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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
1
DUNEI: OCTOBER 23, 2011
AACC: JMO: 6/20/2012AACC: JMO: 6/20/2012
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.
AACC: JMO: 6/20/2012
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
AACC: JMO: 6/20/2012
(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
AACC: JMO: 6/20/2012
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
AACC: JMO: 6/20/2012
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?
AACC: JMO: 6/20/2012
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
AACC: JMO: 6/20/2012
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
AACC: JMO: 6/20/2012
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
AACC: JMO: 6/20/2012
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
AACC: JMO: 6/20/2012
Manage the Clinical Learning Environment
Expectations! – Expectations! – Expectations!
Yours Mine Theirs
STRUCTURE FOR SUCCESS!
AACC: JMO: 6/20/2012
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’
AACC: JMO: 6/20/2012AACC: JMO: 6/20/2012
FOR THE LEARNER:
THE TASK
IS
CRITICAL THINKING
AACC: JMO: 6/20/2012
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
AACC: JMO: 6/20/2012
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!
15
AACC: JMO: 6/20/2012AACC: JMO: 6/20/2012
UTILIZE ACTIVE THINKING STRATEGIES
AACC: JMO: 6/20/2012
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
AACC: JMO: 6/20/2012
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
AACC: JMO: 6/20/2012
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
AACC: JMO: 6/20/2012
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
AACC: JMO: 6/20/2012
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
AACC: JMO: 6/20/2012
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
AACC: JMO: 6/20/2012
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”
AACC: JMO: 6/20/2012
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
AACC: JMO: 6/20/2012
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
AACC: JMO: 6/20/2012
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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AACC: JMO: 6/20/2012
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:___________________________
AACC: JMO: 6/20/2012
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
AACC: JMO: 6/20/2012AACC: JMO: 6/20/2012
COOPERATIVE/COLLABORATIVE
LEARNING ACTIVITIES
Utilizing Peers as Professional Colleagues and Mentors
AACC: JMO: 6/20/2012
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
AACC: JMO: 6/20/2012
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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AACC: JMO: 6/20/2012AACC: JMO: 6/20/2012
DEBATE AND ‘REFLECTIVE’ STRATEGIES
Develops Insights into Perspectives, Context, and Complexity
PromotesIntegrative Processes, Inferences and
Objectivity
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AACC: JMO: 6/20/2012
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
AACC: JMO: 6/20/2012
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
AACC: JMO: 6/20/2012
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
AACC: JMO: 6/20/2012
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
AACC: JMO: 6/20/2012
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
AACC: JMO: 6/20/2012AACC: JMO: 6/20/2012
OUTCOMES
Evaluating the Learner’s Level of Critical Thinking
AACC: JMO: 6/20/2012
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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AACC: JMO: 6/20/2012
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
AACC: JMO: 6/20/2012AACC: JMO: 6/20/2012
CONCLUSIONS
AACC: JMO: 6/20/2012
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
AACC: JMO: 6/20/2012
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
AACC: JMO: 6/20/2012
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:
AACC: JMO: 6/20/2012
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:
AACC: JMO: 6/20/2012
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
AACC: JMO: 6/20/2012
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:
AACC: JMO: 6/20/2012
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: