AACC: JMO: 6/20/2012

STRATEGIES TO AID THE NURSING STUDENT THINK CRITICALLY

IN THE CLINICAL SETTING

Joann M. Oliver, MNEd, RN, CNE

Anne Arundel Community College

jmoliver@aacc.edu

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DUNEI: OCTOBER 23, 2011

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INTRODUCTION AND OVERVIEW:CRITICAL THINKING:

PROGRAM OBJECTIVES

1. Describe how to implement strategies that would promote clinical thinking in the

clinical setting, 2. Indicate how to evaluate whether a learner

is utilizing critical thinking skills in the clinical setting.

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Involves:Clarity, accuracy, precision, consistency, relevance, sound evidence, good reasons, depth, breadth, and fairness (Scriven & Paul, 1987)

Critical thinking for clinical decision-making Ability to think in a systematic and logical mannerOpen to options Ensures safe nursing practice and quality care Requires ongoing appraisal of the reasoning processActive reflection on the intellectual processes and ‘skilled reasoning’ involved (Heaslip, 2008)

CRITICAL THINKING: DEFINED BY THE NATIONAL COUNCIL FOR EXCELLENCE

IN CRITICAL THINKING, 1987

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(Kirkpatrick,1994) URL: http://www.4cleanair.org/Kirkpatrick.pdf

Level 4: Clinical Reasoning

Level 3: Active Thinking

Level 2: Knowledge : Application

Level 1: “Conventional Wisdom”

KIRKPATRICK’S FOUR LEVELS OF EVALUATION

PLAN FOR EVALUATION

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Is the LearnerSystematic and logical

Analysis of variablesOpen to options and input

ReasoningFairness

Safe Provide quality care

Precision Revising and updating as new variables ‘arise’

RelevanceSelf-reflective/self-monitoring

EVALUATION BEHAVIORS ‘FLOW’ FROM DEFINITION

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Know what your Learner Knows:All faculty need to speak the ‘same version’ of the nursing ‘language’ in your program

Brush up on the nursing processKnow what is being taught in lecture, lab & simulationHold learners accountable for previously taught contentExpect adult learning behaviors!!!

Know Your Learner:What do they know about being a nurse?How do they ‘think about’ client care?

WHERE TO BEGIN?

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Faculty Role is Complex:Continuous quality/performance improvementGlobal Perspectives:

Experiential and Cultural LearningInnovative

Teacher/FacilitatorAdvisorCoachCheerleaderAdvocate

Embodies the ‘Spirit of Inquiry”Incorporate evidence into practice

Excellence in Nursing PracticeMeets or exceeds Standards of Care

Socialization to Role of Nursing

Learner Role:

The learners have one role

Learner

BE CLEAR ABOUT ROLES

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newway2see.com 7. DISCOVER YOUR DOMINANT STYLE OF LEARNING

URL: http://newway2see.com/2011/06/30/7-discover-your-dominant-style-of-learning/

UNDERSTAND THE IMPACT OF LEARNING STYLES

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Learner needs to ‘Acquire’ the building blocks &

component skillsPractice integrating components using

active techniquesApply components appropriately to clientSelf-monitoring Modify

Faculty Strategy:Provide Specific and Concrete Feedback

Enhances the Quality of Learning Maximizes learner Effort

DEVELOPING (CRITICAL) THINKING SKILLS

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Overcome learner anxiety

Ask yourself: Do your learners see themselves as powerlessness?

Knowledge deficits r/t unclear faculty/course expectations

Lack of confidence in role/skills

Intimidated by staff and staff expectations

Hospital milieu a mystery

Faculty Strategy:

Be transparent about learner expectationsBuild consensus with learners about learning goals and clinical outcomes

STRUCTURE FOR SUCCESS: CLINICAL ORIENTATION

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Manage the Clinical Learning Environment

Expectations! – Expectations! – Expectations!

Yours Mine Theirs

STRUCTURE FOR SUCCESS!

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Advocate for:Dedicated clinical units vs. Traditional clinical unit assignmentsIdentified staff mentors/preceptors with enhanced skill setsLearners reassigned to same facility when possibleE-mars in the college labs Access to hospital based resources and/or handheld technology

STRUCTURING FOR SUCCESS:PROMOTE CLINICAL

‘CONTINUITY’

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FOR THE LEARNER:

THE TASK

IS

CRITICAL THINKING

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Learning Outcomes

Integrate Processes

Generate Inferences

Confident & Empowered

Clinical Reasoning

IncorporateContextual Information

Identify Complexity

Generate Options

CRITICAL THINKING: PROCESS AND OUTCOMES

Pre- requisites

Nursing Model

Skills & Interventions

Nursing Process

Didactic Content

Skilled Reasoning & Reflection

View Perspectives

ConsiderImplications

Excellence

Relate Concepts

Objectivity

Independent Safe Care

Knowledge Base for Clinical Practice

Critical Thinker

Promote Active Thinking

Socialization

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Relate ConceptsInsightful in relationships; including cause and effectAstute – understanding relationships

Consider ImplicationClever – seeing what isn’t said, but impliedCritical, shrewd – appraising variables

Identify ComplexitySkeptical – asking the question, “REALLY? – isn’t there more?” “What else is going on?”

Incorporate Contextual InformationWhat else contributes that influences the situation or outcome?

Sensitive to differing opinions Sensitive to diversity

View Perspectives – including multiple perspectivesViews the ‘big’ picture from the perspective of ‘other’Self-corrective – observes self for mistakes in logic or bias

Generate OptionsCunning – using metacognition to go beyond facts

ACTIVE THINKING: THE CRITICAL LINK!

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UTILIZE ACTIVE THINKING STRATEGIES

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Non-’system’ questionsAre subjective Affect hard to assessMay address affect

One ‘system’/component questionsRequires evidence and reasoning Outcomes are knowledge level

STRUCTURE FOR ACTIVE THINKING

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Relate Concepts via Multisystem QuestionsRequires evidence, perception and reasoningSome answers/judgments may be better than othersAid learners to relate blocks of knowledge to formulate concepts and postulates

Relate assessment data to pathology/etiology/meds/labs/ Examine context

Identify Multiple PerspectivesDiscuss implicationsIf / then

Review options then Generate OptionsLook at the client within the context of multiple environment/systemsEvaluate real and future care

PROMOTE & REQUIRE ACTIVE THINKING

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Dynamic Process and Methodology thatUser actively ‘selects’ schema/format/context

In which to integrate data By which to evaluate data

Actively manipulate facts and details into transferrable knowledgeEvokes analysis by user as they evaluate and Integrate Information

Faculty Strategy:Focus learners on needed data and nursing process(es) at their current level in curriculum

UTILIZE METACOGNITION

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Faculty Strategy:Client Oriented Questions:

Contributing factors

Correlations or analogies

Clarity

Relevance

Depth

Logic

Significance

Options not selected or supported

Opposing points of view

New examples

Use Higher Level VerbsRelate

Consider

Incorporate

Differentiate

Formulate

Propose

Select among

Identify which

Don’t Forget to Require

Rationales & Evidence

for All Respomses!

UTILIZE METACOGNITION TO PROMOTE CRITICAL THINKING

Conclude

Evaluate

Interpret

Justify

Analyze

Rate

Support

Plan

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Pre-conferences to focus learner’s ‘thinking about’10 Second AssessmentsWalking rounds Discriminating among focused assessment dataSBAR handoffs4-3-2 reporting strategiesDo not underestimate the power of the Nursing process as a metacognition strategyApplying clinical ‘work’ to program’s nursing model(s)Evaluating effect of psychosocial factors on client physiological outcomesUtilizing post-conferences to integrate data over time

Progressive cases/case studies

MORE ‘ACTIVE THINKING’ STRATEGIES

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Prior to learning activity: “Why do you want to learn what you want to learn today?”

During client care:Chart review questions: expected/puzzling/surprising

After conclusion of care:What question do you wish you had asked in report?

What would you have liked to ask the client about their history/symptoms/pain level/etc.?

What did you want you peer to ask you while you were working together?

What question do you wish I had asked you (so you could clarify/brag about your accomplishment/because you felt awkward asking it yourself?

Generating Inferences, Confidence, and Empowerment

HAVE LEARNERS PHRASE OWN QUESTIONS

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Model Desired Behaviors: Faculty shows links between content areas

Cues learners as to what you expect from them

Think on your their feet: Have learner talk it through

Aid in developing inferences

Empower the learner by rewarding competence

Provide for privacy

Allow safety-net

Phone a friend

Allow learner to take a break, but must return to dialogue

THINKING “OUT LOUD”

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Faculty Strategy: Provide activities with options in multiple learning modalities

Present it verbally

Develop a 3-D representation or other ‘visual’

Act it out!

Develop mnemonics

Create their own learning activity

INCORPORATE MULTIPLE LEARNING STYLES

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Concept MapVenn Diagrams

VISUAL METACOGNITIVE TOOLS

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Organized components visually and shows relationships

Aids learners To see relatedness of single components to complex functioningTo see what information might be missingTo determine what connections are missingConsider implications and relatedness of componentsAids in determining relationship of contextual informationAllows validation

CONCEPT MAPS – MIND MAPS

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CONCEPT MAPPING

Health Seeking

Behaviors

Level of Wellness

Past experienc

e in Health Care

SystemEthnicity

GenderAGE

Other Variable ?

?

Economic Factors

DOE; WC

bound; O2

Chronic illness Role stra

in

Lost Job

3 m

inor

ch

ildre

n

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CONCEPT MAP

Pathophysiology

Primary Sign/Symptom:Nursing Dx or Priority:

Related Sign/Symptom:Nursing Dx or Priority

Related Sign/Symptom:Nursing Dx or Priority

Nursing Care: Rationale and Physiologic Result of Nursing Care:

1.

2.

3.

4.

5

Client Diagnosis:___________________________

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3 client variables – develop all three; determine relationships; have learner determine greatest priority; then defend it

Use Venn diagrams with concept map to illuminate specifics

VENN DIAGRAM

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learner 1: Variable 1

learner 3:

Variable 3

learner 2:

Variable 2

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COOPERATIVE/COLLABORATIVE

LEARNING ACTIVITIES

Utilizing Peers as Professional Colleagues and Mentors

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Use to replace or augment traditional post-conferencePromotes Active Learning Strategies:

Explanation, interpretation, inference, & analysis

Pair and ShareCooperative Documentation♦ Need to work together to select the key points to

documentClient teaching:

Kinesthetic ActivitiesPractice doing a procedure with same disability as client’s prior to teaching it to the client

COOPERATIVE LEARNING: AKA - GROUP ACTIVITIES

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Faculty Strategy:4-3-2

Repeating content to fine-tune discrimination skillsSBAR

Peer Mentoring

Learner in ‘Charge’Put learner in charge when you are ‘busy’ or off unit

RAISING THE BAR: USE MULTIPLE SKILL-SETS

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DEBATE AND ‘REFLECTIVE’ STRATEGIES

Develops Insights into Perspectives, Context, and Complexity

PromotesIntegrative Processes, Inferences and

Objectivity

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Moves learners from knowledge to deeper insights

Faculty Strategy:Challenge assumptionsGo beyond on the planned or obvious

Develops contextual informationIdentifies complexitiesRequire objectivityExpect competence in rolePractice results in confidence

Faculty Strategy:Stand BEHIND learners when they are managing a difficult verbal interaction

DEBATE: CLIENT ADVOCATE

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Learners utilize client’s information + projects what would happen ‘if’s …’

Content to Include:Anticipated assessmentsGoal settingNursing interventions & rationalesEvaluation of outcomes

Can be done as a group or individuallyAs group activity

Can work on whole activity or by components

CASE STUDY + PROJECTION

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Projecting the life experiences of the client based onPsychosocialPast and/or current health status

Learners analyze, interpret and share the long-term impact of the health care experience of a client, family, or community

Requires Learners to Infer, Integrate, and Reason Promotes use of

Contextual InformationPerspectivesOptions, andComplexities

DEVELOPING ‘OTHER’-INSIGHTS: NARRATIVE PEDAGOGY

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Purposeful thinkingFocuses on past and present learning or experiences

Used to enhance and extend learning through self-directed dialog, analysis/evaluation

Allows for faculty to determine ‘connections’ between activity and learner ‘experience’ related to it

Often used to assess affective domain

REFLECTION/REFLECTIVE JOURNALING

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Determine goal(s)

of learning activity

Select cognitive skill(s) to be utilized

Determine learning domains for theactivity

Write the activityReview for clarity

How is the learning activity to be evaluated.Is it graded?

Do theActivity: be the coach & cheerleader

Evaluate the activity:Were the directions clear; did it ‘run’ as planned

Evaluate for:Analysis,Discrimination, Logical Reasoning Metacognition

Start with your BIG IDEA

Learner develops competence as a CRITICAL THINKER

DESIGNING YOUR OWN CRITICAL THINKING ACTIVITIES

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OUTCOMES

Evaluating the Learner’s Level of Critical Thinking

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Perceptive – including multiple perspectivesInsightful – relating cause and effectAstute – understanding relationshipsSensitive to Differing OpinionsClever – seeing what isn’t said, but impliedCunning – using metacognition to go beyond factsSensitive to DiversitySkeptical – asking the question, “REALLY? – isn’t there more?” “What else is going on?”Critical, shrewd – appraising variablesSelf-corrective – observes self for mistakes in logic or biasHonest in appraisals

CRITICAL THINKING BEHAVIORS

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Kirkpatrick’s Levels of EvaluationLevel 4: RESULTS / Clinical ReasoningLevel 3: TRANSFER / Active ThinkingLevel 2: LEARNING / Knowledge : ApplicationLevel 1: REACTION / “Conventional Wisdom”

Do you observeIntegration of processedInferencesObjectivityIndependent nursing careSafe nursing care

OUTCOME EVALUATION

ExcellenceConfidenceEmpowermentCritical thinkingClinical reasoning

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CONCLUSIONS

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Use Active Thinking Strategies and Cognitive Skills during all clinical activities until it becomes second nature to the learner : Critical Thinker

Analyzing

Applying standards

Discriminating

Seek information appropriately and

efficiently

Logical reasoning

Metacognition

Predicting and transforming knowledge

LEARNER SUCCESS

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Nursing is a Dynamic Process therefore Nursing Education needs to be DYNAMIC as well!

Stringent Standards of CareEmerging and global health concernsTechnological advancements

The role of the Nurse is Complex:Continuous quality/performance improvementEvidence and rationale basedInnovation‘Spirit of Inquiry”Excellence in Nursing Practice

PREPARING THE GRADUATE FOR PRACTICE

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Faculty Development: Teaching Tips Index. Retrieved 9/2010

URL: http://honolulu.hawaii.edu/intranet/committees/FacDevCom/

guidebk/teachtip/teachtip.htm

Forneris, S. G. and Peden-McAlpine, C. (2007) Evaluation of a reflective learning intervention to improve critical thinking in novice nurses. Journal of Advanced Nursing 57(4), 410 – 421.

Doi: 10.111/j.1365-2647.2006.04120.x

Heaslip, P. (2008 - revised) Critical Thinking and Nursing, 1993 . Thompson Rivers University, The Critical Thinking Community. Retrieved 10/3/2011 URL: http://www.criticalthinking.org/pages/critical- thinking-and-nursing/834

Kupier, R. A. (2004). Promoting cognitive and metacognitive reflective reasoning skills in nursing practice: self-regulated learning theory. Journal of Advanced Nursing , 45 (4), 381 - 391.

 

SELECTED REFERENCES:

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Mandernach, B. J. Thinking Critically About Critical Thinking: Integrating Online Tools to Promote Critical Thinking. Retrieved 9/2010

URL: http://www.insightjournal.net/Volume1/Thinking%20 Critically%20about%20Critical%20Thinking-%20Integrating%20 Online%20Tools%20to%20Promote%20Critical%20Thinking.pdf  

Montana State University. Teaching Resources. Retrieved 9/20

URL: http://www.montana.edu/teachlearn/Papers/teaching strategies.html

Moscato, S. R., et al. (2007). Dedicated education unit: An innovative clinical partner education model. Nursing Outlook, 55, 31-37. 

Myrick, F. a. (2002, May-June). Preceptor Questioning and learner Critical Thinking. Journal of Professional Nursing , 176 - 181.

 

SELECTED REFERENCES:

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Nursing Executive Center. (2008). Bridging the Preparation-Practice Gap Volume I: Quantifying New Graduate Nurse Improvement Needs. The Advisory Board Company.

Notarianni, M. A. (2009). Engaging Learners Across Generations: The Progressive Professional Development Model. The Journal of Continuing Education in Nursing , 40 (6), 261 - 266.

Paul, R. a. (2008). The Miniature Guide to Critical Thinking Concepts and Tools. Dillon Beach, California: The Foundation for Critical Thinking Press. 

Pierce, B. and Prince George’s Community College Faculty Members. 2004-2005 The year of Thinking Critically – Handbook of Critical Thinking Resources. Retrieved 9/20 URL: http://academic. pgcc.edu/~wpeirce/MCCCTR/handbook.pdf

 

SELECTED REFERENCES

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 Reinstein, A. Developing Critical Thinking in College Programs. Retrieved 6/2011. URL: http://www.aabri.com/manuscripts/08046.pdf  

Snyder, M. J.. In The Crawford County READ Program – Open a New World!: Critical Thinking: Teaching Methods & Strategies. Retrieved 9/2010. URL: http://readprogram.net/Documents/HANDOUT%20-%20Critical%20Thinking%20%20Teaching%20Methods%20and%20Strategies.doc

Standing, M. (2008) Clinical judgment and decision-making in nursing – nine models of practice in a revised cognitive continuum. Journal of Advanced Nursing 62(1), 124-134 doi: 10.111/j.1365-2648.2007.04583.x 

The Foundation for Critical Thinking: The Critical Thinking Community

Retrieved 9/2010. URL: http://www.criticalthinking.org/

University of Portland website: http://nursing.up.edu/default.aspx?cid=7700&pid=2959

SELECTED REFERENCES:

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Weimer, M. Think Alouds Shed Light on How Students Grapple with Content. Faculty Focus Retrieved 1/6/12 URL: http://www.facultyfocus.com/articles/teaching-professor-blog/think-alouds-shed-light-on-how-students-grapple-with-content/

Winfrey, E. C. Kirkpatrick's Four Levels of Evaluation. Retrieved 10/2011 . URL: http://www.4cleanair.org/Kirkpatrick.pdf

One of my favorite reminders of why one needs to think

critically; Because Problem Solving DOES NOT = Critical

Thinking YouTube – Takoma URL: http://www.youtube.com/watch?

v=9lQaId DI5 OE&p=5509301396412279&index=1

SELECTED REFERENCES: