Strategies to Aid the Nursing Student Think Critically in the Clinical Setting

1. DUNEI: October 23, 2011 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

2. Introduction and Overview:Critical Thinking: Program Objectives Describe how to implement strategies that would promote clinical thinking in the clinical setting, Indicate how to evaluate whether a learner is utilizing critical thinking skills in the clinical setting.

3. Critical Thinking: Defined by the National Council for Excellence in Critical Thinking, 1987 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 manner • Open to options • Ensures safe nursing practice and quality care • Requires ongoing appraisal of the reasoning process • Active reflection on the intellectual processes and ‘skilled reasoning’ involved(Heaslip, 2008)

4. Kirkpatrick’s Four Levels of Evaluation • Plan for Evaluation • (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”

5. Evaluation Behaviors ‘Flow’ from Definition • Is the Learner • Systematic and logical • Analysis of variables • Open to options and input • Reasoning • Fairness • Safe • Provide quality care • Precision • Revising and updating as new variables ‘arise’ • Relevance • Self-reflective/self-monitoring

6. Where to Begin? • 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 process • Know what is being taught in lecture, lab & simulation • Hold learners accountable for previously taught content • Expect adult learning behaviors!!! • Know Your Learner: • What do they know about being a nurse? • How do they ‘think about’ client care?

7. Be Clear About Roles • Learner Role: • The learners have one role • Learner • Faculty Role is Complex: • Continuous quality/performance improvement • Global Perspectives: • Experiential and Cultural Learning • Innovative • Teacher/Facilitator • Advisor • Coach • Cheerleader • Advocate • Embodies the ‘Spirit of Inquiry” • Incorporate evidence into practice • Excellence in Nursing Practice • Meets or exceeds Standards of Care • Socialization to Role of Nursing

8. Understand the Impact of Learning Styles • newway2see.com 7. DISCOVER YOUR DOMINANT STYLE OF LEARNING • URL: http://newway2see.com/2011/06/30/7-discover-your-dominant-style-of-learning/

9. Developing (Critical) Thinking Skills • Learner needs to • ‘Acquire’ the building blocks & component skills • Practice integrating components using active techniques • Apply components appropriately to client • Self-monitoring • Modify • Faculty Strategy: • Provide Specific and Concrete Feedback • Enhances the Quality of Learning • Maximizes learner Effort

10. Structure for Success: Clinical Orientation • 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 expectations • Build consensus with learners about learning goals and clinical outcomes

11. Structure For Success! • Manage the Clinical Learning Environment • Expectations! – Expectations! – Expectations! • Yours Mine Theirs

12. Structuring for Success:Promote Clinical ‘Continuity’ • Advocate for: • Dedicated clinical units vs. Traditional clinical unit assignments • Identified staff mentors/preceptors with enhanced skill sets • Learners reassigned to same facility when possible • E-mars in the college labs • Access to hospital based resources and/or handheld technology

13. For the Learner: The task IS critical thinking

14. Critical Thinking: Process and Outcomes Skilled Reasoning & Reflection • Promote Active Thinking • Knowledge Base for Clinical Practice Relate Concepts Independent Safe Care Nursing Model Consider Implications Nursing Process Integrate Processes Excellence Identify Complexity Pre- requisites Didactic Content Generate Inferences Incorporate Contextual Information Objectivity Critical Thinker Skills & Interventions Generate Options View Perspectives Socialization Confident & Empowered Learning Outcomes Clinical Reasoning

15. Active Thinking: The Critical Link! • Relate Concepts • Insightful in relationships; including cause and effect • Astute – understanding relationships • Consider Implication • Clever – seeing what isn’t said, but implied • Critical, shrewd – appraising variables • Identify Complexity • Skeptical – asking the question, “REALLY? – isn’t there more?” “What else is going on?” • Incorporate Contextual Information • What else contributes that influences the situation or outcome? • Sensitive to differing opinions • Sensitive to diversity • View Perspectives – including multiple perspectives • Views the ‘big’ picture from the perspective of ‘other’ • Self-corrective – observes self for mistakes in logic or bias • Generate Options • Cunning – using metacognition to go beyond facts

16. Utilize Active Thinking Strategies

17. Structure for Active Thinking • Non-’system’ questions • Are subjective • Affect hard to assess • May address affect • One ‘system’/component questions • Requires evidence and reasoning • Outcomes are knowledge level

18. Promote & Require Active Thinking • Relate Concepts via Multisystem Questions • Requires evidence, perception and reasoning • Some answers/judgments may be better than others • Aid learners to relate blocks of knowledge to formulate concepts and postulates • Relate assessment data to pathology/etiology/meds/labs/ • Examine context • Identify Multiple Perspectives • Discuss implications • If / then • Review options then Generate Options • Look at the client within the context of multiple environment/systems • Evaluate real and future care

19. Utilize Metacognition • Dynamic Process and Methodology that • User actively ‘selects’ schema/format/context • In which to integrate data • By which to evaluate data • Actively manipulate facts and details into transferrable knowledge • Evokes 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

20. Utilize Metacognition to Promote Critical Thinking • 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 Verbs • Relate • Consider • Incorporate • Differentiate • Formulate • Propose • Select among • Identify which Don’t Forget to Require Rationales & Evidence for All Respomses! • Conclude • Evaluate • Interpret • Justify • Analyze • Rate • Support • Plan

21. More ‘Active Thinking’ Strategies • Pre-conferences to focus learner’s ‘thinking about’ • 10 Second Assessments • Walking rounds • Discriminating among focused assessment data • SBAR handoffs • 4-3-2 reporting strategies • Do not underestimate the power of the Nursing process as a metacognition strategy • Applying clinical ‘work’ to program’s nursing model(s) • Evaluating effect of psychosocial factors on client physiological outcomes • Utilizing post-conferences to integrate data over time • Progressive cases/case studies

22. Have Learners Phrase Own Questions • 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

23. Thinking “Out Loud” • 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

24. Incorporate Multiple Learning Styles • 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

25. Visual Metacognitive Tools Concept Map Venn Diagrams

26. Concept Maps – Mind Maps • Organized components visually and shows relationships • Aids learners • To see relatedness of single components to complex functioning • To see what information might be missing • To determine what connections are missing • Consider implications and relatedness of components • Aids in determining relationship of contextual information • Allows validation

27. Concept Mapping 29 Chronic illness Gender Role strain AGE Past experience in Health Care System Ethnicity DOE; WC bound; O2 Health Seeking Behaviors Level of Wellness Lost Job 3 minor children Economic Factors Other Variable ??

28. 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 Concept Map Client Diagnosis:___________________________

29. Venn Diagram • 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

30. Cooperative/Collaborative Learning Activities Utilizing Peers as Professional Colleagues and Mentors

31. Cooperative Learning: AKA - Group Activities • Use to replace or augment traditional post-conference • Promotes Active Learning Strategies: • Explanation, interpretation, inference, & analysis • Pair and Share • Cooperative Documentation • Need to work together to select the key points to document • Client teaching: • Kinesthetic Activities • Practice doing a procedure with same disability as client’s prior to teaching it to the client

32. Raising the Bar: Use Multiple Skill-Sets • Faculty Strategy: 4-3-2 • Repeating content to fine-tune discrimination skills • SBAR Peer Mentoring Learner in ‘Charge’ • Put learner in charge when you are ‘busy’ or off unit

33. Debate and ‘Reflective’ Strategies Develops Insights into Perspectives, Context, and Complexity Promotes Integrative Processes, Inferences and Objectivity

34. Debate: Client Advocate • Moves learners from knowledge to deeper insights • Faculty Strategy: • Challenge assumptions • Go beyond on the planned or obvious • Develops contextual information • Identifies complexities • Require objectivity • Expect competence in role • Practice results in confidence • Faculty Strategy: • Stand BEHIND learners when they are managing a difficult verbal interaction

35. Case Study + Projection • Learners utilize client’s information + projects what would happen ‘if’s …’ • Content to Include: • Anticipated assessments • Goal setting • Nursing interventions & rationales • Evaluation of outcomes • Can be done as a group or individually • As group activity • Can work on whole activity or by components

36. Developing ‘Other’-Insights: Narrative Pedagogy • Projecting the life experiences of the client based on • Psychosocial • Past 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 Information • Perspectives • Options, and • Complexities

37. Reflection/Reflective Journaling • Purposeful thinking • Focuses 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

38. Designing Your Own Critical Thinking Activities Determine goal(s) of learning activity Select cognitive skill(s) to be utilized Write the activity Review for clarity Evaluate the activity: Were the directions clear; did it ‘run’ as planned Learner develops competence as a CRITICAL THINKER Start with your BIG IDEA How is the learning activity to be evaluated. Is it graded? Determine learning domains for the activity Do the Activity: be the coach & cheerleader Evaluate for: Analysis, Discrimination, Logical Reasoning Metacognition

39. Outcomes Evaluating the Learner’s Level of Critical Thinking

40. Critical Thinking Behaviors • Perceptive – including multiple perspectives • Insightful – relating cause and effect • Astute – understanding relationships • Sensitive to Differing Opinions • Clever – seeing what isn’t said, but implied • Cunning – using metacognition to go beyond facts • Sensitive to Diversity • Skeptical – asking the question, “REALLY? – isn’t there more?” “What else is going on?” • Critical, shrewd – appraising variables • Self-corrective – observes self for mistakes in logic or bias • Honest in appraisals

41. Outcome Evaluation Kirkpatrick’s Levels of Evaluation • Level 4: RESULTS / Clinical Reasoning • Level 3: TRANSFER / Active Thinking • Level 2: LEARNING / Knowledge : Application • Level 1: REACTION / “Conventional Wisdom” Do you observe • Integration of processed • Inferences • Objectivity • Independent nursing care • Safe nursing care • Excellence • Confidence • Empowerment • Critical thinking • Clinical reasoning

42. Conclusions

43. Learner Success • 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

44. Preparing the Graduate for Practice Nursing is a Dynamic Process therefore Nursing Education needs to be DYNAMIC as well! • Stringent Standards of Care • Emerging and global health concerns • Technological advancements • The role of the Nurse is Complex: • Continuous quality/performance improvement • Evidence and rationale based • Innovation • ‘Spirit of Inquiry” • Excellence in Nursing Practice

45. Selected References: • 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.

46. Selected References: • 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/teachingstrategies.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.

47. Selected References • 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

48. Selected References: • 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

49. Selected References: • 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