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
AACC: JMO: 6/20/2012
1
INTRODUCTION AND OVERVIEW:
CRITICAL THINKING: PROGRAM OBJECTIVES
1.
2.
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.
AACC: JMO: 6/20/2012
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)
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PLAN FOR EVALUATION
KIRKPATRICK’S FOUR LEVELS OF 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”
AACC: JMO: 6/20/2012
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
AACC: JMO: 6/20/2012
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?
AACC: JMO: 6/20/2012
BE CLEAR ABOUT ROLES
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
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Learner Role:
The learners have one
role
Learner
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/
AACC: JMO: 6/20/2012
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
AACC: JMO: 6/20/2012
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
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STRUCTURE FOR SUCCESS!
Manage the Clinical Learning Environment
Expectations! – Expectations! – Expectations!
Yours
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Mine
Theirs
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
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FOR THE LEARNER:
THE TASK
IS
CRITICAL THINKING
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CRITICAL THINKING: PROCESS AND OUTCOMES
Knowledge Base
for Clinical
Practice
Nursing
Model
Prerequisites
Nursing
Process
Didactic
Content
Skills &
Interventions
Socialization
Learning Outcomes
AACC: JMO: 6/20/2012
Skilled Reasoning &
Reflection
Promote Active
Thinking
Integrate
Processes
Relate
Concepts
Consider
Implications
Identify
Complexity
Incorporate
Contextual
Information
View
Perspectives
Generate
Inferences
Independent
Safe Care
Excellence
Objectivity
Generate
Options
Critical
Thinker
Confident &
Empowered
Clinical Reasoning
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
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UTILIZE ACTIVE THINKING STRATEGIES
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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
AACC: JMO: 6/20/2012
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
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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
AACC: JMO: 6/20/2012
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
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Use Higher Level Verbs
Relate
Consider
Incorporate
Differentiate
Formulate
Propose
Select among
Identify which
Conclude
Evaluate
Interpret
Justify
Analyze
Rate
Support
Plan
Don’t Forget to Require
Rationales & Evidence
for All Respomses!
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
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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
AACC: JMO: 6/20/2012
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
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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
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VISUAL METACOGNITIVE TOOLS
Concept Map
Venn Diagrams
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25
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
AACC: JMO: 6/20/2012
CONCEPT MAPPING
Past
experience
in Health
Care
System
Level of
Wellness
AGE
Gender
Ethnicity
Health
Seeking
Behaviors
Economic
Factors
Other
Variable ??
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CONCEPT MAP
Pathophysiology
Client Diagnosis:___________________________
Primary Sign/Symptom:
Nursing Dx or Priority:
Related Sign/Symptom:
Nursing Dx or Priority
Nursing Care:
1.
2.
3.
4.
5
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Related Sign/Symptom:
Nursing Dx or Priority
Rationale and Physiologic Result of Nursing Care:
VENN DIAGRAM
3 client variables – develop all three; determine
relationships; have learner determine greatest priority;
then defend it
learner 1:
Variable 1
learner 2:
Variable
2
learner 3:
Variable
3
Use Venn diagrams with concept map to illuminate specifics
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COOPERATIVE/COLLABORATIVE
LEARNING ACTIVITIES
Utilizing Peers as Professional Colleagues
and Mentors
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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
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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
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DEBATE AND ‘REFLECTIVE’ STRATEGIES
Develops Insights into
Perspectives, Context, and Complexity
Promotes
Integrative Processes, Inferences and Objectivity
33
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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
AACC: JMO: 6/20/2012
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
AACC: JMO: 6/20/2012
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
AACC: JMO: 6/20/2012
REFLECTION/REFLECTIVE JOURNALING
Purposeful thinking
Focuses on past and present learning or
experiences
Used to enhance and extend learning through selfdirected dialog, analysis/evaluation
Allows for faculty to determine ‘connections’
between activity and learner ‘experience’ related
to it
Often used to assess affective domain
AACC: JMO: 6/20/2012
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
Start
with
your
Determine
learning
domains
for the
activity
AACC: JMO: 6/20/2012
How is the
learning
activity to be
evaluated.
Is it graded?
Do the
Activity:
be the
coach &
cheerleader
Evaluate for:
Analysis,
Discrimination,
Logical Reasoning
Metacognition
OUTCOMES
Evaluating the Learner’s Level of
Critical Thinking
AACC: JMO: 6/20/2012
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
AACC: JMO: 6/20/2012
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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
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Excellence
Confidence
Empowerment
Critical thinking
Clinical reasoning
CONCLUSIONS
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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
AACC: JMO: 6/20/2012
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
AACC: JMO: 6/20/2012
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- thinkingand-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.
AACC: JMO: 6/20/2012
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/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.
AACC: JMO: 6/20/2012
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
AACC: JMO: 6/20/2012
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
AACC: JMO: 6/20/2012
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-professorblog/think-alouds-shed-light-on-how-students-grapple-withcontent/
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
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