senior fac- ulty. The senior physician inter- vened and ordered Mr. Jones to be monitored for 1 more day. The next morning’s assessment revealed the patient was stable and he was dis- charged home. The nurse indicated great experience had been gained working on this unit, but was of the opinion that more collaboration between physicians and nurses and more focus on critical thinking would benefit patient outcomes. The nurse experienced what she believed to be a poor decision-making process and lack of attention to critical details that typically lead to ques- tioning of clinical practice and potentially poor patient outcomes (Lunney, 2009).

A Contrary Case A contrary case consists of a real-

world situation that does not fulfill the requirements of the concept of critical thinking. It meets none of the defining attributes (Walker & Avant, 2005). Mr. Sudan, age 82, had a history of congestive heart failure (CHF) and frequent arrhythmia. He was admitted to the outpatient surgi- cal unit after the placement of a pacemaker with an automatic inter- nal cardiac defibrillator. Mr. Sudan remained overnight for observation. When he was weighed the next morning, the nurse found he had gained 4 pounds in the previous 24 hours. Because the patient’s weight gain indicated a possible acute exac- erbation of CHF, the nurse should have done more than make a note in the patient’s chart. The patient was discharged home but was re-admit- ted within the next 24 hours with severe shortness of breath. This unusual finding shows an obvious antecedent to engaging in critical thinking. At a minimum, the nurse should have contacted the physician

to report a significant weight gain. With appropriate intervention, the patient’s re-admission to the hospital with worsening symptoms could have been prevented.

Antecedents and Consequences

Antecedents Antecedents are events or inci-

dents that must occur prior to the occurrence of the concept. In critical thinking, an antecedent’s initiating factors are occurrences or precursors that trigger a critical thinking episode (Walker & Avant, 2005). A positive or negative event can evoke critical thinking that causes the individual to question his or her knowledge, assumptions, and/or deep-rooted ideas and beliefs (Brookfield, 1987; Facione, 2006). Antecedents create a situation that requires a solution using a holistic perspective, engaging the holistic self. Antecedents for nurs- es related to the concept include analysis, engagement, reflection on and assessment of need, knowledge, communication, relationship, advo- cacy, accountability, judgment, evalu- ation, criticism, and environment conductive to caring. Antecedents for patients are need, illness, disharmo- ny, caring environment, and relation- ship (Lunney, 2009).

Consequences “Consequences are those events

or incidents that occur as a result of the occurrence of the concept – in other words, the outcomes of the concept” (Walker & Avant, 2005, p. 20). The consequences are a decision made to benefit the overall well- being of the individual. There is the assumption that engaging in critical thinking will yield some results; these results are the consequences of the concept of critical thinking. The positive consequences for nurses are self-satisfaction, trust in personal judgment, inner peace, increased job satisfaction, and increased personal and professional development. The positive consequences for patients are improved quality care, safe pas- sage, and healing (Lunney, 2009).

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Empirical Referents The final step in this concept

analysis of critical thinking is to identify the empirical referents that demonstrate how the concept is measured or determined to exist in the real world. “Empirical referents are classes or categories of actual phenomena that, by their existence or presence, demonstrate the occur- rence of the concept itself” (Walker & Avant, 2005, p. 7). Several stan- dardized tests are used to measure critical thinking skills of persons in health care and curriculum develop- ment. The most common are the Watson-Glaser Critical Thinking Appraisal (WGCTA), California Criti - cal Thinking Skills Test (CCTST), Ennis-Weir Critical Thinking Essay Test (EWCTE), and the Cornell Critical Thinking Test (Adams et al., 1996; Kaddoura, 2011).

In an integrative review of progress in the teaching of critical thinking to students in accredited nursing programs, 20 assessment studies were reported from 1977 to 1995 (Goodman, 2008).

Implications for Nursing and Nursing Education

Throughout her book, Lunney (2009) reinforced the most impor- tant endeavor in nursing education as the teaching of critical thinking. However, before effective teaching can occur, nursing leaders and edu- cators must agree on a clear, work- able definition of critical thinking. This will help to maintain consisten- cy of instruction and provide nurs- ing faculty with an outline for struc- turing courses (Kaddoura, 2011; Kataoka-Yahiro & Saylor, 1994). Zygmont and Schaefer (2006) as - sessed critical thinking skills of nurs- ing faculty, and their results indicat- ed considerable variance in their ability to think critically; many had not reached the intellectual level needed for critical thinking. These findings support a direct relationship between the ability of students to engage in critical thinking and the ability of faculty as critical thinkers. Nursing faculty must have both a clear understanding of critical think-

ing and personal critical thinking ability in order to prepare strong nurse generalists to promote safe passage to patients (Seymour, Kinn, & Sutherland, 2003).

Implications for Nursing Practice

Literature consistently indicates critical thinking is essential in arriv- ing at decisions that promote patient well-being (Raterink, 2008; Romeo, 2010; Zygmont & Schaefer, 2006). Nurses engaged in critical thinking must be able to utilize holistic patient characteristics – including family, environment, social, and political implications – to arrive at the optimal solution (Lunney, 2009; Thurmond, 2001). Fero, Witsberger, Wesmiller, Zullo, and Hoffman (2009) assessed criti- cal thinking learning needs of 2,144 new and experienced nurses by showing 10 videotaped case vig - nettes from the Performance-Based Development System, a tool devel- oped by Dorothy del Bueno in the mid-1980s to assess critical think- ing, interpersonal, and technical skill sets among health care pro - viders. Results indicated 25% of the participants did not meet expecta- tions in critical thinking. Areas of deficiency included initiating inde- pendent nursing interventions, dif- ferentiating urgency, reporting es - sential clinical data, anticipating relevant medical orders, providing relevant rationale to support deci- sions, and recognizing problems.

Raterink (2008) conducted nurse focus groups to explore various enhancers and barriers to critical thinking. Findings indicated nurses believe critical thinking strategies build confidence, provide flexibility, allow for better organization, and develop their ability to better handle difficult situations. The enhancing factors included teamwork, staff and administrative support, variety, and acuity of patients. The main barriers were too much paperwork; lack of teamwork; heavy patient assign- ments; overtime with no coverage; and, criticism from co-workers, patients, and their family members.

Critical Thinking at the Bedside: Providing Safe Passage to Patients

Clinical implications of this study included an emphasis on staff devel- opment.

Implications for Nursing Research

Despite several recurrent themes related to critical thinking, no single clear definition has been identified (Kataoka-Yahiro & Saylor, 1994; Paul & Elder, 2008; Ruminiski & Hanks, 1995). There is a great need to explore how practice can nurture and develop critical thinking skills among health care providers. Another major challenge is lack of discipline-specific assessment and evaluation tools related to the criti- cal thinking concept. Gaps found in the literature include lack of descrip- tive research on patients’ and family members’ perceptions of the impor- tance of their nurses’ and physicians’ critical thinking ability in preventing medical errors and promoting safety. Research to date has shown inconsis- tencies in multidisciplinary critical thinking definitions, assessments and evaluation tools, and instruc- tion (Paul & Elder, 2008). These areas of quality patient care need to be explored further through research.

Conclusion Nurses must be able to think crit-

ically to face the challenges of today’s burgeoning technological advances, and ensure safe passage and positive outcomes for patients. Case-based instruction that en - hances opportunities to become skilled at critical thinking may be the best method to develop such skills, which may impact nursing care and improve patient outcomes. Assess - ment of critical thinking skills and, indeed, the definition of what com- prises critical thinking in the field of nursing remain somewhat elusive, although strides have been made. Ultimately, regardless of method or definition, solid, reasonable, organ- ized, strategic thinking enhances the nursing experience for both the pro- fessional nurse and the patient.

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REFERENCES Adams, M., Whitlow, J., Stover, L., & Johnson,

K. (1996). Critical thinking as an educational outcome: An evaluation of current tools of measurement. Nurse Educator, 21(3), 23-32.

Beyer, B.K. (1990). What philosophy offers to the teaching of thinking? Educational Leadership, 47(5), 55-60.

Bell, E.A. (1991). Debate: A strategy for teach- ing critical thinking. Nurse Educator, 16(2), 6-7.

Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison- Wesley Publishing Company.

Bloom B. (1956). Taxonomy of educational objectives, handbook I: The cognitive domain. New York: David McKay Co., Inc.

Bowles K. (2000). The relationship of critical- thinking skills and the clinical judgment skills of baccalaureate nursing students. Journal of Nursing Education, 39, 373- 376.

Brookfield, S.D. (1987). Developing critical thinkers: Challenging adults to explore alternative ways of thinking and acting. Maidenhead, England: Open University Press.

Buerhaus, P., Donelan, K., Ulrich, B., Norman, L., & Dittus, R. (2005). Hospital RNs’ and CNOs’ perceptions of the impact of the nursing shortage on the quality of care. Nursing Economic$, 23(5), 214-221.

Case, R. (2005). Bringing critical thinking to the main stage. Education Canada, 45(2), 45-46.

Daly, W.M. (1998). Critical thinking as an out- come of nursing education. What is it? Why is it important to nursing? Journal of Advanced Nursing, 28(2), 323-331.

Dewey, J. (1933). How we think: A restate- ment of the relation of reflective thinking to the educative process. Boston, MA: D.C. Heath.

Ennis, R. (2011). The nature of critical think- ing: An outline of critical thinking disposi- tions and abilities. Retrieved from http://faculty.education.illinois.edu/rhen- nis/documents/TheNatureofCriticalThink ing_51711_001.pdf

Facione, P.A. (1990a). The Delphi report: Executive summary. Millbrae, CA: California Academic Press. Retrieved from http://assessment.aas.duke.edu/ documents/Delphi_Report.pdf

Facione, P.A. (1990b). Critical thinking: A state- ment of expert consensus for purposes of educational assessment and instruction. The Delphi report: Research findings and recommendations. Washington, DC: American Psycho logical Association.

Facione, P.A. (1991). Using the California Critical Thinking Skills Test in research, evaluation, and assessment. Springfield, VA: United States Department of Education.

Facione, P.A. (2006). Critical thinking: What it is and why it counts. Retrieved from www. insightassessment.com/CT-Resources/ Independent-Critical-Thinking-Research/

pdf-file/Critical-Thinking-What-It-Is-and- Why-It-Counts-PDF

Fero, L.J., Witsberger, C.M., Wesmiller, S.W., Zullo, T.G., & Hoffman, L.A. (2009). Critical thinking ability of new graduate and experienced nurses. Journal of Advanced Nursing, 65, 139-148.

Giancarlo, C., Blohm, S., & Urdan, T. (2004). Assessing secondary students’ disposi- tion toward critical thinking: Development of the California Measure of Mental Motivation. Educational Psychology and Measurement, 64(2), 347-364.

Goodman, W. (2008). Critical-thinking assess- ment: A case applying resampling to ana- lyze the sensitivity of a hypothesis test to confounding. Retrieved from http://www. bentley.edu/centers/files/csbigs/good man.pdf

Hoffman, K., Donoghue, J., & Duffield, C. (2004). Decision-making in clinical nurs- ing: Investigating contributing factors. Journal of Advanced Nursing, 45(1), 53- 62.

Jones, J.J. (2010). Developing critical thinking in the perioperative environment. Association of Peri-Operative Registered Nurses (AORN) Journal, 91(2), 248-256.

Jones, B., & Radcliff, J.L. (1994). National center of post-secondary teaching, learn- ing and assessment, The Pennsylvania State University. U.S. Department of Education‟s Office of Educational Research and Improvement Grant No. R117610037, CFDA No. 84, 117G.

Kaddoura, M. (2011). Critical thinking skills of nursing students in lecture-based teach- ing and case-based learning. Inter - national Journal for the Scholarship of Teaching and Learning, 5(2). Retrieved from http://academics.georgiasouthern. edu/ijsotl/v5n2/articles/PDFs/Kaddoura. pdf

Kataoka-Yahiro, M., & Saylor, C. (1994). A crit- ical thinking model for nursing judgment. Journal of Nursing Education, 33, 351- 356.

King, M.S., Smith P.L., & Glenn, L.L. (2003). Entry-level competencies needed by BSNs in acute health care agencies in Tennessee in the next 10 years. Journal of Nursing Education, 42(4), 179-181.

Knight, K. (2007). Aristotelian philosophy: Ethics and politics from Aristotle to MacIntyre. Cambridge, United Kingdom: Polity Press

Lunney, M. (2009). Critical thinking to achieve positive health outcomes: Nursing case studies and analyses (2nd ed.). Ames, IA: Wiley-Blackwell.

Meyer, G.A. (2002). The art of watching out: Vigilance in women who have migraine headaches. Qualitative Health Re - search, 12(9), 1220-1234.

Meyer, G., & Lavin, M.A. (2005). Vigilance: The essence of nursing. The Online Journal of Issues in Nursing, 10(3), 8.

Meyers, C. (1986). Teaching students to think critically. San Francisco, CA: Jossey Bass.

Mezirow, J. (1991). Transformative dimen- sions of adult learning. San Francisco, CA: Jossey-Bass.

Instructions For Continuing Nursing

Education Contact Hours Critical Thinking at the Bedside: Providing Safe

Passage to Patients

Deadline for Submission: April 30, 2015

MSN J1307

To Obtain CNE Contact Hours 1. For those wishing to obtain CNE con-

tact hours, you must read the article and complete the evaluation through AMSN’s Online Library. Complete your evaluation online and print your CNE certificate immediately, or later. Simply go to www.amsn.org/library

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Objectives This continuing nursing educational (CNE) activity is designed for nurses and other health care professionals who are interest- ed in critical thinking at the bedside. For those wishing to obtain CNE credit, an evaluation follows. After studying the infor- mation presented in this article, the nurse will be able to: 1. Describe the concept of critical thinking. 2. Discuss the relationship of critical think-

ing to patient safety. 3. Analyze cases of critical thinking in prac-

tice. 4. Explain the implications of critical think-

ing for nursing practice, education, and research.

Note: The authors, editor, and education director reported no actual or potential conflict of interest in relation to this continuing nursing education article.

This educational activity has been co-provid- ed by AMSN and Anthony J. Jannetti, Inc.

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March-April 2013 • Vol. 22/No. 2 93

McPeck, J. (1981). Critical thinking in educa- tion. New York, NY: St. Martin’s Press.

McPeck, J. (1990). Teaching critical thinking: Dialogue and dialectic. New York: Routledge.

Merriam Webster Online Dictionary (11th ed.). (n.d.). Critical thinking. Retrieved from http://www.merriam-webster.com/dictio nary/critical thinking

Morrison, S., & Free, K.W. (2001). Writing mul- tiple-choice test items that promote and measure critical thinking. Journal of Nursing Education, 40(1), 17-24.

Myrick, F. (2002). Preceptorship and critical thinking in nursing. Journal of Nursing Education, 41(4), 154-164.

National League for Nursing (NLN) Accrediting Commission. (2006). Accreditation man- ual and interpretive guidelines by pro- gram type for postsecondary and higher degree programs in nursing. New York, NY: Author.

Online Etymology Dictionary. (n.d.). Critical. Retrieved from www.etymonline.com/ index.php?search=critical+&search- mode=none

Paul, R. (1990). Critical thinking: What every person needs to survive in a rapidly changing world. Rohnert Park, CA: Center for Critical Thinking and Moral Critique.

Paul, R. (1993). Critical thinking: What every person needs to survive in a rapidly changing world. Santa Rosa, CA: Foundation for Critical Thinking.

Paul, R., & Elder, L. (2006). Critical thinking tools for taking charge of your learning and your life. Upper Saddle River, NJ: Prentice-Hall Publishing.

Paul, R., & Elder, L. (2008). The miniature guide to critical thinking: Concepts and tools. Tomales, CA: Foundation for Critical Thinking Press.

Perry, W.G., Jr. (1970). Forms of intellectual and ethical development in the college years; a scheme. New York, NY: Holt, Rinehart and Winston.

Petress, K. (2004). Critical thinking: An extend- ed definition education. Journal of Nursing Education, 36(1), 46-48.

Profetto-McGrath, J. (2003). The relationship of critical thinking skills and critical thinking dispositions of baccalaureate nursing stu- dents. Journal of Advanced Nursing, 43(6), 569-577.

Raterink, G. (2008). A descriptive inquiry of the definitions of critical thinking and enhancers and barriers reported by nurs- es working in long-term care facilities. The Journal of Continuing Education in Nursing, 39(9), 407-412.

Rew, L., & Barrow, E.M. (2007). State of the sci- ence: Intuition in nursing, a generation of studying the phenomenon. Advanced Nursing Science, 30(1), E15-25.

Romeo, E.M. (2010). Qualitative research on critical thinking and predicting nursing stu- dents’ NCLEX-RN performance. Journal of Nursing Education, 49(7), 378-386.

Ruminiski, H.J., & Hanks, W.E. (1995). Critical thinking lacks definition and uniform evaluation criteria. Journalism and Mass Communication Educator, 50(3), 4-11.

Seymour, B., Kinn, S., & Sutherland, N. (2003). Valuing both critical and creative thinking in clinical practice: Narrowing the research-practice gap? Journal of Advance Nursing, 42(3), 288-296.

Shirrell, D. (2008). Critical thinking as a predic- tor of success in an associate degree nursing program. Teaching and Learning in Nursing, 3(4), 131-136.

Tanner, C.A. (2005). What have we learned about critical thinking in nursing? Journal of Nursing Education, 44(2), 47-48.

Tao, X., & Cui, Y. (2007). Study on the correla- tion between learning style and academ- ic achievement of nursing students. Journal of Nursing Science, 22, 7-9.

Thaler, R. (2012, July 7). Watching behavior before writing the rules. New York Times, BU4. Retrieved from: http://www.ny times.com/2012/07/08/business/behav ioral-science-can-help-guide-policy-eco- nomic-view.html?ref=economics&_r=0

Thesaurus Online. (n.d). Thinking. Retrieved from http://thesaurus.com/browse/think ing

Thurmond, V.A. (2001). The holism in critical thinking: A concept analysis. Journal of Holistic Nursing, 19(4), 375-389.

Turner, P. (2005). Critical thinking in nursing education and practice as defined in the literature. Nursing Education Perspective, 26(5), 272-277.

Velde, B.P., Wittman, P.P., & Vos, P. (2006). Development of critical thinking in occu- pational therapy students. Occupational Therapy International, 13, 49-60.

Vendrely, A. (2005). Critical thinking skills dur- ing a physical therapist professional edu- cation program. Journal of Physical Therapy, 19(1), 55-59.

Walker, L., & Avant, K. (2005). Strategies for theory construction in nursing (4th ed.). Norwalk, CT: Appleton & Lange.

Watson, G., & Glaser, E.M. (1964). Watson- Glaser critical thinking appraisal. New York, NY: Harcourt, Brace and World.

Watson, G., & Glaser, E.M. (1980). Watson- Glaser critical thinking appraisal. San Antonio, TX: Psychological Corporation.

Watson, G., & Glaser, E. (1991). Watson- Glaser Critical Thinking Appraisal manu- al. Kent, OH: The Psychological Corporation, 29.

Zhang, H., & Lambert, V. (2008). Critical think- ing dispositions and learning styles of baccalaureate nursing students from China. Nursing and Health Sciences, 10, 175-181.

Zygmont, D.M., & Schaefer, K.M. (2006). Assessing the critical thinking skills of faculty: What do the findings mean for nursing education? Nursing Education Perspectives, 27(5), 260-268.

ADDITIONAL READINGS Angel, B., Duffey, M., Belyea, M. (2000). An

evidence-based project for evaluating strategies to improve knowledge acquisi- tion and critical thinking performance in nursing students. Journal of Nursing Education, 39(5), 219-228.

Applegate, M.H. (1998). Curriculum evalua- tion. In D.M. Billings & J.A. Halstead, (Eds.), Teaching in nursing: A guide for faculty (pp. 179-208). Philadelphia, PA: W.B. Saunders.

Beckie, T.S., Lowry, L.W., & Barnett, S. (2001). Assessing critical thinking in baccalaure- ate nursing students: A longitudinal study. Holistic Nursing Practice, 15(3), 18-26.

Brown, J.M., Alverson, E.M., & Pepa, C.A. (2001). The influence of a baccalaureate program on traditional, RN-BSN, and accelerated students’ critical thinking abilities. Holistic Nursing Practice, 15(3), 4-8.

Brunt, B. (2005). Models, measurement, and strategies in developing critical-thinking skills. The Journal of Continuing Education in Nursing, 36(6), 255-262.

Coluciello, M.L. (1997). Critical thinking skills and dispositions of baccalaureate nurs- ing students – a conceptual model for evalulation. Journal of Professional Nursing, 13(4) 236-245.

Dexter, P., Applegate, M., Backer, J., Claytor, K., Keffer, J., Norton, B., & Ross, B. (1997). A proposed framework for teach- ing and evaluating critical thinking in nursing. Journal of Professional Nursing, 13, 160-167.

Emilio, G.A. (2000). Promoting critical thinking in professional military education. Retrieved from http://www.au.af.mil/au/ awc/awcgate/acsc/00-058.pdf

Ennis, R.H. (1962). A concept of critical think- ing. Havard Educational Review, 22(1), 81-111.

Facione, P.A., & Facione, N.C. (1992). The California critical thinking dispositions Inventory test manual. Millbrae, CA: California Academic Press.

Giancarlo, C.A., & Facione, P.A. (2001). A look across four years at the disposition toward critical thinking disposition among undergraduate students. The Journal of General Education, 50(1), 29-55.

Greg, J.B., & Renz, M.A. (1993). “Critical thinking” in teaching and directing the basic communication course. Dubuque, IA: Kendall/Hunt Publishing.

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press.

Kurfiss, J.G. (1988). Critical thinking theory, research, practice and possibilities. (ASHE-ERIC Higher Education Report No. 2). Washington, DC: Association for Study for Higher Education.

Lindeman, C. (1996). A vision for nursing edu- cation. Creative Nursing, 2(1), 5-6.

Magnussen, L., Ishida, D., & Itano, J. (2000). The impact of the use of inquiry-based learning as a teaching methodology on the development of critical thinking. Journal of Nursing Education, 39(8), 360-364.

Martin, C. (2002). The theory of critical think- ing of nursing. Nursing Education Perspectives, 23(5), 243-247.

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May, B.A., Edell, V., Butell, S., Doughty, J., & Langford, C. (1999). Critical thinking and clinical competence: A study of their rela- tionship in BSN seniors. Journal of Nursing Education, 38(3), 100-110.

McCarthy, P., Schuster, P., Zehr, P., & McDougal, D. (1999). Evaluation of criti- cal thinking in a baccalaureate nursing program. Journal of Nursing Education, 38(3), 142-144.

Papadimos, T.J. (2009). Reflective thinking and medical students: Some thoughtful distillations regarding John Dewey and Hannah Arendt. Philosophy, Ethics, and Humanities in Medicine, 4(5), 1-10.

Paul, R. (1995). Critical thinking: What every person needs to survive in a rapidly changing world. Santa Rosa, CA: Foundation for Critical Thinking.

Pepa, C.A., Brown, J.M., & Alverson, E.M. (1997). A comparison of critical thinking abilities between accelerated and tradi- tional baccalaureate nursing students. Journal of Nursing Education, 1, 46-48.

Proctor, P., Compton, W., Grossman, J., & Fanjiang, G. (2005). Building a better delivery system: A new engineering/health care partnership. Institute of Medicine and National Academy of Engineering. Washington, DC: The National Academies Press.

Rubenfeld, M.G., & Scheffer, B.K. (2006). Critical thinking TACTICS for nurses. Sudbury, MA: Jones and Bartlett.

Scheffer, B.K., & Rubenfeld, M.G. (2000). A consensus statement on critical thinking in nursing. Journal of Nursing Education, 39(8), 352-359.

Scott Tilley, D.D. (2008). Competency in nurs- ing: A concept analysis. The Journal of Continuing Education in Nursing, 39(2), 58-64.

Simpson, E., & Courtney, M. (2002). Critical thinking in nursing education: Literature review. International Journal of Nursing Practice, 8(2), 89-98.

Smith-Blair, N., & Neighbors, M. (2000). Use of the critical thinking disposition invento- ry (CCTDI) in critical care orientation. Journal of Continuing Education in Nursing, 31(6), 251-256.

Spelic, S.S., Parsons, M., Hercinger, M., Andrews, A., Parks, J., & Norris, J. (2001). Evaluation of critical thinking out- comes of a BSN program. Holistic Nursing Practice, 15(3), 27-34.

Tawari, A., Chan, S., Wong, E., Wong, D., Chui, C., Wong, A., & Patil, N. (2006). The effect of problem-based learning on students’ approaches to learning in the context of clinical nursing education. Nurse Education Today, 26(5), 430-438.

The Joint Commission (TJC). (2006). Root causes of sentinel events. Retrieved from http://www.jointcommission.org/ SentinelEvents/Statistics/

Theroux, J., & Kilbane, C. (2004). The real- time case method: A new approach to an old tradition. Journal of Education for Business, 79(3), 163-167.

Walsh, C.A., & Hardy, R.C. (1999). Dispositional differences in critical think- ing related to gender and academic major. Journal of Nursing Education, 38(4), 149-155.

Zori, S., & Morrison, B. (2009). Critical thinking in nurse manager. Nursing Economic$, 27(2), 75-80.

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