Debra Sibbald
BScPhm, RPh, ACPR, MA, PhD

Critical
Reasoning Content:
Theory, Rubrics,
Elements &
Standards
Getting Started:
Discover Your
Learning Style
Inventory
Critical
Reasoning Skills -
Guided Reflection:
Theory & Stages
Examples
Critical Reasoning
Guided Reflection
Exercises

Issues important in educating for self-regulated life-long learning:
• Define critical reasoning
• Describe a rubric for elements of critical reasoning
• Describe critical reasoning elements in problem-based learning
• Recognize elements of confidence related to critical reasoning
• Recognize theoretical frameworks to measure critical reasoning
• Recognize elements of thought and logic
• Describe critical reasoning standards for integration in verbal and written tasks

Martha Nussbaum June12, 2010 G&M
The intellectually disciplined process of actively and skillfully
– Conceptualizing
– Applying
– Analyzing
– Synthesizing
– And/or evaluating
Information as a guide to action , gathered from or generated by
– Observation
– Experience
– Reflection
– Reasoning
– Communication
In exemplary form, based on universal intellectual values that transcend subject matter divisions:
– Clarity
– Accuracy
– Precision
– Consistency
– Relevance
– Sound evidence
– Good reasons
– Depth
– Breadth
– Fairness

• Necessary to meet course objectives
– Explain implications of issues and content for pharmacy.
– Analyze these issues from the perspectives of all major stakeholders, such that a balanced assessment is obtained.
– Develop strategic pharmacist-initiated responses to changing situations
• “Critical thinking is a prerequisite skill in making
[professional] judgments.”
• “What every person needs to survive [thrive] in a rapidly changing world.”

The disciplined mental activity of evaluating arguments or propositions [or situations] and making judgments that can guide the development of beliefs and taking action.
(Huitt 1998)
This requires developing expertise

Overall Goal = Medication Therapy Experts
‘As Medication Therapy Experts pharmacy graduates inspire confidence in their ability and commitment to consistently fulfill their professional responsibilities, including having the fundamental knowledge and skills required for their profession; the motivation, professionalism and confidence to apply this knowledge and these skills appropriately and effectively; and an attitude that enables them to make and act upon scientificallysound decisions in a confident manner’.

• Expert reasoners make decisions with
– Confidence (valid)
– Rapidity and efficiency
– Accuracy
– Recognition of when to slow down - recalibration
• The Expert transitions from a Novice through Experience
• Other characteristics experts display include
– progressive problem solving
– deep understanding of knowledge within the context
– commitment to advancing knowledge for society (Patel, Arocha, &
Kaufman, 1999)

• Encourage the transition from novice to expert with combining
– Context
– Modeling
– More experiences
–  using judgment in decision making

1. Self-directed
• Student must be in charge of their own learning goals, method of study/preparation
2. Constructive
• Students anticipate and create learning problem/cases/solutions
3. Contextual
• Specific for the context or area of practice of the course
4. Collaborative
• Involves working with a class community or group of other learners

A: Agency:
– Self-direction & self-regulation in
• determining learning goals, content, assessment measures
C: Collaboration:
– negotiating the fit of individual ideas with peers
– synthesizing & advancing community knowledge – collective responsibility
E: Expertise: derived from
• observation of models
• iterative, progressive active learning contexts to develop:
- evaluation skills
- confidence in conceptualization, judgments & communication
– skill in knowledge transfer at the appropriate audience level

Learning Continuum
Constructs
AFPC
Competencies
Themes
Care Provider Critical
Reasoning
Communicator Critical
Appraisal
Collaborator Pharmaceutical
Care
– PC Process
Entry
Level
Tests
Manager
Ethics &
Professionalism
Advocate
Beginner Intermediate knowledge skills
Formati ve
Tests
Advanced
PEBC
&
NAPRA
Readiness to
Practice
Scholar
Professional
Patient
Safety attitudes

Course Outline is a Guide for students to know how to prepare & study
• Learning objectives for the course are set
– three basic levels :of objectives
• For knowledge
• For skills
• For attitudes
Introductory = knowledge and comprehension of concepts, definitions,
Intermediate = application of concepts to simple situations
Advanced = application of concepts to more complex situations with ability to synthesize and evaluate
• Also may see for each weekly session

• Bloom Taxonomy of Educational Objectives
– 6 levels
• Biggs & Collis – the Solo Taxonomy
(Structure of Observed Learning Outcomes)
– 5 levels
• Miller’s Taxonomy of Competency Performance
– 6 levels

Bloom BS et al, Handbook on formative and summative evaluation of student learning,
McGraw-Hill Book Company,
New York (1971) 932 p
Critical
Reasoning
Skills

Advanced
Intermediate
Introductory
Critical
Reasoning
Skills

– Specific
• Be precise about desired outcomes
– Measurable (avoid ambiguous terms – ‘understand’)
• Quantify objectives using Blooms or other Taxonomies
– Achievable
• Ensure realistic expectations
– Relevant
• Align with practice and/or organizational goals
– Timed
• State when objective will be achieved

Progressive problem solving judge put together see significant parts use understand remember
Analysis :
Analyze
Appraise
Contract
Contrast
Synthesis :
Arrange
Assemble
Collect
Combine
Evaluation :
Appraise
Assess
Choose
Compare
Those that communicate critical reasoning:
Criticize
Debate
Deduce
Detect
Diagram
Differentiate
Distinguish
Experiment
Infer
Inspect
Inventory
Measure
Question
Separate
Summarize
Compose
Construct
Create
Design
Detect
Critique
Decide
Determine
Estimate
Document
Formulate
Generalize
Integrate
Manage
Evaluate
Grade
Judge
Measure
Organize
Outline
Plan
Prepare
Prescribe
Rank
Rate
Recommend
Revise
Produce
Propose
Specify
Validate
Score
Select
Test
Demonstrate
Diagnose
Diagram
Empathize
Hold
Integrate
Internalize
Listen
Those that impart skills :
Massage
Measure
Operate
Palpate
Pass
Percuss
Project
Record
Visualize
Write
Those that convey attitudes :
Acquire
Consider
Exemplify
Modify
Plan
Realize
Reflect
Revise
Transfer

introductory intermediate advanced

introductory advanced intermediate

Knowledge: learning objectives
Introductory Level:
1) describe the structural and functional characteristics of a) the four major classes of tissues, and their locations throughout the human body
Assessment Methodologies Learning Objective Addressed
Assessment 1: 1. a) (October 12)
Assessment 2: 1. b) - h)
Assessment 3: 1. i) - l) introductory
Study Guide: How to Succeed in PHM145H…. (E-value)
PHM145H is divided into three sections, each with its own non-cumulative, multiple choice exam. Students with a background in cell biology may have an advantage during the first section on histology. However, these students are warned not to become complacent as we move on to systems anatomy in the second and third sections of the course. Sample questions for each exam will be posted on the course website.
They are intended to provide a sample of my style of exam question, not to be comprehensive of course content expectations . The latter is reflected in the course objectives.
I do not return exams to students, but once exam marks are released, students are welcome to come to my office to review their exams should they wish to do so.

Biggs, J.B. (1982). Evaluating the quality of learning: the SOLO taxonomy (structure of the observed learning outcome.
Australia: Academic Press, 245 p.
Teaching / Learning Levels for Critical Reasoning introductory intermediate
1
Pre-
Structural
2
Unistructural
3
Multistructural advanced
4
Relational
5
Extended
Abstract
Lack of understanding or cohesive thinking
Exploration of rudimentary ideas
Connections and analysis of multiple components
(formulaic)
Synthesis and integration of situated relevant
components.
Demonstrates transfer:
Insights, extensions, perceptive evaluation , or critical judgements

GLOBAL RATING SCALE LABS
RESPONSE TO PATIENT S FEELINGS NEEDS AND VALUES (EMPATHY)
1 2
Does not respond to obvious patient cues (verbal, and/or tonal, and/or non-verbal and/or responds inappropriately
3
Responds to patient s cues, but not consistently and/or always effectively.
MANAGEMENT OF THE INTERVIEW
1 2
No recognizable plan to the interaction, the plan is not clear to the patient and/or the patient must determine direction of the interview
3
Plan is formulaic, minimally flexible or vague; does not
consistently integrate information for the patient, some information may not seem pertinent to the patient and/or control of the interview is inconsistent
VERBAL AND TONAL EXPRESSION
1 2
Communicates in manner that interferes with and/or
prevents understanding by patient and/or communicates
inappropriately with the patient
NON-VERBAL EXPRESSION
1 2
Fails to engage, frustrates, sends mixed messages to,
and/or antagonizes the patient
3
Exhibits sufficient control of expression to be understood by an active, engaged listener (patient)
3
Exhibits enough control of non-verbal expression to engage a patient willing to overlook deficiencies such as passivity, self-consciousness, or inappropriate aggressiveness
4 5
Responds consistently in a perceptive and genuine manner to the patient s cues.
4 5
Plan consistently and skilfully integrates all pertinent information for the patient, demonstrating control of
transitions, flexibility and consistent control of the interview.
4 5
Exhibits command of expression (fluency, diction, grammar, vocabulary, tone, volume and modulation of voice, rate of speech, pronunciation)
4 5
Exhibits finesse and command of non-verbal expression
(eye contact, gesture, posture, use of silence, etc.)
•Yes •No •Comments •# •Key Points
Communication
Assessment
DTPs
Care Plan -Therapy management introductory advanced
OVERALL ASSESSMENT OF THE KNOWLEDGE AND SKILLS DEMONSTRATED IN THE INTERVIEW
1 2 Responds
inappropriately and ineffectively to the task indicating a lack
of knowledge and/or undeveloped interpersonal and interviewing skills.
3
Responds effectively to some components of the task indicating an adequate knowledge base and some development of interpersonal and interviewing skills
4 5
Responds precisely and perceptively to the task, demonstrating mastery of the subject matter, of interpersonal and interviewing skills and consistently integrating all
components.

Miller GE The assessment of clinical skills competence and performance
Acad Med 1990 65 (s) s63-s67
Practice
PEBC
Year
One
Does
Shows
How
Knows How
Know
Knows About
Heard Of
Reasoning
Skills intermediate introductory

Preparing for Class
Reflect on Elements of Thought & Logic
• Purpose
– What are my learning objectives for this topic
• Questions
– What question(s) will I be attempting to answer?
• Information
– What information do I need to support my positions?
• Inferences
– What do I want to convince the patient /the class / teacher of?
• Concepts
– What are the main ideas I need to use in my thinking to effectively express my opinion?
– Which of these ideas do I need to explicitly define and elaborate?
• Assumptions
– Should I question what I am taking for granted in presenting information?
– Should I explicitly state my assumptions?
• Point of View
– What am I looking at and how I am seeing it?
– Should I include other viewpoints?
• Implications
– What am I implying when I give a response?
– What am I trying to get the patient to believe and/or do?
• Interpretations
– Are there are interpretations I have missed in preparation?

Participating in Class and Written Assignments:
Use Critical Reasoning Standards
• Clarity
– Tell us your main ideas with examples, clear meaning
• Precision
– Give adequate detail
• Logic
– make thoughtful connections, indicate transitions when you shift your focus
• Relevance
– Maintain clear and consistent focus
• Significance
– Provide the most NB questions & concepts
• Depth
– Provide sufficient detail of complexities
• Fairness
– Allocate a perspective from all viewpoints
• Accuracy
– Only give factual details, from credible sources

Language:
Compare ?
Contrast ?

Schon (’83) referred to a crisis of confidence in professional knowledge
Kruger & Dunning (multiple disciplines; n = 65; Cornell undergrad, 4 studies )
– 1/4 (top quartile) underestimate performance - 68 cf. 86 th percentile
• will correct with expert models [**disposition – motivated**]
– 2/4 (mid-two quartiles) – mixed
• 3rd quartile accurately estimate
• 2nd quartile overestimate
• neither recalibrates when shown an expert model
– 1/4 – bottom quartile - unskilled and unaware
• overestimate performance - (bottom quartile estimated 68 vs 12 percentile actual)
– The ‘above average’ effect observed in the average (10 references)
• lack metacognitive skills to self-assess
• cannot correctly recalibrate even observing experts
• Lacked motivation to redress gaps
Verified by Hodges (n = 24 psychiatry residents) and Austin (2006)
Kruger, J., & Dunning, D. (1999). Unskilled and unaware of it: how difficulties in recognizing one’s own incompetence lead to inflated self-assessments. J. Pers Soc Psychol, 77, 1121-114.
Hodges, B. (2001, October). Difficulties in recognizing one’s own incompetence: novice physicians who are unskilled and unaware of it. Acad med, 76 (10) S87-89.

Perspectives on Guided
Reflection
Debra Sibbald, Ph.D.

• Recognize theoretical frameworks and key attributes of reflection
• Describe stages in a reflective exercise
• Recognize classroom or online teaching methods which foster guided reflection
• Observe models of guided reflection exercises
• Recognize what constitutes effective and supportive collaborative peer feedback (‘assessment’)
• Define your personal learning style inventory

Examples of Assessment Methodologies:
– Multiple Choice questions (MCQs)
– Short written answers (SAs)
– Objective Structured Clinical Examination (OSCE)
– Oral exam
– Case study seminar discussion
– Peer-assessment
– Self-assessment
– Hand-held audience response meters
– Performance-based (e.g. in lab, in experiential)

KOLB :
Kinds
Of
Learners
Concrete
Experience
(feelers)
Active
Experimentation
(changers)
Abstract
Conceptualization
(analyzers)
Reflective
Observation
(perceivers)
Thought or
Emotional
Preference
Task
Preference

Need to encourage Feedback and Change based on Learning Cycle
Describe
Concrete
Experience
(feel)
Active
Experimentation
(change)
Abstract
Conceptualization
(analyze)
Reflective
Observation
(perception)

• Apply Kolb’s Learning Style Inventory as a reflective learning cycle
• Use multiple examples and multiple cycles
• Each time allow for reflection and improvement
– What would you do differently, what would you change
• Enable flexibility – knowing when to slow down
• ‘ Editing ’ yourself

A. Concrete Experiencer:
Qualities/needs: Receptive experience-based approach; Relies on feeling-based judgments; Learns from specific examples
– considers unique features from each; Feedback and discussion with other learners
B Reflective Observer: Perceives
Qualities/needs: Tentative, impartial, reflective approach; Careful observation;
Takes information through objective observations: lectures, library
C. Abstract Conceptualizer: Analyzes
Qualities/needs: Analytical conceptual approach; Relies heavily on logical thinking and rational evaluation; Emphasis on theory and systematic analysis; Impersonal learning situations
D. Active Experimenter: Changes
Qualities/needs: Active doer; Relies on experimentation;
Engages in projects or small groups not lectures

Do-er Watcher
Concrete
Experience
Active
Experimentation
(change)
Abstract
Conceptualization
(analyze)
Reflective
Observation
(perception)
Feeler Thinker

The ‘’critical incident’’ technique : a well-known process for encouraging reflection.
• A critical incident can be defined as
– any event that challenges learning within the scope of desired competencies
• Is used as the trigger for reflections
– Self-selected
– Instructor-determined
• Guided prompts
– Direct stages of awareness, critical analysis & development of new perspectives.
– Encourages thought with intellectual, emotional and operational quotients.
• Final summary
– develop personal learning goals
• add to understanding and analysis of the issues raised

Reflection & Feedback on Experience
Recall the experience(s)
How did you feel during the experience
Why did you feel this way , why things happened this way
Suggestions for future changes based on above
Describe
Reflect
Analyze
Change

Repetitive Formative Practice
Objective
Precision
Normative
Verification
Empathic
Authenticity
Complexities
Understanding
Deductive Inductive

on
 
in
• The best professionals ‘know’ more than they can describe
• To meet workplace challenges, they rely on improvisation learned in practice
• Practicing reflectionin-action can improve this creative expertise in your future as professionals
– Reflect while doing
• “Thinking on your feet”
• “Keeping your wits about you”
– Able to reflect–in–action on a situation that falls outside the norm
– Experts need to act on the spot
Schon, David A: The Reflective Practitioner – How Professionals Think in Action 1983

• Handfield - Jones et al (Handfield-Jones, 2002) – Selfassessment model of the process of self-regulation for daily practice (persistent monitoring and retrospective reflection):
– assessment of performance;
– identification of limitations in knowledge or skills
– decision to seek improvement opportunities
– pursuing measures to address deficiencies
– integration of new or relearning skills into practice
– re-assessment of performance
– continual reiteration of this process

Meta-analysis of health care professionals:
Despite being self-regulating professionals:
– practitioners do not recognize the gaps in their understanding when they self-assess
– If made aware of gaps, lack the motivation to redress these gaps
(Regehr & Eva)

Self-Assessment: Use Guided Reflection to think critically
During Analysis Step with Elements of Thought & Logic
• Purpose
– What is my purpose in this activity I am reflecting about
• Question
– What question(s) am I attempting to answer about what happened?
• Information
– What information do I need to recall or look up
• Inferences
– What do I want to imply about what happened
• Concepts
– What are the main ideas I need to use in my thinking
– Which of these ideas do I need to explicitly define and elaborate?

Self-Assessment: Use Guided Reflection to think critically
During Analysis Step with Elements of Thought & Logic
• Assumptions
– Should I question what I am taking for granted?
– Should I explicitly state my assumptions?
• Point of View
– What am I looking at and how I am seeing it?
– Should I include other viewpoints?
• Implications
– What am I implying?
– What am I trying to get others to believe and/or do?
• Interpretations
– Are there are interpretations I have missed?

• Cannot be marked on the quality of your feelings
• Can be assessed to deepen the breadth and depth of your reflection
– Instructor insights regarding level of critical reasoning
– Especially when done with a peer who is experiencing the same context:
• readiness for and meeting a similar challenge
• Integrated will be assessed only for improvement or perhaps to award house points

• Share with a partner
• Share with a group
• Share with house members
• Online
– Peer examines depth and breadth of what you have considered
• your analysis
• suggestions for change

General Integrated Year One Guided Reflection
Think of the experiences you hope to have this semester.
Recall one incidents that has already occurred and describe.
You may wish to comment on
 what was intended to happen
 what actually happened.
Reflection:
How did you feel about your preparation and readiness to participate?
Describe
Reflect
Self-Assessment and Self-Efficacy Analysis:
What factors might have made you feel this way?
Lack of knowledge?
Lack of skills?
Other:
Analyze
Expectations of other people?
Before: o Did you not anticipate preparation was required, was your preparation insufficient or not in a timely manner, or did it meet or exceed expectations?
o Was the information you had prepared valid and at the appropriate level of understanding?
o Did you organize your own information ?
During: o Did learning occur beyond your own preparation?
o What measures supplemented this learning best? What did you find most challenging during this episode?
o Was the environment of your site receptive, engaging interesting, etc.?
After: o What followup did you do afterwards to consolidate your total learning? How much recalibration of preparation for the next episode occurred?
Change Plan for Change and Development:
What specific behaviours could you do to optimize your own learning situation when these incidents come up in the next few months?
Did you learn anything from the first that may impact future situations?
What do you need to do to obtain or enhance your knowledge and skills?
What are the best ways to achieve this?
Who will you be accountable to and how will you be accountable during this process?
Action

Learning Outcomes
Constructs
AFPC
Competencies
Themes
Care Provider Critical
Reasoning
Communicator (Critical
Appraisal)
Collaborator Pharmaceutical
Care
– PC Process
Entry
Level
Tests
Manager
Ethics &
Professionalism
Advocate
Beginner Intermediate knowledge skills
Formative
Tests
Scholar
Professional
Patient
Safety attitudes
Advanced
PEBC
&
NAPRA
Readiness to
Practice

Learning Outcomes
Constructs
AFPC
Competencies
Themes
Care Provider Critical
Reasoning
Communicator (Critical
Appraisal)
Collaborator Pharmaceutical
Care
– PC Process
Entry
Level
Tests
Manager
Ethics &
Professionalism
Advocate
Beginner Intermediate knowledge skills
Formative
Tests
Scholar
Professional
Patient
Safety attitudes
Advanced
PEBC
&
NAPRA
Readiness to
Practice

Integrated Semester Guided Reflection
Description:
Recall two situations concerned with the one of three themes: patient safety; pharmaceutical care/patient care process or
Reflection:
How did you feel about uncovering this learning need in your performance?
Self-Assessment and Self-Efficacy Analysis:
What factors might have made you feel this way? Eg.
Lack of knowledge?
Lack of skills?
Other:
Expectations of the course.. ? etc.
Describe how a fully competent pharmacist would have performed in this situation. Compare and contract your performance.
Were there significant differences between your two episodes? If so, what were they and why did they exist?
Did you learn anything from the first that impacted the second?
Plan for Change and Development:
What goals do you have to improve your performance in similar situations in the future?
Establish a learning plan to correct these differences. Eg:
What specific behaviours could you do to optimize your own learning situation when these incidents occur ?
What do you need to do to obtain or enhance your knowledge and skills?
What are the best ways to achieve this?
Who will you be accountable to and how will you be accountable during this process?
Reflect
Analyze
Change
Action

• Complete a learning style inventory

TODAY
Discover the style which most reflects how you learn.
A.
B
C.
D.

This session is completed. You should now understand issues important in educating for self-regulated life-long learning, including:
• Recognize theoretical frameworks and key attributes of reflection
• Describe stages in a reflective exercise
• Recognize classroom or online teaching methods which foster guided reflection
• Recognize guided reflection exercises
• Recognize what constitutes effective and supportive collaborative peer feedback (‘assessment’)
• Define your personal learning style inventory