Assessing clinical decision making skills using an online interactive tool

1. Assessing clinical decision making skills using an online interactive tool Ali Wyllie & Verina Waights Faculty of Health and Social Care COLMSCT CETL Fellows Open CETL Conference: Building bridges 24-25th September 2008

2. Outline • Context of Project • Quality eLearning experience • Outline characteristics of CDM tool • Demo CDM • Findings to date • Looking to the future

3. Background • Nurses make clinical decisions in response to changes in each patient's condition, which may occur within very small time-frames • The ability to make clinical judgements depends on both a sound theoretical background and good decision-making skills • Clinical decisions are strongly influenced by the context in which they are made (Bucknall 2000) • As the complexity of decision tasks increases, so context-specific knowledge determines the effectiveness of decision-making (Botti & Reeve 2003)

4. Aims • to develop a web-based tool to provide decision-making opportunities, building on Laurillard (2002): who suggests that: • ‘Traditional modes of assessment of knowledge are seen as inadequate because they fail to assess students‘ capability in the authentic activities of their discipline’. • to assess nursing students’ decision-making skills in a context-driven virtual environment.

5. Quality eLearning for learner enagagement • Boud and Prosser’s (2002) principles for designing a high quality learning environment suggests learning activities should: • support learner engagement - build on prior knowledge • acknowledge the learning context – integral with study • seek to challenge learners – active participation • provide practice – through individual and/or group activities

6. Pedagogical approach • Based on principles of case-based learning design and experiential learning (Kolb 1984). • Students’ options are scaffolded • Learning is student - led and asynchronous • Feedback is contexual, individualised to student’s learning journey and timely (Nicol and Milligan 2007: 72, Principle 6) • Intention is to assist students to practice in risk-free environment until ready to practice in work setting.

7. Research methods • Students’ perceptions of their decision-making skills and efficacy of the tool will be evaluated through: • Individual completion of an online questionnaire to enable quantitative and qualitative evaluation • Qualitative output from video observation and ‘Think aloud’ techniques with students’ interacting in the IET Userlab

8. Case study: patient with a leg ulcer • Context: Miss Alice Phelps, a (fictitious) 80 year old lady with an ulcer on her left lower leg. • Realistic: case prepared in collaboration with a practice nurse to mimic reality • Ethical: consent obtained from the ‘real’ patient and anonymity assured • Relevant: Wound healing and clinical decision-making are integral components of Nursing Programme of study.

9. Case study – patient with leg ulcer

10. Narrative • The story evolves over a series of consultations depending on the treatment the patient receives. • At each stage students consult resources to find out about their patient’s condition. • They determine the best treatment from 3 available options. • Their decisions result in the patient progressing through successive consultations until an end point is reached. • They are encouraged to have a second attempt at the maze if their first attempt is unsuccessful. • Images of the consultations and patient’s final outcome create a visual narrative within the maze

11. Practice Resources • The students have a range of media resources to consult: • Audios of consultations between the nurse and patient • Photos of leg ulcers • Instruction sheets on possible treatments • Patient charts and records • Patient records • Laboratory reports • Links to the BNF (British National Formulary)

12. Reflective Log • The Reflective Log captures each decision point and the student’s reasons for their choice. • At the end of each attempt the student can review their pathway and reflect on their decisions and reasoning. • The final attempt additionally provides author feedback on decision-making at each stage.

13. Example Feedback in Reflective log • Reflective log • Miss Alice Phelps, a lively and independent 80 year old lady came to the surgery on 17th February with an ulcer on her left lower leg. How would you help her? You chose: A. Take a swab and apply a viscopaste dressingWhy:The wound assessment chart indicates a venous ulcerFeedback: The correct decision here would be to apply a viscopaste dressing and take a swab to check for infection. It would also be an acceptable decision to apply a silver dressing to prevent infection. Algae-based dressings are unsuitable in this instance because they are used to absorb exudates and Miss Alice Phelps’ ulcer has only low levels of exudate. Miss Alice Phelps has returned to your clinic. You chose: A. Prescribe penicillin and apply a viscopaste dressingWhy: It needs an antibiotic and penicillin is broad spectrum.Feedback:The correct decision here would be to prescribe erythromycin and apply a viscopaste dressing as there are bacteria present in the ulcer. Although S.aureus is sensitive to penicillin as well as to erythromycin, you should not prescribe penicillin to Miss Phelps because her records show that she is allergic to penicillin.

14. Scoring • Scoring at each decision point depends on the type of decision as outlined below and whether it is the first or second attempt: • For example: • 1st attempt: a 5 b 3 c 0 2nd attempt: a 3 b 2 c 0 • The final score is an average of the two attempts at the maze.

15. Demo • http://learn.open.ac.uk/mod/resourcepage/view.php?id=79337&superfluous=357

16. Findings to date - score • 11 students completed tool/27 students partly completed tool

17. Findings to date - questionnaire

22. Students felt using CDM tool: • Increased their confidence in decision-making and caring for leg ulcers - support learner engagement • ‘a very helpful tool in confidence-building’ ‘helped a great deal - more please!’ • Would assist in their practice - acknowledge the learning context • ‘I found that it made you think about what you are doing for the patient’. • Seek to challenge learners – active participation • ‘very keen to expand my new skills, these questions taxed me!’

23. Looking toward the future • The approach piloted in this project can be applied in part or whole in other courses, programmes or disciplines. • The tool can be combined with other VLE tools, such as online discussion forums and voting tools, to create flexible and collaborative learning and assessment sequences. • The Reflective Log can become part of a TMA. • Our findings are being used to inform future assessment strategies within HSC. We are particularly interested in: Contextualised CMA questions; Narratives; Embedded multiple media; Case-based CMAs; Decision-Making;

24. Contact • If you are interested in our work we can be contacted on: • Ali Wyllie (a.j.wyllie@open.ac.uk) • Verina Waights (v.waights@open.ac.uk)