Delivering Value Through Evidence-Based PracticeMacias, Charles .docx

Delivering Value Through Evidence-Based Practice
Macias, Charles G; Loveless, Jennifer N; Jackson, Andrea N;
Srinivasan, Suresh. Clinical Pediatric Emergency Medicine;
Maryland Heights Vol. 18, Iss. 2, (2017): 89-97.
DOI:10.1016/j.cpem.2017.05.002
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Unwanted variation in care is a challenge to high-quality care
delivery in any healthcare system. Across the Emergency
Medical Services for Children (EMSC) continuum, there is wide
variation in care delivery for which best practices have
demonstrated opportunities to minimize that variation through
clinical standards (evidence-based pathways, protocols, and
guidelines for care). A model of development of clinical
standards is delineated and tools used in that process are
described. Implementation strategies for improving utilization
are also described with clinical decision support tools being a
promising strategy for accelerating uptake of guidelines.

Critical to implementing guidelines through improvement
science strategies is the ability to make iterative improvements
directed by data and analytics. The progression of sophistication
in a system's informatics and analytics capabilities is driven by
a maturity of data reporting to analytics that drives decision
support for implementing clinical standards. Integration of
financial data into the clinical standards processes and analytics
platforms is necessary to determine value of the work. Within
the EMSC continuum, a number of initiatives will drive national
clinical standards activities and are fueled by current pockets of
successful development and implementation activities within
organizations and systems.
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Health care organizations and our health care system as a whole
should be striving towards achieving high value. All
stakeholders in health care delivery systems benefit from
increased value including patients, providers, payers, and
suppliers who reap benefit from a stable and well-supported
system. As value is defined by outputs, measurement and
outcomes are critical to demonstrating increased value and
driving iterative improvement to achieve even greater value.
The relationship of outcomes relative to cost may define value,
and this has been popularized as a value equation where value is
equal to quality over cost (dollars spent).1,2
Quality itself has been defined as “the degree to which health
services for individuals and populations increase the likelihood
of desired health outcomes and are consistent with current
professional knowledge.”3 Professional knowledge implies
consideration for the best evidence to inform clinical decision-
making based on studies and scientific literature with a goal of
provision of the right care to the right child at the right time.

Evidence-based practice should not be construed to imply that
published or high quality scientific evidence is available to
inform all clinical questions, rather, that an evidence-based
model of care includes consideration for scientific evidence,
physician clinical expertise, patient and family values and
preferences, clinician preferences, and available resources
contextualized to the specific clinical care question for which a
recommendation will be derived.4
Variation and the emergency medical services for children
continuum
The Institute for Healthcare Improvement has suggested a triple
aim framework for optimizing health system performance: (1) a
better overall patient experience, (2) improving the health of a
population, and (3) delivering care at a better value.5
Application of the triple aim would be relevant for care
delivered across the pediatric emergency medicine (emergency
medical services for children or EMSC) care continuum.
Although thought of as beginning in prehospital or hospital
care, the EMSC continuum begins with an incident and involves
potentially multiple care venues and providers with ultimate
return of the patient to the community and their medical home
(Figure 1).
Health care has become increasingly complex, and variation in
care delivery has contributed to that complexity and potential
gaps in quality. The understanding that unwanted variation is
the enemy of quality has been attributed to W. Edwards
Deming, statistician, professor, and expert in quality
management,6 and can be applied to any type of care delivery,
including that within the EMSC continuum of care. Unwanted
variation in health care can contribute to waste, inefficiency and
ineffectiveness in providing diagnostic accuracy and therapeutic
reliability. Several studies across the pediatric emergency care
continuum have described wide variations in practice. In
prehospital care, Shah and colleagues described the prehospital
transport of 250 actively seizing children to 10 urban EDs in
which a wide variation in delivery of medication routes for

midazolam were noted with approximately half resulting in
dosing errors.7 Similar variation also has been noted in
utilization patterns for trauma specialty care for children with
moderate and severe injuries.8 Although variation in care
delivery for children treated in EDs has been well described,4
the association between this variation with cost and quality is
becoming increasingly highlighted. Data from the Pediatric
Health Information System, a comparative pediatric database
housed in the Children's Hospital Association, was used to
assess the management of 3 pediatric conditions treated in 21
hospital EDs (ie, gastroenteritis, asthma, and simple febrile
seizures). While wide variation in care was noted, higher costs
were not associated with better quality.9 ED based care also has
implications on the quality of care delivered in inpatient
settings. One study of children treated on inpatient units for
bronchiolitis noted variations in diagnostic testing and
management among 16 US hospitals that was unrelated to
patient demographics or severity of illness.10
Clinical standards in EMSC
Because unwanted variation can exist anywhere in the
continuum, a gap in quality can have the net effect of less than
optimal outcomes for the child. Aligning care with clinical
standards supported by systematic approaches to guideline
development will improve the probability that patient
populations will receive care based on the most current
professional knowledge. Clinical guidelines serve to synthesize
available evidence and bridge the gap between science and
clinical practice; not through rigid protocol adherence but by a
framework for care delivery, thus contributing to efficiency,
cost containment, and improved patient outcomes.11 Clinical
standards may refer to pathways, protocols, evidence-based
summaries, or full guidelines, and ideally are developed in a
patient-/family- centric manner in order to address care across
the continuum.
National attention for the need for evidence-based clinical
standards for prehospital care has been growing despite the

limited research on the direct benefits of existing prehospital
evidence-based guidelines (EBGs), mostly because of the wealth
of evidence to illustrate their contributions to improved
outcomes in other medical fields and other EMSC settings.12-14
One pediatric study used improvement science methodology to
improve adherence to national septic shock guidelines,
consequently demonstrating improvement in process and
outcome measures.15 A study of over 180,000 children with
gastroenteritis found that hospitals adhering to published
guidelines had 50% lower charges for ED or observation
patients without adverse effects on other outcomes.16
Guidelines for diagnosis and management of bronchiolitis both
in the ED and across the hospital continuum have been
associated with improved outcomes through decreases in
utilization of unnecessary testing and interventions, including
decreases in costs.17-21
Several organizations and systems have developed strategies for
minimizing unwanted variation in clinical care by utilizing
systematic approaches to development of evidence-based
clinical standards. Concurrently, they have described improved
processes and outcomes, many of which include reduced
costs.4,22-24 Thus, there is a plethora of experiential learning
from clinical standards work that is applicable to the EMSC
environment.
Developing clinical standards: One model
At Texas Children's Hospital/Baylor College of Medicine, the
Evidence-Based Outcomes Center has had a decade of
experience in the development and implementation of clinical
standards. The core elements of systematic clinical standards
development are described below and are applicable to any
venue of care.
Selection of a clinical topic can be determined by both
importance of outcomes (as defined by high prevalence, high
rate of morbidity and mortality, resource intensiveness, or wide
variation in care) and organizational readiness for improvement.
Internal data can help identify importance quantitatively,

especially when including cost of care for each disease process
being considered for clinical standards. Simply defined,
organizational readiness is the institutional member's
commitment to the complex change that might ensue from
development and implementation of the clinical standard;25
they must value the development process as well as the
potential in order to assure ongoing engagement for
development, implementation, and sustainability.
Guideline development teams should be created with a
multidisciplinary, “bottom up” approach to allow front line
content experts rather than authoritative leaders to voice all
opinions. Patient and family participation and feedback should
be incorporated into the guideline development process in order
to ensure that important clinical questions and outcomes to the
patients and their families are considered.
Determining the scope of the clinical standard, along with
patient inclusion criteria and exclusion criteria, is a prerequisite
to identifying the important clinical questions to be addressed.
Focused clinical questions should be brainstormed based on
areas of variation in care, new research availability, areas with
performance outcomes below benchmark, and/or identified
patient care concerns. Clinical questions should be presented in
Patient Intervention Comparison Outcome (PICO) format in
order to ensure searchable keywords and specific
recommendations (eg, in children with acute asthma in the ED
[P], do anticholinergic agents [I] versus standard albuterol care
[C] reduce admission rates [O]).26 Patient-centered outcomes
are preferred and should be rated on their degree of importance
to the patient. The Grading of Recommendations Assessment,
Development and Evaluation (GRADE) methodology currently
utilizes 3 categories for outcome rating (critical, important but
not critical, and limited importance). Outcomes of limited
importance are not included in the development of the clinical
standard as they should not have an effect on decision-making
related to patient care.27
A systematic search for existing national guidelines and

pertinent clinical research for each question should be
completed using research databases, evidence-based practice
websites, and professional organization websites (eg, American
Academy of Pediatrics, Agency for Healthcare Research and
Quality National Guideline Clearinghouse, or specialty specific
professional societies pertinent to the guideline topic).
Existing guidelines and clinical research should be critically
appraised utilizing an established appraisal method (eg, Texas
Children's Hospital has implemented the use of Appraisal of
Guidelines for Research and Evaluation II [AGREE II] and28
GRADE methodologies for guidelines and clinical research,
respectively29). With the review of evidence for each PICO
question, unambiguous practice recommendations will be
developed that give guidance to clinicians on the care of the
patient. Remarks outlining the values and preferences of the
patients, families, and providers can be incorporated into
recommendations, especially when the desired effects of an
intervention are closely balanced with the undesired effects.28
Where evidence is lacking, consensus amongst the guideline
development team is needed with transparent statements to
reflect the paucity of evidence.
Assessments of existing guidelines utilizing tools should be
transparently demonstrated in the guideline. AGREE II is a 23-
item instrument encompassing 6 domains: scope and purpose,
stakeholder involvement, rigor of development, clarity of
presentation, applicability, and editorial independence. Each
item is ranked on a 7-point Likert scale and the item ratings are
used to formulate an overall rating of the guideline quality.29
Ultimately, the guideline is either adopted, adopted with
modifications (most common), or rejected. Other tools in
addition to the AGREE II tool, such as the Institute of Medicine
Standards for Developing Trustworthy Clinical Practice
Guidelines, also exist.30,31
For each PICO question, studies should be critically evaluated
as a body of evidence using an appraisal tool, such as
GRADE.32 GRADE is a widely adopted global tool that allows

for a seamless, transparent process of translating the evidence
into clinically useful practice recommendations. Each practice
recommendation is categorized as strong or weak and is
supported by high, moderate, low, or very low-quality evidence.
Limitations in study design and execution, inconsistency
between studies, indirectness between the PICO question and
the studies, imprecision of the studies, and publication bias can
lower the overall quality of evidence. Large estimates of
treatment effect, evidence of a dose-response gradient, and
plausible confounding that would increase confidence in an
estimate of effect can raise the quality of evidence. The strength
of the recommendation is “the extent to which we can be
confident that adherence to the recommendation will do more
than harm.” It is formulated by weighing the risks versus the
benefits of the intervention and by considering the
patient/family values and preferences, quality of evidence,
importance of the outcome, ease of implementation, costs, and
resources.
Implementation of clinical standards
Implementation of clinical standards, described here briefly as
the context in which guidelines are implemented, is broadly
variable and literature for successful uptake specific to the
EMSC continuum is limited. With rare exception, the entirety of
guidelines or components of the guideline may represent the
shared baseline by which a quality improvement (QI) initiative
is driven. Nonetheless, opportunities in utilizing improvement
methodologies such as the Model for Improvement with its
embedded Plan-Do-Study-Act (PDSA) cycles are used at Texas
Children's Hospital (TCH) as the method of choice, although
many other methods are also incorporated.33 Iterative
improvements are discovered during the planning phase and
multiple QI tools are utilized to understand the workflow,
leverage points, metrics, and analytics to manage change and
drive improvement in outcomes. The Agency for Healthcare
Research and Quality suggests that a QI implementation team be
comprised of individuals connected to or a part of hospital

leadership, clinical experts in the intervention or disease
process of focus, persons proficient in QI methodology, and
influential personnel from the areas most affected by the
change.34 Critical to understanding the financial impact and
value of clinical standards is the incorporation of finance team
members into our implementation teams.
Factors that influence implementation success of clinical
standards have been described and include the following:35-40
Characteristics of the guideline that improve uptake:
a low complexity guideline (ie, easy to understand and use)
the scientific nature of the guideline being evidence-based
rather than lacking a scientific basis
development by the target group and stakeholders who will use
it
Characteristics of the implementation strategies that improve
success:
multifaceted, intensive strategies involving system redesign
Characteristics of professionals that will decrease success:
lack of familiarity or limited familiarity
lack of agreement with the clinical standard
younger age or less experience of the professional
Characteristics of patients that decrease uptake by the user:
patients who perceive no need for guideline recommendations or
reject them
patients with comorbidities
Environmental characteristics that decrease success:
limited time and personnel resources
limited perceived support from peers or superiors
Clinical decision support
Clinical decision support (CDS) built within the electronic
medical record (EMR) is a powerful means to leverage
guideline uptake. CDS encompasses a variety of approaches to
provide clinicians, staff, patients, and other users with timely,
relevant information that can improve decision making, prevent
errors, and enhance health and health care.41 Qualitative
research has defined 3 categories of CDS: (1) Alerting CDS:

alerts and reminders that fire to deliver information and
interrupt workflow; (2) Workflow CDS: eases data entry,
documentation, and resource location, and (3) Cognitive CDS:
provides a patient management and planning overview.42 CDS
tools and interventions include computerized alerts and
reminders, order sets, patient data reports and dashboards,
documentation templates, diagnostic support, and clinical
workflow tools.41 CDS tools allow for dissemination of the
right information to the right people at the right time. At TCH,
we offer our clinicians a plethora of CDS tools, including
algorithms, evidence-based order sets, suggestion records,
interdisciplinary plans of care (IPOCs), best practice alerts
(BPAs), and navigators. Suggestion records use discrete
variables from the patient chart to promote the use of evidence-
based order sets by passively suggesting targeted order set use
to the ordering clinician on the order entry screen.
Interdisciplinary plans of care display goal-driven interventions
for the entire care team. Best practice alerts are pop-ups that
prompt a clinician to address an issue before continuing and can
be programmed with hard stops.
Algorithms or flowcharts provide a visual representation of the
practice recommendations. Evidence-based order sets allow for
timely application of evidence at the bedside. Orders that are
supported by evidence can be defaulted and orders that are not
supported by evidence are intentionally omitted or listed last on
order lists if minimal evidence supports their use. For example,
chest radiographs for bronchiolitis are not offered on ED- based
bronchiolitis order sets, and generic oral antibiotic choices are
listed first on options for community- acquired pneumonia order
sets and other ED- based infectious disease related order sets.
Order sets may have hyperlinks to resources (eg, clinical
standard, algorithm, or other pertinent internal or external
resources) to provide transparency to CDS. In addition, clinical
and information services governance structures at Texas
Children's Hospital prohibit consensus- or silo-based order set
builds if an existing evidence-based order set exists.

The implementation of evidence-based order sets, clinical
guidelines, and QI interventions driven by a CDS tool for early
recognition of severe sepsis and septic shock at our institution
led to an improvement in a number of quality metrics. The
trigger tool, designed as a hard stop alert, had an 81%
sensitivity and 99.9% negative predictive value.43 After
implementation of the protocol, measurement of impact
compared to baseline data revealed significant improvements in
time from triage to first bolus (decrease from a median of 56 to
22 minutes) and triage to first antibiotics (decrease from a
median of 130 to 38 minutes).44
Analytics
As with all quality improvement initiatives such as the sepsis
example above, measurement is critical to defining success.
This would include demonstration of clinical, operational, and
financial measures (including process and outcome measures for
those domains) for quantifying value in clinical standards work.
The science of informatics (data plus meaning), as it relates to
pediatrics, must target population health (including ED care
within a continuum) It must simultaneously address the rising
costs associated with implementation and maintenance of
computerized systems of care coordination, while at the same
time contribute towards excellence in patient care.45 Analytics
(data plus information) plays a key role in predictive
assessment, clinical decision support, and various patient
throughput measures.46 To illustrate this, an initiative to create
and implement clinical standards for asthma included EMSC
related activities comprised of prehospital and hospital based
interventions that included early steroid delivery;
standardization of scoring scales and pathways linking protocols
for care; standardization of first line, adjunct, and second line
therapies; standardization of asthma action plans; and control
medication for persistent asthma from any acute venue of care
including emergent care settings. One component of the bundle
driven by the ED is illustrated in Figure 2A, where efforts to
decrease orders for unnecessary chest radiographs was targeted.

Comprehensive guidelines for care were implemented with
education, CDS, dashboard dissemination, and enhanced
communication strategies that included components pertinent to
the ED. As this bundle of activities aligned with the asthma
guideline also included inpatient, critical care, and outpatient
activities, the resultant decreases in length of stay, reductions in
unnecessary test ordering, reductions in readmissions, and other
improvements in clinically relevant quality metrics led to a
decrease in cost of care for the population of thousands of
children with asthma treated in our enterprise and is
demonstrated in Figure 2B.
In order to support the analytics capabilities necessary to
demonstrate improvements from clinical standards, health care
systems must drive increasing sophistication in informatics and
analytics. To meet this demand, data systems must move from
simple data gathering and reporting, as can be done from a
patient EMR report at the bedside, to aggregating and analyzing
data in populations or themes (data analytics), to predicting
patients at risk (predictive analytics), or linking health
observation with health knowledge to influence clinical
decisions (prescriptive analytics or clinical decision support).47
(See Figure 3). Although many EMRs are developing analytics
platforms that embed some of these capabilities into their
existing workflows, robust analytics must still overcome gaps in
interoperability and the sharing of data between relevant health
care systems to track data related to the health of a population.
Guidelines developed along a patient- centric model ideally
would be able to track metrics across systems, such as EMSC
entities; however, current limitations in technology and culture
for data sharing provide restrictions for understanding the
complete value of clinical standards implemented across a
system. Nonetheless, demonstrations of improvements in value
likely understate the true impact across an entire health care
system. At Texas Children's Hospital, the integration of data
across multiple entities linked to our institution (eg, health plan
data, pediatric practice data, hospital data, and prehospital data)

can be housed in our Enterprise Data Warehouse (EDW) to
encompass the EMR, financial information and staffing data,
and other sources of data across its infrastructure. Future
integration of health information exchanges, government hosted
databases, and other big data sources will aid in providing
analytics support for identifying opportunities for driving,
assessing impact, and iterating quality improvement initiatives
driven by clinical standards.
When assessing the impact on quality of evidence-based
guidelines and other clinical standards products clinical
outcomes as illustrated above are important, but these may be
linked to financial outcomes to establish value. At Children's
Hospital of Pittsburgh, a hospital aim to integrate actionable
analytics into the broader framework of disease management
targeted an existing appendicitis guideline (preoperative and
postoperative phases) as its initial project. A self-service web-
based tool provided measurement to provide clinical leaders and
administrators analytics accessible in their offices or at the
point-of-care. These interventions for guideline-driven care
across the care continuum led to a 25% reduction in the median
length of stay of patients with appendicitis, and also a
significant decrease in the controllable (direct) cost per case.
This illustrates that collection, analysis, and timely
dissemination of accurate clinical and throughput data aligned
with clinical pathways changed behavior and improved care
outcomes.48 Across the Texas Children's Hospital continuum,
from ED to inpatient units to discharge, the total cost savings
across a subset of 21 diseases for which guidelines were
available in fiscal year 2016 was a net difference of $33.5
million in variable direct costs, or the costs directly attributable
to the additional burden of care for the patient calculated
relative to the personnel time and resources consumed.
Summary and future directions
Clinical standards drive value in health care by improving
quality of care: removing unwanted variation in a system drives
reductions in waste, minimizes error, and improves throughput.

Systematically developed guidelines can be implemented
effectively utilizing best evidence for leveraging known
enablers and eliminating barriers to adoption. Across the EMSC
continuum, wide variations in practice have demonstrated
opportunities for clinical standards to improve value. These
strategies may include system- based clinical decision support
and local analytics platforms to drive iterative improvement
centered on such a shared baseline of care.
Across the EMSC continuum, we anticipate a continued growth
in clinical standards activities and improvement science
initiatives to develop and implement them as stakeholders
demand greater transparency in data, and attribution models for
best practices illustrate new opportunities for spread. Efforts to
support prehospital clinical standards development and
implementation have been driven and supported by a number of
agencies such as the National Highway Traffic Safety
Administration, the Health Resources Services Administration
through the EMSC program, the Federal Interagency Committee
on EMS, and the National EMS Advisory Council. Strategies
included the creation of a prehospital guidelines consortium, the
development, promotion and implementation of prehospital
evidence-based guidelines, education and research on
prehospital evidence-based guidelines, and standardization of
evaluation methods for prehospital evidence-based
guidelines.41 The greatest potential for establishing value of
clinical standards in prehospital work will likely emerge from
standardization of evaluation strategies to link outcomes to
local, regional, state, and federal efforts at implementing
pediatric prehospital evidence-based guidelines.
The EMSC federal program has recently supported a conversion
of its coordinating center to one embedded in improvement
science (EMSC Innovation and Improvement Center), of which
its initiatives includes efforts to minimize unwanted variation in
care (www.EMSCImprovement.center). One such initiative
includes a partnership with the American Academy of Pediatrics
for development of national ED- based evidence-based

pathways. To date, these have included publically accessible
pathways for septic shock, bronchiolitis, and community
acquired pneumonia.49Hospital-based efforts are currently
limited by gaps in data sharing across institutions to evaluate
outcomes and costs related to implementation of these
pathways. However, local implementation of these and other
evidence-based clinical standards products will likely continue
to describe the value of clinical standards in pockets across the
EMSC continuum. The Pediatric Initiative for Clinical
Standards (PICS), now in its second year, is moving from its
development of hospital-based guidelines activities within this
consortium of children's hospitals to a phase of data collection
on quality metrics in order to demonstrate value in clinical
standards implementation that will include components of ED
based care.
Although limitations to big data sharing will continue to limit
the nation's ability to demonstrate the aggregate value in
clinical standards across the EMSC continuum, demonstrated
successes in defining value for components of the system will
fuel more comprehensive and widespread approaches to
development and implementation. Ultimately, these patient
centric approaches to clinical standards work will continue to
drive improved outcomes of care, a better patient experience,
and decreased costs of care--achieving the triple aim.
Acknowledgements
Travis L. Rodkey, Ph.D., Outcomes Analyst, Outcomes and
Impact Service, Texas Children's Hospital, Houston, TX.
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29 J. Andrews, G. Guyatt, A. Oxman, GRADE guidelines: 14.

Going from evidence to recommendations: the significance and
presentation of recommendations, J Clin Epidemiol, Vol. 66,
2013, 719-725
30 S. Hollon, P. Areán, M. Craske, Development of clinical
practice guidelines, Annu Rev Clin Psychol, Vol. 10, Iss. 29,
2014, 213-241
31 National Academy of Sciences, Clinical practice guidelines
we can trust, Available at:, Accessed 4-29-17
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33 G. Langley, R. Moen, K. Nolan, The improvement guide: a
practical approach to enhancing organizational performance,
2009, Jossey-Bass, San Francisco, CA
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in hospitals, Available at:, Accessed 4-29-17
35 A.L. Francke, M.C. Smit, A.J. de Veer, P. Mistiaen, Factors
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36 M.S. Bauer, A review of quantitative studies of adherence to
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practice. A systematic review of theoretic concepts, practical
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1458-1465
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41 American Medical Informatics Association, Clinical
Decision Support, Available at:, Accessed 4-27-2017
42 J.E. Richardson, J.S. Ash, D.F. Sittig, Multiple perspectives
on the meaning of clinical decision support, AMIA Annu Symp

Proc, Vol. 2010, 2010, 1427-1431
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in pediatric septic shock, Pediatr Emerg Care, Vol. 28, 2012,
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2017, Available at:
49 American Academy of Pediatrics Section on Emergency
Medicine, Publications, Available at:, Accessed 4-14-17
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Ulen i
Outline
Thesis: Recycling should be strictly enforced by the government
and people should be penalized for not following regulations.
Introduction.Most states do not enforce recyclingBenefits of
recyclingReduce wasteEnvironmental considerationsRecycling
in the homeNot using recycling
binsContaminationProgramsEducation
Make recycling easierUlen 5
Anthony Ulen
R. Sullivan
Composition 1301
5 October 2019

Government Regulations on Recycling
Recycling has many benefits, unfortunately, many states
do not force people to recycle. Some states, Alaska for
example, have zero systems in place to get people to recycle;
other states, however, do provide recycling bins or charge a
refundable fee on aluminum cans, this is not enough. States
have undermined the problems the US have been facing when it
comes to recycling for over 70 years. Since we can’t leave it to
just a few volunteer agencies that offer recycling benefits and
accessibility, then ultimately it should just be enforced by the
federal government. Unless States or the federal government
take action nothing will change, landfills will continue to grow
and the environment will worsen. Recycling should be strictly
enforced by the government and people should be penalized for
not following regulations. This would increase revenue and
create jobs that would ultimately boost the economy. But, in
order for these things to take place the US government would
have to regulate the several harmful single use plastic
companies that have been thriving on the sales of their products
for decades without being held accountable for the impact
they’re leaving on the economy and the planet.
In order to understand why recycling needs to be strictly
enforced by some form of the government you first need to
understand the benefits of recycling. Reducing waste has
several beneficial factors; like the ability to decrease the carbon
footprint that we’re leaving for our children and future
generations. Second those harmful single use goods like
aluminum cans or beverage plastics can end up being re-used, to
decrease the amount of waste in landfills polluting the soil and
potentially the under-ground water system; or in the oceans
where they are for sure devastating the very delicate eco-system
that drives life on our planet. “More plastic has been created the
past decade than the past 100 years.” (Susan Freinkel). By the
government enforcing recycling that number can be brought
down. Recycling can also increase jobs within our own country
which would inevitably increase our way of life by living in a

cleaner environment in which to raise a family, or boost the
American economy.
The problem is that even if recycling bins are provided there is
nothing stopping people from throwing away recyclable goods.
If there was a law that penalized people for putting cans or
plastics in the proper bin this would cause people to be more
aware of their actions. It sounds harsh but if people are not
going to help take care of their country with keeping it clean
and trash free then it may just be a necessary evil. This could
be enforced from spot checks on bins looking for recyclable
material and the owner would be ticketed for not complying.
Another issue is that recyclable material is contaminated.
Several items like single use plastic water bottles, fast food
straws and aluminum cans begin emitting potentially harmful
toxins when exposed to direct sunlight or water. This could
change by households cleaning off what they are putting in the
bin and making sure they are not cross contaminating; and use
the same type of fine penalty. In an article from the weekly
states; “It's estimated that about 25 percent of American
recyclables are contaminated with food waste and non-
recyclable materials, according to the National Waste &
Recycling Association trade group.” (The recycling crisis).
Once a recyclable good is contaminated it can no longer be
recycled and then turns to waste. Creating a new law could
have an impact on not contaminating recyclable goods.
In the home is where recycling starts, and many households do
not make a conscious effort to recycle. This problem is mostly
the lack of education. Americans feel that if they put all their
garbage; glass, plastics, bio-degradable items, anything they
want, into a plastic bag and take that plastic bag to the end of
their driveway into their trash bins and the trash is collected
and taken away then the problem disappears. This mindset is
what has created this enormous problem that we could’ve fixed
if only we were more educated on the subject. In a study by the
National Waste and Recycling Association said that ’’One third
of Americans are not sure what can be recycled.” (Allan

Gerlat). Very little information on the benefits of recycling are
available to the public. If the state or federal government
emplaced laws at the household level recycling would increase.
Recycling really could make an enormous difference but before
it can be enforced it must be made available. This is one way to
make the recycling crisis go away, is if state or federal
governments actually made programs available to those who
actually want to make a difference by recycling and creating a
beret and cleaner country in which to live in. A cleaner waste
free country has enormous benefits for the environment.
Education is going to have the best impact for people to change
their ways and government enforced programs is the only way
to make this work because what current systems that are in
place are not working.
Work Cited
Gerlat, Allan. “Americans Can Benefit from More Recycling
Education – Study.” Waste360, 22 Apr. 2014,
https://www.waste360.com/research-and-statistics/americans-
can-benefit-more-recycling-education-study.
Staff, The Week. “The Recycling Crisis.” Image, The Week, 30
Mar. 2019, https://theweek.com/articles/831864/recycling-
crisis.
Freinkel, Susan. Plastic: a Toxic Love Story. Houghton Mifflin
Harcourt (HMH), 2011.

AU Did you use research material in this assignment? Research
is REQUIRED for this assignment.AU Do you have a Works
Cited page at the end of your essay with the title Works
Cited?AU Do you have three appropriate sources (see the
guidelines in this lesson) listed on the WC page?AU Are those
three sources cited in the paper using either paraphrases or
direct quotations?AU Did you define words, use a dictionary, or
use an encyclopedia? If so, those sources and information from
those sources must be removed. Most common words or words
used with their well-known definition do not need to be defined
in an essay. Dictionaries and encyclopedias are NOT
argumentative sources.AU Did you use MLA 8th edition to cite
your sources within the text and in the WC list?AU Have you
used parenthetical references within the text to show that you
are paraphrasing or quoting? AU Does the word/name in each
parenthetical reference match the first word/name in the
corresponding WC entry?AU Does the alphanumeric outline
appear in the same file as the essay itself (it should)? Is it the
first page in the document? (It should be.)AU Is the outline
page numbering different than your text pages? Outlines use
lowercase Roman numerals (i, ii, iii), while text pages use
Arabic numerals. AU Are your last name and page number in
the header (inside of the margin), NOT in the text? See the
examples online from Diana Hacker and youtube (for specific
instructions using your version of your word processing
program).AU Does your thesis appear in the outline AND in the
introduction? Is it the same thesis? They should be the same.AU
Is your thesis a single, concise sentence?AU Does the thesis
state the argument the essay will make?AU Is the file properly
named, as advised on Bb? (yourlastnameARGUEdraft)AU
REMOVE all FIRST and SECOND person pronouns (no you, I,
me, my, your, etc.). Remove all commands, too.AU Does the
method of organization suit the arguments you
are presenting?AU Does the essay refer to itself? (For example,

are you writing lines like, “In this essay I will . . .? If so,
remove them.)AU Have you checked MLA format for proper
margins (one inch all around--pre-formatted settings sometimes
use 1.5 inches on the side, so be sure to double check), heading
information, header placement, font, font size, outline structure,
etc.? Your grammar handbook has an example for you, as
does Bb. AU Did you run spellcheck? AU Does your conclusion
make a so what point? AU Did you begin the conclusion with
"in conclusion"? If so, remove that phrase.AU Have you met
the minimum word requirement? AU Have all contractions been
removed? (This is a formal essay.)AU Does the essay have
logical transitions throughout? AU Are all of your sentences in
each paragraph in the subject + verb sentence structure? If so,
review the grammar handbook's chapter on coordination and
subordination in order to avoid choppiness.
Ulen i
Outline
Thesis: Recycling should be strictly enforced by the government
and people should be penalized
for not following regulations.
I. Introduction.
A. Most states do not enforce recycling
II. Benefits of recycling
A. Reduce waste

B. Environmental considerations
III. Recycling in the home
A. Not using recycling bins
B. Contamination
IV. Programs
A. Education
B. Make recycling easier
Ulen 1
Anthony Ulen
R. Sullivan
Composition 1301
5 October 2019
Government Regulations on Recycling
Recycling has many benefits, unfortunately, many states do not
force people to recycle.
Some states, Alaska for example, have zero systems in place to
get people to recycle; other
states, however, do provide recycling bins or charge a

refundable fee on aluminum cans, this is
not enough. States have undermined the problems the US have
been facing when it comes to
recycling for over 70 years. Since we can’t leave it to just a
few volunteer agencies that offer
recycling benefits and accessibility, then ultimately it should
just be enforced by the federal
government. Unless States or the federal government take
action nothing will change, landfills
will continue to grow and the environment will worsen.
Recycling should be strictly enforced by
the government and people should be penalized for not
following regulations. This would
increase revenue and create jobs that would ultimately boost the
economy. But, in order for
these things to take place the US government would have to
regulate the several harmful single
use plastic companies that have been thriving on the sales of
their products for decades without
being held accountable for the impact they’re leaving on the
economy and the planet.
enforced by some form of the
government you first need to understand the benefits of

recycling. Reducing waste has several
beneficial factors; like the ability to decrease the carbon
footprint that we’re leaving for our
children and future generations. Second those harmful single
use goods like aluminum cans or
beverage plastics can end up being re-used, to decrease the
amount of waste in landfills polluting
Commented [RS1]: Comma splice
Commented [RS2]: Comma splice
Commented [RS3]: This is not a first-person assignment.
Remove 1st person pronouns throughout.
Commented [RS4]: checklist
Commented [RS5]: unclear pronoun reference
Commented [RS6]: Is this the argument in each
paragraph? If not, then it is the so what point, the solution
for what should happen when the government actually
enforces its own rules.
Commented [RS7]: redundant. All of this says the same
basic thing.
Commented [RS8]: If the previous sentence is the thesis,
what is the purpose of this information? Leave the details
to the body paragraphs.
Commented [RS9]: Last time noted: NO essay this
semester will use second person.

Commented [RS10]: Does this topic address why the
government should enforce recycling rules?
Commented [RS11]: fragment
Ulen 2
the soil and potentially the under-ground water system; or in the
oceans where they are for sure
devastating the very delicate eco-system that drives life on our
planet. “More plastic has been
created the past decade than the past 100 years.” (Susan
Freinkel). By the government enforcing
recycling that number can be brought down. Recycling can also
increase jobs within our own
country which would inevitably increase our way of life by
living in a cleaner environment in
which to raise a family, or boost the American economy.
nothing stopping people
from throwing away recyclable goods. If there was a law that
penalized people for putting cans
or plastics in the proper bin this would cause people to be more
aware of their actions. It sounds

harsh but if people are not going to help take care of their
country with keeping it clean and trash
free then it may just be a necessary evil. This could be
enforced from spot checks on bins
looking for recyclable material and the owner would be ticketed
for not complying. Another
issue is that recyclable material is contaminated. Several items
like single use plastic water
bottles, fast food straws and aluminum cans begin emitting
potentially harmful toxins when
exposed to direct sunlight or water. This could change by
households cleaning off what they are
putting in the bin and making sure they are not cross
contaminating; and use the same type of
fine penalty. In an article from the weekly states; “It's
estimated that about 25 percent of
American recyclables are contaminated with food waste and
non-recyclable materials, according
to the National Waste & Recycling Association trade group.”
(The recycling crisis). Once a
recyclable good is contaminated it can no longer be recycled
and then turns to waste. Creating a
new law could have an impact on not contaminating recyclable
goods.

not make a conscious
effort to recycle. This problem is mostly the lack of education.
Americans feel that if they put all
Commented [RS13]: Only the period at the end of the
sentence is used. Take this one out.
Commented [RS14]: Only last names are used in the
parenthetical reference because that is what starts the
corresponding entry.
Commented [RS15]: Quotations cannot stand alone like
this. They must be woven into the argument. Go back to Bb
and review the information there.
Commented [RS16]: Doesn’t this go off topic?
Commented [RS17]: Yes, this is a problem. How should
the government controlling recycling fix this?
Commented [RS18]: I’m not sure I follow this. How does
washing change the fact that the items themselves—straws,
cans, bottles—give off harmful toxins? If washing is the key,
the leftover food or products in those straws, cans, or
bottles are to blame.
Commented [RS20]: Is this a title?
Commented [RS21]: Creates a fragment. Review how to
introduce quotations on Bb.

Commented [RS22]: Weekly Staff
Ulen 3
their garbage; glass, plastics, bio-degradable items, anything
they want, into a plastic bag and
take that plastic bag to the end of their driveway into their trash
bins and the trash is collected
and taken away then the problem disappears. This mindset is
what has created this enormous
problem that we could’ve fixed if only we were more educated
on the subject. In a study by the
National Waste and Recycling Association said that ’’One third
of Americans are not sure what
can be recycled.” (Allan Gerlat). Very little information on the
benefits of recycling are available
to the public. If the state or federal government emplaced laws
at the household level recycling
would increase.
Recycling really could make an enormous difference but before
it can be enforced it must
be made available. This is one way to make the recycling crisis
go away, is if state or federal

governments actually made programs available to those who
actually want to make a difference
by recycling and creating a beret and cleaner country in which
to live in. A cleaner waste free
country has enormous benefits for the environment. Education
is going to have the best impact
for people to change their ways and government enforced
programs is the only way to make this
work because what current systems that are in place are not
working.
Commented [RS23]: All of this is true and is related to
recycling, but is it related to your topic? Go back and look
at your thesis: Recycling should be strictly enforced by the
government and people should be penalized for not
following regulations. Does any portion of this mention
enforcement, the government, or penalties?
Commented [RS24]: Mixed construction
Commented [RS25]: hyphenate

Ulen 4
Work Cited
Gerlat, Allan. “Americans Can Benefit from More Recycling
Education – Study.” Waste360, 22 Apr. 2014,
https://www.waste360.com/research-and-statistics/americans-
can-benefit-more-recycling-education-
study.
Staff, The Week. “The Recycling Crisis.” Image, The Week, 30
Mar. 2019,
https://theweek.com/articles/831864/recycling-crisis.
Freinkel, Susan. Plastic: a Toxic Love Story. Houghton Mifflin
Harcourt (HMH), 2011.
Anthony,
All of the information here is inter-related and COULD support
the thesis. Right now, though, the
connection between each body paragraph and the thesis is not
entirely clear. Remember your
argument: Recycling should be enforced by the government.
When you take your topic sentences out
and list them, do they directly address that statement?
Recycling should be enforced by the government.

enforced by some form of the
government you first need to understand the benefits of
recycling. [this says I am going to give
you information about the benefits of recycling. Yes, the first
part of the sentence mentions
wording from the thesis, but the emphasis is on the second part
of the sentence—giving
information.]
nothing stopping people from
throwing away recyclable goods.
not make a conscious effort to
recycle.
Do you see how the topic sentences do not indicate a direct
support of the thesis? Because they do not,
the paragraphs wander before coming back to the thesis. All of
this information could be brought back,
though, by rewriting topic sentences and working in the
connection throughout the body paragraphs

instead of waiting for one or two sentences at the end of the
paragraphs.
See the in-text details for additional details.
Commented [RS26]: Plural—more than one source listed
here.
Commented [RS27]: Use the appropriate font. Entries
should be alphabetized and should use hanging indent.
Commented [RS28]: Week Staff. “The Recycling Crisis.”
Commented [RS29]: ???
Commented [RS30]: This is the name of the page sponsor
Ulen 5
1. AU Did you use research material in this assignment?
Research is REQUIRED for this assignment.
2. AU Do you have a Works Cited page at the end of your essay
with the title Works Cited?
3. AU Do you have three appropriate sources (see the guidelines
in this lesson) listed on the WC page?
4. AU Are those three sources cited in the paper using either
paraphrases or direct quotations?
5. AU Did you define words, use a dictionary, or use an
encyclopedia? If so, those sources and information
from those sources must be removed. Most common words or

words used with their well-known definition do not
need to be defined in an essay. Dictionaries and encyclopedias
are NOT argumentative sources.
6. AU Did you use MLA 8th edition to cite your sources within
the text and in the WC list?
7. AU Have you used parenthetical references within the text to
show that you are paraphrasing or quoting?
8. AU Does the word/name in each parenthetical reference
match the first word/name in the corresponding WC
entry?
9. AU Does the alphanumeric outline appear in the same file as
the essay itself (it should)? Is it the
first page in the document? (It should be.)
10. AU Is the outline page numbering different than your text
pages? Outlines use lowercase Roman
numerals (i, ii, iii), while text pages use Arabic numerals.
11. AU Are your last name and page number in the header
(inside of the margin), NOT in the
text? See the examples online from Diana Hacker and youtube
(for specific instructions using your
version of your word processing program).
12. AU Does your thesis appear in the outline AND in the
introduction? Is it the same thesis? They
should be the same.
13. AU Is your thesis a single, concise sentence?
14. AU Does the thesis state the argument the essay will make?
15. AU Is the file properly named, as advised on Bb?
(yourlastnameARGUEdraft)
16. AU REMOVE all FIRST and SECOND person pronouns (no

you, I, me, my, your, etc.). Remove
all commands, too.
17. AU Does the method of organization suit the arguments you
are presenting?
18. AU Does the essay refer to itself? (For example, are you
writing lines like, “In this essay I will . .
.? If so, remove them.)
19. AU Have you checked MLA format for proper margins (one
inch all around--pre-formatted settings
sometimes use 1.5 inches on the side, so be sure to double
check), heading information, header
Ulen 6
placement, font, font size, outline structure, etc.? Your
grammar handbook has an example for you, as
does Bb.
20. AU Did you run spellcheck?
21. AU Does your conclusion make a so what point?
22. AU Did you begin the conclusion with "in conclusion"? If
so, remove that phrase.
23. AU Have you met the minimum word requirement?
24. AU Have all contractions been removed? (This is a formal
essay.)
25. AU Does the essay have logical transitions throughout?
26. AU Are all of your sentences in each paragraph in the
subject + verb sentence structure? If so,
review the grammar handbook's chapter on coordination and
subordination in order to avoid choppiness.

Critical Thinking and Caring in Nursing Students
Arli, Senay Karadag, PhD; Bakan, Ayse Berivan, PhD; Ozturk,
Senay, PhD; Erisik, Ela; Yildirim, Zubeyde. International
Journal of Caring Sciences; Nicosia Vol. 10, Iss. 1, (Jan/Apr
2017): 471-478.
1. Full text
2. Full text - PDF
3. Abstract/Details
Abstract
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The literature shows us the nursing students can improve this
ability in undergraduate clinical education and they should learn
how to think critically for giving better care. This study
identifies the relationship between disposition toward critical
thinking and caring behaviour of nursing students. This cross-
sectional study used a convenience sample that comprised 167
undergraduate nursing students enrolled in a four-year nursing
course in Eastern Turkey. The data was obtained through a
sociodemographic characteristics form, the Caring Nurse-
Patient Interaction Scale (CNPI-Long Scale) and the California

Critical Thinking Disposition Inventory (CCTDI). We
determined that there was a positive relationship between
overall critical thinking dispositions and caring behaviours (r =
0.470, p < 0.01). The simple linear regression analysis result
was analysed and it was observed that 22% of the Caring Nurse
Patient Interactions were predicted by critical thinking
disposition (R^sup 2^ = 0.221, p < 0.01). The findings indicate
that caring behaviours relate to critical thinking disposition.We
suggest critical thinking which promote the development of the
intellectual capacities of student nurses as independent critical
thinkers so that critical thinking should be in all nursing
curriculum. Therefore, quality client care will be better.

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Abstract
Background: The literature shows us the nursing students can
improve this ability in undergraduate clinical education and
they should learn how to think critically for giving better care.
Objective: This study identifies the relationship between
disposition toward critical thinking and caring behaviour of
nursing students.
Methodology: This cross-sectional study used a convenience
sample that comprised 167 undergraduate nursing students
enrolled in a four-year nursing course in Eastern Turkey. The
data was obtained through a sociodemographic characteristics
form, the Caring Nurse-Patient Interaction Scale (CNPI-Long
Scale) and the California Critical Thinking Disposition
Inventory (CCTDI).
Results: We determined that there was a positive relationship
between overall critical thinking dispositions and caring
behaviours (r = 0.470, p < 0.01). The simple linear regression

analysis result was analysed and it was observed that 22% of the
Caring Nurse Patient Interactions were predicted by critical
thinking disposition (R^sup 2^ = 0.221, p < 0.01).
Conclusions: The findings indicate that caring behaviours relate
to critical thinking disposition.We suggest critical thinking
which promote the development of the intellectual capacities of
student nurses as independent critical thinkers so that critical
thinking should be in all nursing curriculum. Therefore, quality
client care will be better.
Keywords: Critical Thinking Disposition, Caring Behaviour,
Nursing Students
Introduction
Critical thinking skills are now an expected outcome of nursing
education programmes. The American Association of Colleges
of Nursing (1998), the National League for Nursing (1992), and
the National League for Nursing Accrediting Commission
(2002) identified critical thinking as an essential component of
baccalaureate nursing education. Schools of nursing are
required to produce outcome assessments of students'
competence in critical thinking as accreditation criteria. As
nursing is a practice profession, it is important for the faculty to
know the cognitive process characteristics of expert nurses, lead
by example and impart critical thinking in clinical settings. The
current healthcare environment reflects societal patterns of
constant change and complexity. The rapid growth of
knowledge and technology related to health and illness requires
nurses who are able to solve problems and make crucial
decisions in clinical situations. Nurse educators must address
the challenge of preparing nurses who can think critically
(Twibell et al., 2005).
Background
Nursing is an aid-oriented profession and its main role is
caring. Nursing is a profession that requires complex
behavioural practices. The responsibilities of practitioners
include physical, psychological, mental and spiritual care for a
variety of clients. A nurse affects the patient and is affected

them through positive communication and planned nursing
initiatives (Tutuk et al., 2002; Ozcan, 2006).
Watson (2005) advocated patient-nurse interaction-based
nursing care, and developed Caring Theory from a humanistic
and holistic point of view. It is essential to improve knowledge
regarding caring, which is the basis for nursing (Watson, 1990;
Ozer et al., 2006; Yurtsever and Altiok, 2006; Yildirim and
Tasci 2013). According to Watson, a nurse must develop and
sustain a helping-trusting, authentic caring relationship with
their patient in order to promote healing and health. Moreover,
in Watson's theory, the nurse-patient caring relationship
protects, enhances and preserves the patient's dignity, humanity
and wholeness. Therefore, Watson's theory-focusing mainly on
the nurse-patient relationship as a variable central to nursing-
serves as a guide for developing a scale that captures the core of
nursing practice. Watson suggests ten carative factors for nurses
engaging in caring. The guidelines do not attempt to describe
specific clinical activities, but simply highlight essential
elements at the core of caring nursing practice. They identify
the elements of humanism in nursing care in therapeutic
relationships and clinical activities. The ten carative factors are
as follows: (1) humanistic-altruistic value system; (2) faith-
hope; (3) sensitivity to self and others; (4) helping-trusting,
human care relationship; (5) expressing positive and negative
feelings; (6) creative problem-solving caring processes;
(7)transpersonal teaching-learning; (8) supportive, protective
and/or corrective mental, physical, societal and spiritual
environment; (9) human needs assistance; and (10)
existentialphenomenological-spiritual forces (Watson, 1988;
Cossette et al., 2005).
It is well-known that occupational knowledge, experience,
critical thinking skills and critical thinking processes are very
important in the nursing profession. That is why, while
managing the caring process, nurses are obliged to assess the
problems of the patient and decide on the method of caring
according to the data obtained. Most of the time, nurses must

assess a number of options concurrently and make quick
decisions. Sometimes the right decision made by the nurse plays
a vital role in a patient's life. This is why critical thinking is
crucial in nursing (Ozdelikara et al., 2012).
In this modern healthcare environment, with its complex
technology and patient interventions, nurses require critical
thinking skills. Therefore, many studies have emphasised the
need for critical thinking (Cho, 2005; Zygmont and Schaefer,
2006; Hoffman, 2008; Vacek, 2009; Wood and Toronto, 2012).
Critical thinking ensures that the nurse reflects the basic
nursing training they have received, their occupational
experiences and research results which they had assessed
logically, when caring for patients. A lack of critical thinking
skills can negatively affect the quality, sufficiency and
efficiency of service and the professionalism, autonomy and
authority in profession. The more effective the nurses are in
critical thinking, the better their services become in increasing
quality of life and protecting and improving public health. That
is why it is highly important to provide students with an insight
into critical thinking (Ozturk and Ulusoy, 2008).
Consequently, nursing can be defined as the science and art of
caring, whereas caring can be defined as an interpersonal
process/interaction. Moreover, in this modern healthcare
environment-with its complex technology and patient
interventions-nurses require critical thinking skills. Therefore,
many studies have emphasised the need for critical thinking;
however, there is a gap in our understanding of the dimensions
of critical thinking as related to certain behaviours, especially
caring, which is the core of nursing. This study thus analyses
the relationship between critical thinking disposition and caring
behaviour of nursing students, and it sought to answer the
following question: 'What is the relationship between caring
behaviour and disposition toward critical thinking?'
Methods
Design
This study was a cross-sectional study.

Participants and sampling methods
The participants were a convenience sample of nursing students
from a four-year nursing course in Eastern Turkey. The final
sample comprised 167 nursing students (95 males and 72
females). The sample age range was from 18 to 28 years (M =
22.28). The participants of the research were in the first, third
and fourth years of the Nursing Department of the Health
School: we had no second-year students because the university
did not admit any students for one year because of a shortage of
lecturers. Moreover, all the students were practicing in clinics
from their first year so had clinical experience. All participants
reported having no education on critical thinking.
Data collection
Data collection for this study took place at a university in
Turkey. The data was collected between May and June of 2015.
A convenience sample of nursing students was invited to
participate in the study to be held in a classroom, and the
students were asked to sign on a consent form. The students
completed the questionnaire, which was written in Turkish.
Instruments
Socio-Demographic Characteristics Form
The Socio-Demographic Characteristics Form was developed by
the authors. Demographic data collected included a participant's
year of study, age and gender.
The Caring Nurse-Patient Interaction Scale (CNPI-70)
The Caring Nurse-Patient Interaction Scale (CNPI-Long Scale)
was developed by Cosette in 2005 to assess attitudes and
behaviours which were related to the Watson's Care Theory. The
scale comprised 70 items in 10 subscales: humanism, hope,
sensitivity, helping relationship, expression of feelings,
problem solving, teaching, environment, needs and spirituality.
The scale has the dimensions of importance, competence and
feasibility. The lowest score that can be obtained in the three
dimensions of the scale is 70 and the highest is 350.
The students rated their addressing perceptions about how
realistic attitudes or behaviours on a scale of 1 to 5, with 1

being 'not at all' and 5 being 'extremely'. The Turkish version
validity and reliability were conducted by Atar and Asti (Atar
and Asti, 2012). The Turkish version of the scale was used in
this study and permission was obtained from the scale's authors.
For internal consistency, the scale's item-total correlations were
0.56-0.81 and Cronbach's alphas were 0.99, 0.98 and 0.99,
respectively, for the three dimensions.
When participants' scores increased on the scale, their nurse-
patient interaction value related to attitudes and behaviours
increased positively (Cossette et al., 2006).
Cossette, along with Pepin, Cote' and De Courval, also
developed a shorter version of the scale (CNP-Short Scale) in
2008; however, they suggested using the 70-item long version
for evaluating nursing students' attitudes and behaviours related
to caring nurse-patient interaction (Cossette et al., 2008).
Two things led them to abridge their original scale into a more
concise version (CNPI-Short Scale). First, many of their
subscales were moderately to highly correlated: this is an
empirical reflection of the theoretical nonindependence of the
carative factors. Secondly, the lengthy 70-item questionnaire
was problematic in the clinical research setting, particularly
with severely ill patients. This shortened scale was based on
three a priori caring domains that were synthesised from the
original ten carative factors (Cossette et al., 2006).
The California Critical Thinking Disposition Inventory (CCTDI)
This inventory was developed based on the results of the Delphi
Report, in which critical thinking and disposition toward it were
conceptualised by a group of critical thinking experts (Facione,
1990). The original CCTDI includes 75 items loaded on seven
constructs: inquisitiveness, open-mindedness, systematicity,
analyticity, truth-seeking, critical thinking selfconfidence and
maturity.
Kokdemir (2003) carried out an adaptation study to transform
this inventory into a Turkish version because of cultural
concerns. After all items were translated into Turkish by eight
experts-six psychologists, a simultaneous translator and

Kokdemir himself-it was given out to 913 students in the
Faculty of Economic and Administrative Sciences.
First, item-total score correlations were estimated and 19 items
whose correlation was under 0.20 were eliminated from the
scale. Factor analysis was performed on the reduced scale.
Kokdemir's study revealed that five items had factor loadings
lower than 0.32 and that items under the constructs of open-
mindedness and maturity were loaded on one construct. Finally,
51 items with six constructs were kept in the scale. Reliability
of the whole scale was found to be 0.88. Reliability coefficients
of each subscale ranged from 0.61 to 0.78 (Kokdemir, 2003).
Statistical analysis
The SPSS Statistics Packet Program was used in the data
analysis for the descriptive statistics such as one-way ANOVA,
Pearson correlation and simple linear regression analysis. The
significance level was set at p < 0.05 for all statistical tests.
Ethical consideration
Ethical approval was obtained from a university in Turkey,
where the study took place. The Ethics Approval Number is
11002.
Results
Participants and Descriptive statistics
Socio-demographic characteristics of the nursing students were
determined. From 167 students participating in the study, 56.9%
were males and 50.9% out of those were in their fourth year of
study. When the Nurse-Patient Interaction Scale average was
analysed in accordance with factors such as gender and year of
study, no significant difference was found.
The Total Scores of the California Critical Thinking Disposition
Inventory and the Caring Nurse-Patient Interaction Scale
The critical thinking disposition scale average of the group was
254.39 ± 26.69 and the Caring Nurse-Patient Interaction Scale
average was 283.36 ± 41.27.
However, a significant decrease was found in the critical
thinking scale average when the year of study decreased. The
difference was found to be caused by freshmen and seniors with

the help of a Post Hoc Tukey HSD test (Table 2).
The Simple Linear Regression Result in Terms of Predictive
Factors of the Caring Nurse-Patient Interaction
When analysed in accordance with a Pearson correlation, a
positive link was found between critical thinking disposition
scale results and the Caring Nurse-Patient Interaction Scale
results (R = 0.470, p < 0.01). The simple linear regression
analysis result was analysed and it was observed that 22% of the
caring nurse-patient interactions were predicted by critical
thinking disposition (R2 = 0.221, p < 0.01) (Table 3).
Discussion
Information and experiences provided in a clinical atmosphere
play an essential role along with the theoretical information
when providing critical thinking insight to nurses. Clinical
practice is a training process that provides the student with an
opportunity to put theory into use and become a professional.
Clinical skills play a key role in nursing training. At the same
time, clinical skills allow students to interact with the patient,
giving them the opportunity to improve and utilise their
occupational know-how and skills regarding nursing, make
correct decisions, solve problems, improve their ability to
understand themselves and think critically (Eskimez et al.,
2005).
Critical thinking allows a nurse to utilise their basic nursing
training and occupational experience and provides an
opportunity to assess the search results logically and reflect
them in patient care. Lack of critical thinking skills can
negatively affect quality, sufficiency and efficiency in service;
it also affects professionalism, autonomy and authority in
profession. The more effective the nurse is in critical thinking,
the better their services become in increasing quality of life,
protecting and improving public health. Thus, it is highly
important to provide students with insights into critical thinking
(Ozturk and Ulusoy, 2008).
Some studies revealed that university students in Turkey have a
relatively low capacity of critical thinking (Dil and Oz, 2005;

Ozturk and Ulusoy, 2008; Bulut et al., 2009; Beser and Kissal,
2009; Akkus et al., 2010). In this study, the average score of the
nursing students for the critical thinking disposition scale was
254.39 ± 26.69. According to the results of CCTDI, scores less
than 240 are low, between 240 and 300 are average and above
300 are accepted to reflect a high critical thinking capacity (Dil
and Oz, 2005). This scale showed that our group had an average
level of critical thinking skills. According to Colucciello,
'critical thinking dispositions are essential for the development
of higher-order critical thinking and learning'. As such, these
students need more training in critical thinking (Colucciello,
1999).
A number of studies have shown that the more training the
students receive the higher their critical thinking capacity
becomes (Shin, 1998; Adams et al., 1999; Gunes and Kocaman,
2005; Dil and Oz, 2005; Ozturk and Ulusoy, 2008). As the
number of years of study increases, the knowledge capacity
increases, resulting in a higher capacity of critical thinking
(McGovern and Valiga, 1997). However, in this study a
significant decrease was found in the critical thinking capacity
average when the number of years of study was lower. With the
help of a Post Hoc Tukey HSD test, this decrease was identified
between freshmen and seniors (Table 2). This result is
considered to be obtained because of factors such as the lack of
trained staff in the analysis/synthesis and interpretation fields,
tendency of the students to avoid critical thinking as they gain
experience, insufficiency of practice fields in quality and event
or the lack of training in their schedule regarding critical
thinking. According to the study carried out by Akkus, Kaplan
and Kaçar in 2010, third year students have a lower average
score on the critical thinking disposition scale. However,
because they face many events that require problem solving,
independent decision-making and multidimensional thinking,
the capacity of critical thinking of nursing students is expected
to increase as they participate in the higher classes (Bulut and
Ertem, 2009; Akkus, 2010).

The Caring Nurse-Patient Interaction Scale average of nursing
students in this study was found to be 283.36 ± 41.27 (Table 2).
In the three dimensions of the scale, the highest score that can
be obtained is 350 and the lowest is 70. As the score increases,
the behaviours and attitudes of students regarding caring nurse-
patient interaction improves. In this study, a moderately
positive improvement was observed in the behaviours and
attitudes of students regarding caring nurse-patient interaction.
Thus, students with greater caring behaviours reported more
positive critical thinking dispositions (Pai and Eng, 2013).
These results support the view of Watson (1990) that caring is
at the core of nursing practice, and they are consistent with the
research that demonstrates the important role of caring in
critical thinking (Zimmerman and Phillips, 2000; Pai and Eng,
2013). This implies that caring motivates students to listen to
and consider patient demands, which provides a foundation for
critical thinking and the provision of high-quality care. This
finding is also supported by the perspective of Redding, who
described caring as involving the integration of internal and
external sources of information and taking valid action through
holistic critical thinking (Redding, 2001).
In improving the clinical decision-making skills of health care
professionals, critical thinking allows better and independent
decision-making regarding patients. Critical thinking efficiency,
attitudes necessary for critical thinking and critical thinking
standards, fundamental occupational knowledge and experience
are important in the decision-making process. Critical thinking
skills are affected by occupational training and clinical
experience (Hicks et al., 2003; Ay, 2011).
Implications for nursing practice and education
In nursing, critical thinking for clinical decisionmaking is the
ability to think in a systematic and logical manner with
openness to question and reflect on the reasoning process used
to ensure safe nursing practice and quality care (Paul and
Heaslip, 1997). Critical thinking when developed in the
practitioner includes adherence to intellectual standards,

proficiency in using reasoning, a commitment to develop and
maintain intellectual traits of the mind and habits of thought
and the competent use of thinking skills and abilities for sound
clinical judgments and safe decision-making. We suggest
critical thinking which promote the development of the
intellectual capacities of student nurses as independent critical
thinkers so that critical thinking should be in all nursing
curriculum. Therefore, quality client care will be better.
Conclusions
It is essential to examine the factors that improve critical
thinking skills and select the methods that encourage students to
search and think. Moreover, clinical practices positively affect
critical thinking. Clinical practice fields should be amended to
improve caring nurse-patient interaction; thus, the efficiency
and productivity of practices should be ensured. These types of
studies should be carried out for nurses and nursing students in
larger groups. Consequently, future research should use a
random sample or wider geographic region to obtain
participants and utilise a longitudinal design.
Acknowledgements We thank our nursing students for
participating in the study.
References
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AuthorAffiliation
Senay Karadag Arli, PhD

Assist Prof. Department of Nursing, Agri Ibrahim Cecen
University School of Health, Turkey
Ayse Berivan Bakan, PhD
Senay Ozturk, PhD
Ela Erisik
Department of Nursing, Agri Ibrahim Cecen University School
of Health, Turkey
Zubeyde Yildirim
of Health, Turkey
Corespondence: Assist Prof. Dr. Senay Karadag Arli
of Health, Turkey email: [email protected]
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