Chapter Three

Teaching NANDA-I
NIC and NOC: Novice to Expert
 Teaching NANDA-I
NIC and NOC: Novice to Expert
Contributor
Margaret Lunney
Learning Objectives
• Explain Three Propositions Related to Teaching NNN

• Set Expectations for Students at Novice to Expert Stages of

Development

• Implement Teaching Strategies

• Integrate NNN With Nursing Curricula

(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)
Objective 1: Explain Propositions
• Use of NNN Requires Intellectual, Interpersonal, and Technical
Competencies, Tolerance of Ambiguity and Reflection

• Accurate Diagnoses are the Basis for Use of NIC and NOC

• Use of NNN Differs from the Traditional Nursing Process

(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)
Proposition #1: Skills/Competencies
•Intellectual

•Knowledge Related to:

•Diagnoses

•Interventions

•Outcomes

•Thinking Processes
•Research Findings:
•Human Beings Vary in Thinking Process Abilities
•Thinking Process Abilities can be Improved
Variation in Nurses’ Thinking Abilities
Basic Thinking Abilities Mean SD Range

DMU-Fluency 21.3 7.2 6–41.5

DMC-Flexibility 10.8 6.5 0–27.5
DMI-Elaboration 17.8 4.9 7–30.5

N = 86 (Lunney 1992)
Intellectual Skills
Research Findings related to Women
•Thinking Processes of Women Develop Through Relationships
•Women’s Perspectives on Thinking (Belenkey et al. 1986)

•Silence

•Received Knowledge

•Subjective Knowledge

•Procedural Knowledge

•Constructed Knowledge

•Nursing Students and Nurses may have Lower Level Perspectives

Intellectual Skills: Critical Thinking
•Critical Thinking (CT) Processes can be Improved
•Stimulate to Use
•Expect Use
•Validate Appropriate Use
•Demonstrate Support and Confidence in Abilities

•CTAbilities - Essential for Accuracy of Diagnoses and Use of

NOC and NIC
(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)
Intellectual Skills: What is CT in Nursing?
•Delphi Study of 55 Nurse Experts
(Scheffer and Rubenfeld 2000)

•Purpose:
Identify the Components of CT that Relate to Nursing

•Results - Definition for Nursing:

•7 Cognitive Skills
•10 Habits of Mind
Cognitive Skills
•Analyzing

•Applying Standards

•Discriminating

•Information Seeking

•Logical Reasoning

•Predicting

•Transforming Knowledge
Habits of Mind
•Confidence •Intellectual Integrity
•Contextual Perspective •Intuition
•Creativity •Open-Mindedness
•Flexibility •Perseverance
•Inquisitiveness •Reflection
Intellectual Skills: CT Process
•CT Involves Continuous Processing of Data and Inferences

•In
Any Situation, Two or More Cognitive Skills are Probably Being
Used

•Habits of Mind Support Cognitive Skills

•The Combination of CT Abilities Needed is Unique

to the Situation
Proposition #1: Interpersonal Skills
•Exquisite Communication

•Promote Trust

•Work n Partnership, Share Power

•Validate Perceptions

•Accept That We Do Not “Know” Others

Proposition #1: Technical Skills
•Obtain Valid and Reliable Data

•Health Histories: Comprehensive

•Physical Exams: Focused

•Perform Nursing Interventions

•Technical Aspects of Using NNN

Proposition #1: Personal Strengths
•Tolerate Ambiguity

•Decisions are Relative to Context and Specific Nature of Individuals

•Multiple Factors Influence Clinical Situations

•Human Beings are Complex and Diverse

•Ambiguity is the Norm

Proposition #1: Personal Strengths
•Reflect on Practice Experiences

•Accept Possible Flaws

•Thinking

•Interpersonal

•Technical

•Aim - Develop and Grow

Proposition #2: Accurate Interpretations
Foundational
•Cues/Data may be Incorrect
•Examples

Objective Data:
•Diagnostic Tests

Subjective Data:
•Patients

•Families
Proposition #2: Accurate Interpretations
Foundational
•Use of NNN Requires Many Decisions
•All Decisions are Based on Patient Data
•Data Amounts are Overwhelming

•Short-Term Memory = 7 ± 2 Bits of Data

•Data are Converted to Interpretations

(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)
Proposition #2: Accurate Interpretations
Foundational
•InterpretationsDetermine Actions
•Additional Data Collection

•Subsequent Decisions

•Possible Outcomes to Consider

•Choices of Interventions

•HighPotential for Inaccuracy

•Diagnosis and Etiology
High Potential for Inaccuracy
Case Study: Marian Hughes
(1) Marian Hughes is a 16-year-old girl with a medical diagnosis of diabetes mellitus. (2) She was admitted
3days ago for treatment of an acute episode of diabetic ketoacidosis. (3) When Marian discussed with you
how she managed the therapeutic regimen before hospitalization, she states that she was not adhering to her
prescribed diet. (4) You decide that Marian needs assistance to improve her management of the therapeutic
regimen, especially the types of foods she eats. (5) Marian's stay in the hospital unit is uneventful in that
medical treatments are successfully resolving the crisis.

(6) Marian's daily habits include getting up for school about 7.00 a.m. and rushing to get the bus by 7.30. (7)
She says that she should get up about 6.30 but she likes to sleep. (8) She states that she does not want her
mother to help her get up earlier. (9) The meal that she eats at school is consistent with her prescribed diet
while the two meals at home are not. (10) In the morning she grabs whatever is quick and easy, usually toast
and butter. (11) In the evening, her mother makes meals that comply with the diabetic diet but Marian states
that she does not like them so she only eats part of her supper and then snacks on other foods later.

(12) Marian is able to explain to you what she should be eating and she can adjust her diet to her lifestyle. (13)
The knowledge of what foods are on her diet that she likes was not discussed with her mother because she
doesn't want to sit down and talk with her. (14) In general, Marian and her mother argue over many of Marian's
behaviors, such as school grades, smoking, and coming in late at night.
High Potential for Inaccuracy
Case Study: Marian Hughes
•16-Year-Old Diabetic (#1)

•Hospitalized, DKA (#2)

•“Did Not Follow Prescribed Diet” (#3)

•NDx: Ineffective Management of Therapeutic Regimen, Related to _______

(Fill in the Blank)
High Potential for Inaccuracy
Case Study: Marian Hughes
Possible Interpretation/Diagnosis
•Knowledge Deficit

•Disconfirming Cues:
•Meals Eaten at School are Consistent with Diet (#9)

•Able to Explain What She Should be Eating (#12)

•She can Adjust Her Diet to Her Lifestyle (#13)

•Conclusion: Low Accuracy Diagnosis

•Teaching is Waste of Time, Effort, and Money

(Herdman 2012)
High Potential for Inaccuracy
Case Study: Marian Hughes
Highest Accuracy Diagnosis
•Ineffective
Self-Health Management, Related to Communication Difficulties
Between Marian and Her Mother

•Patient
Outcome (NOC):
•Communication = 3 (Moderately Compromised), Increase to 5 (Not
Compromised)

•Nursing
Intervention
•Communication Enhancement
(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)
44 Diagnoses by 80 Nurses
Examples
•Communication Difficulties Mother/Daughter
•Stressful Mother/Child Relationship

•Altered Family Dynamics

•Ineffective Coping

•Ineffective Time Management

•Adolescent Image
•Low Self-Esteem

•Denial

•Deficient Knowledge
Seven Levels of Accuracy
+5 Highest Level of Accuracy
+4 Close to the Highest Level But Not Quite
+3 General Idea But Not Specific Enough
+2 Not Enough Highly Relevant Cues or Not
the Highest Priority
+1 Suggested by Only One or a Few Cues
0 Not Indicated by Data
-1 Should be Rejected, Disconfirming Cues
Diagnostic Accuracy Scores
•Communication Difficulties Between
Mother and Daughter +5
•Stressful Mother/Child Relationship +4
•Altered Family Dynamics +3
•Ineffective Coping +2
•Ineffective Time Management +2
•Adolescent Image +1
•Low Self-Esteem +1
•Denial 0
•Deficient Knowledge -1
Research Findings
•Studies: 1966 to Present
•Conclusions: Interpretations Vary Widely
•All Interpretations are Not High Accuracy
•Influencing Factors (Carnevali 1983; Gordon 1982)
•Nurse Diagnostician
•Diagnostic Task
•Situational Context
Research: Positive Influences
•Diagnostic Task

•Lesser Amounts and Complexity of Data

•Nurse Diagnostician

•Education Related to Nursing Diagnoses

•Knowledge of Diagnostic Process and Concepts

•Teaching Aids for Diagnostic Reasoning

•Variety of Thinking Processes

•Experience Specific to Diagnostic Task

Challenge: Achieving Accuracy
Puzzle: What is the Diagnosis?
Solving the Puzzle
Is It This? Or This? Or This?
Proposition #2: Accurate Interpretations
Foundational
•Supporting Factors:
•Acknowledge that Data Interpretations are Probabilistic; Question
Accuracy

•Use CT, Interpersonal and Technical Skills

•Develop Tolerance ofAmbiguity

•It’s OK Not to Have an Answer

•Accept that We Might Make Mistakes

•Develop Reflective Practice

Proposition #2:
New Perspectives on Nursing Process
Traditional Use of NNN
•Limited # of Concepts •Currently 1147 Concepts
•Collect Comprehensive Data •Cue-Based and Hypothesis-Driven
•No Accountability for Data Collection
Diagnoses
•Fully Accountable for Diagnoses
•Intervene Based on Data
•Intervene Based on Data
•Behavioral Outcomes
Interpretations
•Disorganized Follow-Up
•Neutral Terms with Scale
•Systematic Follow-Up

(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)

Changing from Traditional to Use of NNN
•Acknowledge Difficulty Level: Simple to Complex

•Influencing Factors:
•Similarityof Terms in Three Systems
•Structure of Classifications

•Resources (Books, Pamphlets, Other)

•Complexity of Clinical Situations

•Nurses Perspective/Model for Practice

•Experience With NNN

(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)

Examples: User-Friendly Simplicity
NANDA-I NOC NIC
Anxiety: Anxiety Control: Anxiety Reduction:
Vague uneasy feeling; Personal actions to Minimizing
autonomic response; eliminate or reduce apprehension, dread,
feeling of apprehension; feelings of foreboding or
altering signal warning of apprehension and uneasiness related to
impending danger tension from an unidentified source of
unidentifiable source anticipated danger

Risk ofInfection: Infection Status: Infection Protection:

Increased risk ofbeing Presence and extent of Prevention and early
invaded by pathogens infection detection of infection in
a patient at risk

(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)

Changing from Traditional to Use of NNN
•Use Theoretical Perspective
•Change Theory

•Diffusion of Innovations (Rogers 2003)

•S-Shaped Diffusion Curve
•Perceived Characteristics:
•Relative Advantage (+)
•Compatibility (+)
•Complexity (-)
•Trial Ability (+)
•Observability (+)
(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)
Changing from Traditional to Use of NNN
•Be a Champion
•Sell First to Opinion Leaders
•Goal: Create a Critical Mass
•Share Demonstration Projects
(For Example, Protocols and Journals)
•Faculty Development Program
•Adoption by System
•Adoption by Individuals

(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)

Objective 2: Set Expectations
Novice to Expert
•Novicesand Advanced Beginners (ABS) Learn to Use NNN as Well
as Experienced Nurses

•Novices
and ABS may be Easier to Teach than Nurses at
Competent, Proficient and Expert (Expert) Stages

•Expert Nurses must be “Sold” on New Way to Think and Document

(Benner 1984; Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)
Selling NNN to Experts
•EHR is Imminent
•NNN = File Names for EHR
•NNN Describes What Nurses Bring to the Table
•NNN Makes Knowledge Available at Bedside
•Aggregated Data = Knowledge
•Measurement of Care = Improved Quality
•Linguistics Theory Supports SNLS
•Fits with Nursing Theories
Set Expectations
•Expect (At All Levels of Expertise):
•Correct Use of the Three Systems:
•Nursing Diagnoses are used to Guide Interventions, Not for
Labeling per se
•Intervention Label is the Intervention, Not the Activities

•Outcome Label is the Outcome, Not the Indicators

•Correct Use of Concepts:

•NANDA-I: Social Isolation
•NIC: Coping Enhancement

•NOC: Knowledge (Specify)

(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)

Set Expectations
•Do Not Underestimate Nursing Students or Nurses:
•“…Nursing and Nursing Knowledge must be Presented in All Its
Complexity …

• Help Students and Nurses to “… Experience the Complex and Messy

World of Nursing … and Learn How to Navigate Through It …”
(Doane and Varcoe 2005, p.xi)
Set Expectations
•All Levels:
•Self-Evaluation

•Integrate with New Theories, for Example:

•Pender’s Health Promotion Model

•Integrate with Strategies for Evidence-Based Nursing

(Pender et al. 2010)

Set Expectations
•Encourage Experts to:
•Integrate with Previous Knowledge

•Use NNN in:

•Communicating Scope of Practice
•Developing Standards of Care

•Evidence-Based Nursing Projects

•Research Projects

•Evaluate Clinical Applications of NNN

•Teach CE Programs to Nursing Personnel

(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)
Objective 3: Teaching Strategies
Intellectual
•Assume that Thinking Is Human, Imperfect, Attainable

•Encourage Thinking in Class and Clinical:

•Ask Questions Instead of Giving Answers

•Provide Opportunities for Problem Solving

Objective 3: Teaching Strategies
Intellectual: Deflate Authority
Objective 3: Teaching Strategies
Intellectual
•Think Out Loud with Students

•Act as Midwife or Coach

•Helpthem Think About Thinking:

•Ask: What Kind of Thinking is Needed?
•Use the 17 CT Terms and Definitions

•Evaluate Thinking Processes

•Expect Self-Evaluation of Thinking

Objective 3: Teaching Strategies
•Share Paradigm Cases (e.g. Marian Hughes)

•Simplify Representations, Identify High Relevance Cues

•Conduct Iterative Hypothesis Testing

Objective 3: Teaching Strategies
Intellectual
•SeminarsInstead of Lectures: Why?
•Groups Represent Wide Variations in Thinking Abilities

•Promotes “In-Class” Thinking

•Recognizes Students’ Abilities to Think and Learn without

Authority/Experts

•SupportsFuture Work in Groups to Describe, Analyze and

Synthesize Information, Solve Problems (e.g. What is the
diagnosis?)
Objective 3: Teaching Strategies
Intellectual
•Seminars: How?
•Assign Readings, Provide Discussion Questions

•Lead the Group, Ask the Discussion Questions

•Be Respectful; Protect Students’ Self-Esteem

•Address:

•What is the Author Saying?

•What is the Fit with Previous Knowledge?
•How Does This Information Apply to Practice?

•25-30% of Grade for Discussion of Readings

Objective 3: Teaching Strategies
Intellectual
•Expect Self Evaluation
•Ask Questions, Instead of Giving Answers

•Discussion in Class

•Discussion Online
•Journal Writing (Degazon and Lunney 1996)
Objective 3: Teaching Strategies
Interpersonal
•Expect Accountability For Patient Relationships

•Demonstrate:

•Good Interviewing
•Validation of Diagnoses

•Partnership Processes to Select

Outcomes and Interventions

•Reward Power Sharing

•Teach and Support Assertiveness

Objective 3: Teaching Strategies
Interpersonal
•Expect Accountability For Using Standardized Methods

•Demonstrate Use of Diagnostic Reasoning

•Show Technical Use of NNN Using Case Studies

(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)

Objective 3: Teaching Strategies
General
•Demonstrate Correct Use of NNN

•Provide Incentives for Correct Use of NNN, e.g. Percentage of Grade

•Integrate with Theories of Nursing

(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)

Case Study
With Permission of Dr Arlene Farren

•30-Year-Old Woman in Good Health

•Smokes 1-1.5 Packs Per Day for >12 years

•Asked for assistance to quit

•Stated “I know it’s not good for me and I want to stay healthy”
What is the Diagnosis?
•Readiness for Enhanced Self-Health Management
Definition: A Pattern of Regulating and Integrating Into Daily Living a
Therapeutic Regime for Treatment of Illness and Its Sequelae that is
Sufficient for Meeting Health-Related Goals and can be Strengthened

(Herdman 2012)
What is the Outcome?
Smoking Cessation Behavior
•Personal Actions to Eliminate Tobacco Use

•Rarely Demonstrated (3), Goal = 5

•Indicators:
•Expresses Willingness to Stop Smoking (3)
•Identifies Benefits of Smoking Cessation (3)
•Adjusts Tobacco Elimination Strategies as Needed (3)
•Uses Strategies to Cope with Withdrawal Symptoms (2)
•Develops Effective Strategies to Eliminate Tobacco Use (2)

(Moorhead et al. 2008)

What are the Interventions?
•Smoking Cessation Assistance
•Teaching: Medication, Nicotine Replacement Therapy

(Bulecheck et al. 2008)

NIC: Smoking Cessation Assistance
Helping Another to Stop Smoking

•Activities:
•Give Laura Clear, Consistent Advice to Quit
•Assist Laura in Choosing Strategies

•Motivate Her to Set a Quit Date

•Refer to Group Programs/Individual Therapy

•Inform Laura of Possible Symptoms

•Help Plan Coping Strategies and Problem Resolution

(Bulecheck et al. 2008)

Evaluation of Outcomes
Smoking Cessation Behavior

•After 6 Weeks, Nurse and Laura Rate Outcome as 5

•Laura Consistently Monitors Her Environment and Personal Behaviors
for Factors that Affect Her Tobacco Use
•Laura Developed Effective Strategies and Remains Consistently
Committed to Controlling Her Use
•Laura Uses Friends and Group for Help

•Laura Has Not Smoked for 6 Weeks

(Moorhead et al. 2008)

Case Study
With Permission of Coleen Kumar
•49 Years Old; Single, Italian-American Woman
•Type 2 Diabetes Mellitus (DM) with Adequate Control

•Overweight

•Head of Household; 80-Year-Old Dependent Mother

•Works Full Time, Provides Care for Self and Mother

•Accepts Care of Mother But has Many Frustrations

•Attempts to Reduce Her Workload have Failed

•Mother Thinks Stella “Can Do It All”

•Mother Discourages Son’s Involvement

•Stella Expresses Conflicting Emotions, Stress, Lack of Control

What are the Diagnoses?
•TheDiagnostic Process:
•Which are Important Cues?

•What are Possible Diagnoses?

•Which Diagnoses Have the Best Support?

•Are the Diagnoses Consistent with the Situational Context?

•Can the Nurse Help Stella with the Diagnoses?

What are the Diagnoses?
•NANDA-I Diagnoses:
•Riskof Caregiver Role Strain
•Readiness for Enhanced Family Coping

•Checking for Accuracy:

•Are There a Sufficient Number of Confirming Cues?
•Are There Any Disconfirming Cues?

•Did Stella Validate the Diagnosis?

•Should Other Providers be Consulted?

(Herdman 2012)
What are the Outcomes?
Caregiver Well-Being
•Caregiver Satisfaction with Health and Lifestyle Circumstances
•Moderately Compromised (3), Goal = 4 or 5

•Indicators:
•Satisfaction with Physical Health (3)
•Satisfaction with Emotional Health (2)
•Satisfaction with Usual Lifestyle (3)
•Satisfaction with Instrumental Support (2)
•Satisfaction with Social Relationships (3)

(Moorhead et al. 2008)

What are the Outcomes?
Family Coping
•Family Actions to Manage Stressors that Tax Family Resources
•Moderately Compromised (3); Goal = 4 or 5

•Indicators:
•Demonstrates Role Flexibility (3)
•Family Enables Member Role Flexibility (3)
•Expresses Feelings and Emotions Freely (2)
•Arranges for Respite Care (2)
•Seeks Assistance When Appropriate (3)
•Uses Social Support (3)

(Moorhead et al. 2008)

What are the Interventions?
•Assertiveness Training
•Self-Esteem Enhancement
•Emotional Support
•Caregiver Support
•Role Enhancement
•Family Involvement Promotion
•Respite Care

(Bulecheck et al. 2008)

NIC Example
Assertiveness Training
•Assistance
with the Effective Expression of Feelings, Needs, and Ideas
While Respecting the Rights of Others

•Activities:
•Determine Barriers to Assertiveness (for Example, Family Roles)
•Help Stella Recognize and Reduce Cognitive Distortions
•Instruct Stella in Different Ways to Act Assertively
•Facilitate Practice Opportunities Using Discussion, Modeling and Role Playing
•Help Stella Practice Conversational Skills

(Bulecheck et al. 2008)

Evaluation of Outcomes
Caregiver Well-Being
After 4 Weeks, Nurse and Stella Rate Outcome as 4
•Stella’s Physical Health has Improved; Satisfaction with Physical Health (4)
•Stella
Uses Assertiveness Skills to Make Time for Herself After Work and to
Plan Recreation; Satisfaction with Emotional Health (4)
•StellaContinues to Need Help in The Performance of Caregiver Roles;
Satisfaction with Performance of Usual Roles (4)
•StellaFeels n Control of Her Caregiver Routines; Satisfaction with Caregiver
Role (4)

(Moorhead et al. 2008)

Evaluation of Outcomes
Family Coping
After 4 Weeks, Nurse and Stella Rate Outcome as 4
•Stella’s
Assertiveness Behaviors Work Well to Accomplish Goals; Demonstrates
Role Flexibility (4)
•Stella’s
Mother Agrees with the Plan to Relieve Her of Some of the Workload;
Family Enables Member Role Flexibility (4)
•Stella’s
Brother Stays with Her Mother So Stella can Go Away for Short Periods;
Arranges For Respite Care (4)
•Family Exhibits a Wider Repertoire of Coping Behaviors (4)

(Moorhead et al. 2008)

Use Case Studies
•Case Studies Help Students to Practice Thinking and Clinical Judgment in a
Safe Environment

•Standardized: Everyone Uses the Same Clinical Data

•Additional Case Studies, and Their Interpretations, can be Found in Lunney

(2009)
Teaching Strategies: Summary
Observe Students Grow in Abilities through Encouragement,
Trust, and Respect
Objective 4: Integrate with Curricula
•Prepare Faculty
•Diffusionof Innovations (Rogers 2003)
•Talking Points:
•Electronic Health Record
•Quality-Based Nursing Care
•Ability to Develop Information and Knowledge

•Involve Clinical Faculty

•Evaluation/Peer Observation
Objective 4: Integrate with Curricula
•Simplify
Complexity-Map of Diagnoses, Interventions and Outcomes
for Courses

•All Faculty Evaluate Students’:

•Correct Use of NNN
•Partnership Processes, Use of “We”
•Technical Skills
•Individualize NNN Content with Patients

(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)

Objective 4: Integrate with Curricula
•Fundamentals of Nursing
•NNN - Framework for Skills Learning
•Thinking - High Priority Diagnoses, Include in Testing
•Expect Students to Use CT Terms and Definitions (for Example, in
Journal Writing and Discussion)
•Develop Case Studies (Lunney 1992)

•Iterative Hypothesis Testing

(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)

Objective 4: Integrate with Curricula
•Educators and Practice-Based Leaders: Spread the Word to Nurses
in Other Agencies

•Meet with Leaders; Use Marketing Strategies

•Demonstrate Advantages of NNN

•Provide CE Programs

•Disseminate Your Success in Using NNN to Others

(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)

Questions/Discussion
•“Teamwork is the Fuel that Allows Common People to Attain
Uncommon Results” (Unknown)

•“The Illiterate of the 21st Century will Not be Those Who Cannot
Read and Write, But Those Who Cannot Learn, Unlearn and Relearn”
(Alvin Toffler)
References
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Degazon CE, Lunney M. (1995) Clinical journal: a tool to foster critical thinking for advanced levels of competence. Clinical Nurse Specialist 9(5): 270-274.
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