Evaluating Undergraduate Nursing Students’ Critical Thinking in Clinical Practice

1. Evaluating Undergraduate Nursing Students’ Critical Thinking in Clinical Practice Kathleen Ohman, EdD, MS, RN, CCRN College of St. Benedict/St. John’s University St. Joseph, MN USA

2. The basis for utilizing any teaching and testing strategy lies in the associated critical thinking component. • So… What is this?

3. Now….What does this have to do with critical thinking? • Analysis(examining ideas, identifying arguments, analyzing arguments) • Inference (querying evidence, alternatives, drawing conclusions) • Interpretation (categorizing, decoding, clarifying meaning) • Explanation (stating results, justifying presenting arguments) • Self-regulation (self-examination, self-correction).

4. Commercial critical-thinking instruments are not specific to nursing (Simpson & Courtney, 2002) Difficulty measuring critical thinking in clinical because changing clinical situations (Oermann, 1998; Staib, 2003) A variety of ways to measure critical thinking outside of clinical practice (Brunt, 2005; Simpson & Courtney, 2002 Watson et al, 2002) Literature: Evaluating Critical Thinking in Clinical Situations

5. Measuring Critical Thinking • Standardized exams • Case scenarios • Problem-based learning • Clinical exams

6. How Can You Objectively Evaluate Student’s Critical Thinking in Clinical Practice? • “You didn’t see all the great things I did with my patient.” • “How can you evaluate me, you hardly saw me all morning?” • “My patient had so many meds and procedures, how can you expect me to be finished on time?”

7. Develop A Clinical Exam Away from the Clinical Environment!!! • Measures course outcomes • Is objective • Tests comparable situations for which each student has prepared • Is administered in a controlled environment • Removes “situational cognition”

8. Clinical should be an opportunity for LEARNING Anxiety is inherent in the clinical experience Students need to see faculty as their “safety net” not their evaluators Clinical experiences should be formative Faculty should be able to role model for students Rationale for Clinical Exam Away from the Clinical Site

9. Grading student critical thinking in clinical courses is difficult Using only paper work artificially inflates grades Finding equivalent patient care situations for all students is impossible Grading actual patient care situations is subjective or based on circumstances Rationale for Clinical Exam

10. How are Clinical Exams Developed? • The clinical exam is based on the clinical outcomes of the course • Example: Interpret objective and subjective data to identify actual and potential health deviations. • The exam would need to provide the student with objective and subjective data of an actual or potential health problem and ask them to interpret that data

11. Video tape vignettes of clinical situations (Example 1: OB Exam) Student demonstration and role playing (Example 2: med administration) Simulations with patient mannequins where students respond to a scene (Example 3: lung sounds) Decide on Methodology to be used for the ClinicalExam

12. Video Vignettes: Example 4 • Adult Health Nursing Vignette • “Your first patient is Kim Bronson, a 55- year-old female admitted yesterday for femoral-popliteal bypass. She has a history of PAD and type 1 DM. She smokes 1 PPD.”

13. Development continued • Wrote script for scenarios • Made exam setup as much like clinical as possible • Exam timed • Student prepares for clinical by reviewing data • Students have relevant clinical forms • Kardex (Chart form w/orders noted) • Medication Administration Record • Teaching record • Care plan • Resources available: NIC and NOC books

14. Least Complex to Develop Example 2: Med Administration • Faculty developed situations of administering medications • Student role play situation • Teaching Assistant (TA) videotaping

15. Most Complex to Develop • Example 4: Video Vignettes

17. Adding On-line Resources to the Exam • Heart Sounds http://www.med.ucla.edu/wilkes/intro.html • Scenes • http://thatwasrandom.com/video/no_seatbelt.php • Guy Doesn't Wear Seatbelt - Shocking footage of in-car accident

18. Considerations • Faculty time • Who will be the actors? • Where will it be filmed and who does the filming? • Lighting? • Who will edit the scenes? • Time the scenes and the exam • How will you correlate the written exam with the vignettes? • Exam on colored paper and sequenced

19. Grading of the Exam • Exam is keyed by each individual faculty and combined prior to grading the exams • Exams are graded with ID numbers only; no student names • Exam is graded by a group of faculty • One faculty member scores the same items on all exams • Questionable responses are discussed by faculty group and added to the key • Exam items often reviewed a second or third time if additions made to the key

20. Reliability of Exam • Student clinical exam scores are consistent with other exam scores for students • Student exam scores more objective than faculty professional judgment concerning student’s clinical performance • Display of confidence and efficiency often misinterpreted as good clinical judgment and critical thinking by student

21. Faculty Evaluation of the Methodology • Reviewed aggregated student scores • Discussed advantages & disadvantages of exam • Evaluated student responses for critical thinking and meeting course outcomes • Recommended areas for changes in items or methodology

22. Faculty Findings • Found areas where students as a group were not meeting course outcomes • Phone confidentiality • Prioritizing • Environment more controlled and consistent across students • Examination is a summative evaluation in a relatively nonthreatening situation and provides objective data

23. Student Findings • Majority felt it accurately measured their critical thinking during clinical • Majority recommended continuing with the exam • Some felt the clinical situations should be ones that all students have experienced

24. Students and faculty are HAPPY!!

25. Key References • Brunt, Barbara A. MA, RN, BC Critical Thinking in Nursing: An Integrated Review.Journal of Continuing Education in Nursing. 36(2):60-67, March/April 2005. • Feingold, Carol E. MS, RN; Calaluce, Margaret BSN, RN; Kallen, Michael A. PhD, MPH Computerized Patient Model and Simulated Clinical Experiences: Evaluation With Baccalaureate Nursing Students.Journal of Nursing Education. 43(4):156-163, April 2004. • Giddens, Jean PhD, RN; Gloeckner, Gene W. PhD The Relationship of Critical Thinking to Performance on the NCLEX-RN(R).Journal of Nursing Education. 44(2):85-89, February 2005. • Twibell, Renee DNS, RN; Ryan, Marilyn EdD, RN; Hermiz, Mary EdD, RN Faculty Perceptions of Critical Thinking in Student Clinical Experiences.Journal of Nursing Education. 44(2):71-79, February 2005. • Walthew, Patricia J. MEd, RGON Conceptions of Critical Thinking Held by Nurse Educators.Journal of Nursing Education. 43(9):408-411, September 2004.