Critical thinking development in undergraduate midwifery students: an Australian validation study using Rasch analysis.

BACKGROUND: Well-developed critical thinking skills are required to provide midwifery care that is safe, evidence-based, and woman-centred. A valid, reliable tool to measure is required the application of critical thinking in midwifery practice. The Carter Assessment of Critical Thinking in Midwifery (CACTiM) has previously been psychometrically assessed using classical methods at a single site. This study aims to further evaluate the properties of CACTiM tools using Rasch analysis in a diverse group of midwifery students and preceptors.  METHODS: The CACTiM tools were completed by undergraduate midwifery students studying at three Australian universities and their preceptors. Midwifery students' critical thinking was evaluated separately through student self-assessment and preceptor assessment and then matched. Rasch analysis was used to evaluate the validity of the tools.  RESULTS: Rasch analysis confirmed both the preceptor and student CACTiM tools demonstrated good reliability and unidimensionality. The items can differentiate between students' ability to apply critical thinking in midwifery practice. Person reliability and item reliability were above .92 for both scales indicating excellent reliability and internal consistency. Several improvements were identified to the tools, including enhanced wording to some items, and reduction to a 5-point Likert scale. Through analysis of lower-scoring items, midwifery programs can identify curricula enhancements. CONCLUSION: The CACTiM student and preceptor tools are valid and reliable measures of critical thinking in midwifery practice. The tools can assess students' critical thinking abilities and identify areas for development for individuals and across student cohorts through curricula enhancements.

School and educational support programmes for paediatric oncology patients and survivors: A systematic review of evidence and recommendations for future research and practice.

OBJECTIVES: The Psychosocial Standards of Care (PSSC) in paediatric oncology prescribe the minimum standards for education support. It is unknown, however, if published education support programmes for children with cancer meet the PSSC standards for education support. Successful implementation of standards for education support is challenging but may be achieved with guidance. We aimed to (1) review education support programmes for childhood cancer patients and survivors against the PSSC standards and (2) provide practical recommendations for future research and implementation of education support programmes. METHODS: We searched PsycINFO, PubMed, CINAHL, EMBASE, and Educational Resources Information and Center databases. We reviewed the education support programmes using five evaluation criteria derived from the PSSC and summarised the structure of identified programmes. We examined the features and limitations of programmes that met all evaluation criteria. RESULTS: We identified 20 education support programmes in paediatric oncology, including peer programmes (n = 3), teacher programmes (n = 5), and school re-entry programmes (SRPs n = 12). We found that three SRPs met all evaluation criteria and that SRP components were timed according to the child's position on the cancer trajectory (e.g., diagnosis and treatment, school re-entry, and follow up throughout schooling). The supporting evidence of the programmes, however, is unclear due to the lack of adequately designed studies. CONCLUSIONS: SRPs provide a promising structure for future education support programmes. We recommend strategies for developing and evaluating education support that adheres to the PSSC and adapts to international and local contexts.

Using naturalistic incubation temperatures to demonstrate how variation in the timing and continuity of heat wave exposure influences phenotype.

Most organisms are exposed to bouts of warm temperatures during development, yet we know little about how variation in the timing and continuity of heat exposure influences biological processes. If heat waves increase in frequency and duration as predicted, it is necessary to understand how these bouts could affect thermally sensitive species, including reptiles with temperature-dependent sex determination (TSD). In a multi-year study using fluctuating temperatures, we exposed Trachemys scripta embryos to cooler, male-producing temperatures interspersed with warmer, female-producing temperatures (heat waves) that varied in either timing during development or continuity and then analysed resulting sex ratios. We also quantified the expression of genes involved in testis differentiation (Dmrt1) and ovary differentiation (Cyp19A1) to determine how heat wave continuity affects the expression of genes involved in sexual differentiation. Heat waves applied during the middle of development produced significantly more females compared to heat waves that occurred just 7 days before or after this window, and even short gaps in the continuity of a heat wave decreased the production of females. Continuous heat exposure resulted in increased Cyp19A1 expression while discontinuous heat exposure failed to increase expression in either gene over a similar time course. We report that even small differences in the timing and continuity of heat waves can result in drastically different phenotypic outcomes. This strong effect of temperature occurred despite the fact that embryos were exposed to the same number of warm days during a short period of time, which highlights the need to study temperature effects under more ecologically relevant conditions where temperatures may be elevated for only a few days at a time. In the face of a changing climate, the finding that subtle shifts in temperature exposure result in substantial effects on embryonic development becomes even more critical.

Role of ureides in source-to-sink transport of photoassimilates in non-fixing soybean.

Nitrogen (N)-fixing soybean plants use the ureides allantoin and allantoic acid as major long-distance transport forms of N, but in non-fixing, non-nodulated plants amino acids mainly serve in source-to-sink N allocation. However, some ureides are still synthesized in roots of non-fixing soybean, and our study addresses the role of ureide transport processes in those plants. In previous work, legume ureide permeases (UPSs) were identified that are involved in cellular import of allantoin and allantoic acid. Here, UPS1 from common bean was expressed in the soybean phloem, which resulted in enhanced source-to-sink transport of ureides in the transgenic plants. This was accompanied by increased ureide synthesis and elevated allantoin and allantoic acid root-to-sink transport. Interestingly, amino acid assimilation, xylem transport, and phloem partitioning to sinks were also strongly up-regulated. In addition, photosynthesis and sucrose phloem transport were improved in the transgenic plants. These combined changes in source physiology and assimilate partitioning resulted in increased vegetative growth and improved seed numbers. Overall, the results support that ureide transport processes in non-fixing plants affect source N and carbon acquisition and assimilation as well as source-to-sink translocation of N and carbon assimilates with consequences for plant growth and seed development.

Life stages differ in plasticity to temperature fluctuations and uniquely contribute to adult phenotype in Onthophagus taurus dung beetles.

Adaptive thermal plasticity allows organisms to adjust their physiology to cope with fluctuating environments. However, thermal plasticity is rarely studied in response to thermal variability and is often measured in a single life stage. Plasticity in response to thermal variability likely differs from responses to constant temperature or acute stress. In addition, life stages likely differ in their plasticity, and responses in one stage may be affected by the experiences in a previous stage. Increasing the resolution with which we understand thermal plasticity in response to thermal variation across ontogeny is crucial to understanding how organisms cope with the thermal variation in their environment and to estimating the capacity of plasticity to mitigate costs of rapid environmental change. We wanted to know whether life stages differ in their capacity for thermal plasticity under temperature fluctuations. We reared Onthophagus taurus dung beetles in either low or high temperature fluctuation treatments and quantified thermal plasticity of metabolism of pupae and adults. We found that adults were thermally plastic and pupae were not. Next, we tested whether the plasticity observed in the adult life stage was affected by the thermal conditions during development. We again used low and high temperature fluctuation treatments and reared individuals in one condition through all egg to pupal stages. At eclosion, we switched half of the individuals in each treatment to the opposite fluctuation condition and, later, measured thermal plasticity of metabolism in adults. We found that temperature conditions experienced during the adult stage, but not egg to pupal stages, affect adult thermal plasticity. However, temperature fluctuations during development affect adult body size, suggesting that some aspects of the adult phenotype are decoupled from previous life stages and others are not. Our data demonstrate that life stages mount different responses to temperature variability and uniquely contribute to the adult phenotype. These findings emphasize the need to broadly integrate the life cycle into studies of phenotypic plasticity and physiology; doing so should enhance our ability to predict organismal responses to rapid global change and inform conservation efforts.

Different amplitudes of temperature fluctuation induce distinct transcriptomic and metabolomic responses in the dung beetle Phanaeus vindex.

Most studies exploring molecular and physiological responses to temperature have focused on constant temperature treatments. To gain a better understanding of the impact of fluctuating temperatures, we investigated the effects of increased temperature variation on Phanaeus vindex dung beetles across levels of biological organization. Specifically, we hypothesized that increased temperature variation is energetically demanding. We predicted that thermal sensitivity of metabolic rate and energetic reserves would be reduced with increasing fluctuation. To test this, we examined the responses of dung beetles to constant (20°C), low fluctuation (20±5°C), or high fluctuation (20±12°C) temperature treatments using respirometry, assessment of energetic reserves and HPLC-MS-based metabolomics. We found no significant differences in metabolic rate or energetic reserves, suggesting increased fluctuations were not energetically demanding. To understand why there was no effect of increased amplitude of temperature fluctuation on energetics, we assembled and annotated a de novo transcriptome, finding non-overlapping transcriptomic and metabolomic responses of beetles exposed to different fluctuations. We found that 58 metabolites increased in abundance in both fluctuation treatments, but 15 only did so in response to high-amplitude fluctuations. We found that 120 transcripts were significantly upregulated following acclimation to any fluctuation, but 174 were upregulated only in beetles from the high-amplitude fluctuation treatment. Several differentially expressed transcripts were associated with post-translational modifications to histones that support a more open chromatin structure. Our results demonstrate that acclimation to different temperature fluctuations is distinct and may be supported by increasing transcriptional plasticity. Our results indicate for the first time that histone modifications may underlie rapid acclimation to temperature variation.

Evidence of embryonic regulation of maternally derived yolk corticosterone.

In recent years, the potential for maternal stress effects to adaptively alter offspring phenotype has received considerable attention. This research has identified offspring traits that are labile in response to maternal stress; however, an understanding of the mechanisms underlying these effects is lagging and is crucial to appreciating the significance of this maternal effect. In the present study, we sought to better understand maternal stress effects by examining the potential for embryonic regulation of corticosterone exposure, determining the phenotypic consequences of elevated corticosterone during development, and characterizing the levels of maternally transferred corticosterone in unmanipulated eggs using Trachemys scripta By dosing eggs with tritiated corticosterone and tracking the steroid throughout development, we found that most corticosterone is metabolized, and less than 1% of the corticosterone dose reaches the embryo as free corticosterone. We also found that exogenous dosing of corticosterone, in concentrations sufficient to overwhelm embryonic metabolism, reduces embryonic survival and negatively impacts hatchling traits important to fitness. Our results demonstrate that concentrations of maternal corticosterone in the yolks of unmanipulated eggs are low and are significantly lower than the doses of corticosterone required to elicit phenotypic effects in hatchlings. Taken together, these results provide evidence that both the embryo and the female may minimize corticosterone accumulation in the embryo to avoid reductions in embryonic survival and negative impacts on offspring phenotype and fitness.

Intron sequences that stimulate gene expression in Arabidopsis.

KEY MESSAGE: Related motifs strongly increase gene expression when added to an intron located in coding sequences. Many introns greatly increase gene expression through a mechanism that remains elusive. An obstacle to understanding intron-mediated enhancement (IME) has been the difficulty of locating the specific intron sequences responsible for boosting expression because they are redundant, dispersed, and degenerate. Previously we used the IMEter algorithm in two independent ways to identify two motifs (CGATT and TTNGATYTG) that are candidates for involvement in IME in Arabidopsis. Here we show that both motifs are sufficient to increase expression. An intron that has little influence on expression was converted into one that increased mRNA accumulation 24-fold and reporter enzyme activity 40-fold relative to the intronless control by introducing 11 copies of the more active TTNGATYTG motif. This degree of stimulation is twice as large as that of the strongest of 15 natural introns previously tested in the same reporter gene. Even though the CGATT and TTNGATYTG motifs each increased expression, and CGATT matches the NGATY core of the longer motif, combining the motifs to make TTCGATTTG reduced the stimulating ability of the TTNGATYTG motif. Additional substitutions were used to test the contribution to IME of other residues in the TTNGATYTG motif. The verification that these motifs are active in IME will improve our ability to predict the stimulating ability of introns, to engineer any intron to increase expression to a desired level, and to explore the mechanism of IME by seeking factors that might interact with these sequences.

Re-evaluating the health of coral reef communities: baselines and evidence for human impacts across the central Pacific.

Numerous studies have documented declines in the abundance of reef-building corals over the last several decades and in some but not all cases, phase shifts to dominance by macroalgae have occurred. These assessments, however, often ignore the remainder of the benthos and thus provide limited information on the present-day structure and function of coral reef communities. Here, using an unprecedentedly large dataset collected within the last 10 years across 56 islands spanning five archipelagos in the central Pacific, we examine how benthic reef communities differ in the presence and absence of human populations. Using islands as replicates, we examine whether benthic community structure is associated with human habitation within and among archipelagos and across latitude. While there was no evidence for coral to macroalgal phase shifts across our dataset we did find that the majority of reefs on inhabited islands were dominated by fleshy non-reef-building organisms (turf algae, fleshy macroalgae and non-calcifying invertebrates). By contrast, benthic communities from uninhabited islands were more variable but in general supported more calcifiers and active reef builders (stony corals and crustose coralline algae). Our results suggest that cumulative human impacts across the central Pacific may be causing a reduction in the abundance of reef builders resulting in island scale phase shifts to dominance by fleshy organisms.

Incubation temperature causes skewed sex ratios in a precocial bird.

Many animals with genetic sex determination are nonetheless capable of manipulating sex ratios via behavioral and physiological means, which can sometimes result in fitness benefits to the parent. Sex ratio manipulation in birds is not widely documented, and revealing the mechanisms for altered sex ratios in vertebrates remains a compelling area of research. Incubation temperature is a key component of the developmental environment for birds, but despite its well-documented effects on offspring phenotype it has rarely been considered as a factor in avian sex ratios. Using ecologically relevant manipulations of incubation temperature within the range 35.0-37.0°C, we found greater mortality of female embryos during incubation than males regardless of incubation temperature, and evidence that more female than male embryos die at the lowest incubation temperature (35.0°C). Our findings in conjunction with previous work in brush turkeys suggest incubation temperature is an important determinant of avian secondary sex ratios that requires additional study, and should be considered when estimating the impact of climate change on avian populations.

Improving maternal and neonatal outcomes for women with gestational diabetes through continuity of midwifery care: A cross-sectional study.

PROBLEM: Gestational Diabetes Mellitus (GDM) is a complication of pregnancy which may exclude women from midwife-led models of care. BACKGROUND: There is a paucity of research evaluating the safety and feasibility of continuity of midwifery care (CoMC) for women with GDM. AIM: To investigate the impact of CoMC on maternal and neonatal outcomes, for otherwise low-risk women with GDM. METHODS: This exploratory cross-sectional study observed maternal and neonatal outcomes including onset of labour, augmentation, labour analgesia, mode of birth, perineal trauma, gestation at birth, shoulder dystocia, infant birth weight, neonatal feeding at discharge. FINDINGS: Participants were 287 otherwise low-risk pregnant women, who developed GDM, and either received CoMC (n=36) or standard hospital maternity care (non-CoMC) (n=251). Women with GDM who received CoMC were significantly more likely to experience an spontaneous onset of labour (OR 6.3; 95% CI 2.7-14.5; p<.001), labour without an epidural (OR 4.2; 95% CI 2.0 - 9.2,<0.001) and exclusively breastfeed (OR 4.3; 95% CI 1.26 - 14.32; p=0.02). DISCUSSION: Receiving CoMC may be a public health initiative which not only improves maternal and neonatal outcomes, but also long-term morbidity associated with GDM. CONCLUSION: Findings provide preliminary evidence suggesting CoMC improves maternal and neonatal outcomes and is likely a safe and viable option for otherwise low-risk women with GDM. Larger studies are recommended to confirm findings and explore the full impact of CoMC for women with GDM.

A Rare Case of NUT Carcinoma of the Thyroid.

NUT carcinoma is an aggressive, poorly differentiated squamous cell carcinoma, defined by rearrangement of the NUTM1 (Nuclear Protein in Testis) gene. Diagnosis is challenging due to histologic similarities with other poorly differentiated tumors requiring advanced diagnostic techniques. There is no established treatment, and prognosis remains extremely poor. A 27-year-old woman without known medical history presented with a rapidly enlarging neck mass and compressive symptoms. Chemotherapy for presumed squamous cell carcinoma with a component of anaplastic thyroid cancer based on pathology was initiated. Next-generation sequencing revealed thyroid NUT carcinoma with high PD-L1 expression, prompting PD-1 targeted therapy. The patient expired shortly afterwards from progressive disease. NUT carcinoma of thyroid origin is an extremely rare disease. This case brings awareness to the disease, highlights the importance of advanced diagnostic techniques and complexities in managing patients with NUT carcinoma.

Deposition of pathogenic Mycoplasma gallisepticum onto bird feeders: host pathology is more important than temperature-driven increases in food intake.

Although ambient temperature has diverse effects on disease dynamics, few studies have examined how temperature alters pathogen transmission by changing host physiology or behaviour. Here, we test whether reducing ambient temperature alters host foraging, pathology and the potential for fomite transmission of the bacterial pathogen Mycoplasma gallisepticum (MG), which causes seasonal outbreaks of severe conjunctivitis in house finches (Haemorhous mexicanus). We housed finches at temperatures within or below the thermoneutral zone to manipulate food intake by altering energetic requirements of thermoregulation. We predicted that pathogen deposition on bird feeders would increase with temperature-driven increases in food intake and with conjunctival pathology. As expected, housing birds below the thermoneutral zone increased food consumption. Despite this difference, pathogen deposition on feeders did not vary across temperature treatments. However, pathogen deposition increased with conjunctival pathology, independently of temperature and pathogen load, suggesting that MG could enhance its transmission by increasing virulence. Our results suggest that in this system, host physiological responses are more important for transmission potential than temperature-dependent alterations in feeding. Understanding such behavioural and physiological contributions to disease transmission is critical to linking individual responses to climate with population-level disease dynamics.

Development and testing of the Midwifery Perceptions and Assessment of Clinical Teaching (MidPaACT) tool.

OBJECTIVE: Develop and test a tool to measure midwives' perceptions of their role in preceptoring midwifery students. DESIGN: A multi method exploratory study design was used. POPULATION: Preceptor midwives from three maternity units in south-east Queensland Australia. METHODS: A three-phase process was used: item generation; expert review; psychometric testing including content analysis of qualitative responses. The survey was online or paper-based and included demographic details, the Clinical Preceptor Experience Evaluation Tool (CPEET) role subscale and draft tool. A focus group discussion explored the open-ended responses. FINDINGS: A large sample of preceptors (n = 164, 64.2 % response rate) participated. Factor analysis revealed a two-factor structure with 24 items accounting for 40.2 % of variance. The mean total score of the Midwifery Perceptions and Assessment of Clinical Teaching (MidPaACT) tool was 103.31 (SD = 9.47). The scale was reliable (Cronbach's alpha 0.89) and valid. Test-retest reliability showed moderate to excellent temporal stability across the scale and subscales. Measures of concurrent validity showed little agreement with the CPEET tool. Qualitative analysis revealed the way midwives were taught as students had a powerful influence on their approach to teaching in practice. CONCLUSION: This tool is specifically designed to assess midwifery preceptors' perceptions of their role in student learning in practice. Psychometric testing of the MidPaACT tool confirms its reliability and validity. IMPLICATIONS FOR PRACTICE: Midwifery preceptors are a key influence on the development of students' capability as a midwife. Midwives' perceptions of their proficiency in student learning are under-reported. The MidPaACT tool provides a reliable and valid means of measuring preceptors' perceptions and identifying areas for future educational and workforce improvement.

Impact of women's feedback on midwifery student learning: A thematic analysis of students' reflections.

PROBLEM: Little is known about the educational impact of providing routine, online feedback from women on midwifery student learning and clinical practice. BACKGROUND: Feedback on students' clinical performance has historically been provided by lecturers and clinical supervisors. Women's feedback is not routinely collected or evaluated for impact on student learning. AIM: To evaluate the impact of women's feedback about continuity of care experiences with a midwifery student on learning and practice. DESIGN: Descriptive, exploratory qualitative study. METHODS: All second-and third-year Bachelor of Midwifery students undertaking clinical placement between February and June 2022 at one Australian university, submitted formative, guided written reflections on de-identified women's feedback they received through their ePortfolio. Data were analysed using reflexive thematic analysis. FINDINGS: Forty-four of the 69 eligible students (64%) submitted reflections on feedback received. Three themes emerged: 1) Confidence boosting, 2) Deeply integrating Midwifery Metavalues, and 3) Enhancing commitment to continuity. Three subthemes: connection, future practice and advocacy were identified. Women's feedback positively impacts student learning and places the woman in the educational feedback loop. CONCLUSION: This study is an international first evaluating the impact of feedback from women on midwifery students' learning. Students reported greater confidence in their clinical practice, a deeper understanding of their midwifery philosophy, and an intention to advocate for, and work in, midwifery continuity models after graduation. Routine feedback about women's experiences should be embedded into midwifery education programs.

An evaluation of the use and efficacy of behavioural therapy when treating paediatric patients with radiation therapy.

INTRODUCTION: The paediatric radiation therapy group (PRTG) provided a multidisciplinary network to support patients accessing radiation therapy (RT). This study aims to evaluate the use and efficacy of behaviour therapy practices used by the PRTG. METHODS: A retrospective cross-sectional review of general anaesthetic (GA) utilisation for paediatric patients was completed between 1 January 2010 and 30 June 2014. The PRTG incorporated behavioural therapy techniques into all appointments but offered additional play appointments to children unable to comply with the requirements of RT. This aimed to increase their compliance and minimise GA use. RESULTS: Two-hundred and seventy-four patients had 5402 occasions of service, of which 1361 were delivered under GA (25.2%). Two-hundred and fifty-seven patients met the eligibility criteria. Patients under 8 years who required GA for their entire treatment reduced for each year of increase in age (odds ratio 0.37, 95% confidence interval 0.27-0.51, P < 0.001). Participants 3 years and younger were shown not as likely to change their GA requirements with the use of play appointments. Seventy-eight per cent (83/106) of 3-8-year-olds used no GA or ceased GA during treatment. CONCLUSIONS: Most paediatric patients <3 years will gain minimal benefit to reduce GA use from additional play appointments. Children older than nine were not likely to require play appointments to be compliant with RT. Encouragingly, 53.3% of 3-8-year-olds who were categorised as full GA after CT planning did not continue to a full course of GA due to the behavioural therapy interventions of the PRTG.

Care at Your Fingertips: Codesign, Development, and Evaluation of the Oncology Hub App for Remote Symptom Management in Pediatric Oncology.

PURPOSE: To codesign, develop, and evaluate a smartphone app that includes patient-reported measures of symptoms and real-time advice in children's cancer. METHODS: The Oncology Hub is a comprehensive approach to symptom management that includes a suite of codesigned tools and resources including clinical algorithms to determine the level of concern, symptom management advice, and resources for families of children with cancer. The evaluation involved Think Aloud interviews with parent and adolescent patients to complete tasks in the app as well as a User Experience questionnaire (score range, 0-120) and qualitative feedback. The accuracy of algorithms was determined by repeated testing of inputs and outputs over 4 weeks. RESULTS: Design and wireframes were iteratively refined through consultation with parents and adolescents confirming the final design. Beta testing evaluation was then completed by 25 participants including two adolescents. Across all participants, 84% of tasks were easy to navigate, and the Oncology Hub demonstrated high usability, usefulness, and acceptability with participants' scores ranging between 90 and 120 (mean = 112.2, standard deviation = 9.43). Qualitative feedback was positive. Testing of algorithms identified inconsistencies in understanding between clinical research and coding teams; refinements were made until the expected response notifications were returned with 100% accuracy. CONCLUSION: Technology offers new ways to think about how clinicians and families communicate and share information to harness the best of community and hospital services. Understanding how information is exchanged using health apps, and how this affects clinical workflow is critical to successful implementation, and optimizing symptom assessment and management in children with cancer.

International consensus definition of critical thinking in midwifery practice: A Delphi study.

PROBLEM: Currently there is no discipline-specific definition of critical thinking in midwifery practice. BACKGROUND: Critical thinking in midwifery practice is the cornerstone for safe, evidence based, and woman centred clinical decision-making. Available definitions of critical thinking in other disciplines do not align with midwifery practice which is distinctive, multidimensional and complex. AIM: To develop an international consensus definition of critical thinking in midwifery practice. METHODS: A two round Delphi study was used. Thirty-two international midwifery experts contributed to the first round which was qualitative in nature. Twenty one of these experts then ranked the relevance and clarity of concepts from round one. FINDINGS: A consensus definition of critical thinking in midwifery practice was achieved. The expert panel identified and defined 14 'Habits of Mind' and 12 Skills that are the core of critical thinking in midwifery practice. Skills included; analysis, constructive application and contextualisation of best available evidence, problem solving, discriminating, predicting, evaluation of care, collect and interpret clinical cues, collaboration/ negotiation, reflexivity, facilitates shared decision-making, communication, and transforming knowledge. Habits of Mind included; intellectual curiosity, reflective, holistic view, intellectual integrity, flexibility, questioning/challenging, participatory, open mindedness, listening with understanding and empathy, cultural humility, woman centred, being brave, confidence, and creativity. DISCUSSION/CONCLUSION: This study is an international first and delineates characteristics of critical thinking in midwifery. Development of a consensus definition provides a common and shared understanding of the skills and attributes required for critical thinking in midwifery practice and can also be applied in education and research.