ENHANCING CLINICAL REASONING: TEACHING THINKING THROUGH DEBRIEFING

Transcription

1 ENHANCING CLINICAL REASONING: TEACHING THINKING THROUGH DEBRIEFING Susan Gross Forneris, PhD, RN, CNE Jone Tiffany, DNP, MA, RNC Diana Odland Neal, PhD, RN Mary Beth Kuehn, Ed.D, RN, PHN Linda Blazovich, DNP, RN, CNE

2 A BIG THANK YOU TO INACSL FOR SUPPORTING OUR STUDY WITH THE DEBRA SPUNT MINI-GRANT. IT IS MUCH APPRECIATED!

3 LEARNING OUTCOMES describe the use of the Debriefing for Meaningful Learning (DML) tool as a methodology for debriefing discuss how the DML tool is used during a simulation scenario discuss the outcome of the DML methodology and the implications for nursing education

4 Part 1: The search for evidence

5 The search for evidence.. Susan Gross Forneris, PhD, RN, CNE Linda Blazovich, DNP, RN, CNE Melanie Smerillo, RN, BSN Heidi Meyer, MSN, RN Lynnea Myers, MSN, RN, CPNP Diana Odland Neal, PhD, RN Mary Beth Kuehn, Ed.D, RN, PHN Jone Tiffany, DNP, MA, RNC Ann Holland, PhD, RN

6 Clinical Reasoning

7 NOVICE NURSES SEE DIFFERENT CLINICAL SIGNS

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9 Explore strategies that integrate content knowledge with knowledge of the context creating dialogue that invites questions in a reflective and critical manner.

10 MCNER FULL-SCALE STUDY Full Scale Study: Quasi-experimental, pre-test-post-test, repeated measure research design Purpose: To determine if undergraduate nursing students demonstrate a positive change in clinical reasoning skills using the Debriefing for Meaningful Learning (DML) model

11 RESEARCH QUESTIONS 1. Does the use of the DML debriefing strategy positively impact the development of clinical reasoning skills in undergraduate nursing students compared to usual and customary debriefing? 2. Do nursing students perceive a difference in the quality of debriefing when the DML strategy is used compared to usual and customary debriefing?

12 DR. DREIFUERST S THEORETICAL FRAMEWORK Constructivism Reflective Cycle (Gibbs, Farmer, & Eastcott, 1988) Interactive Learning Cycle from the Significant Learning Framework (Fink, 2003) E 5 framework for effective teaching (Bybee et al., 1989) Engage Explore Explain Elaborate Evaluate

13 Dreifuerst, K.T. (2010). Debriefing for meaningful learning: Foster development of clinical reasoning through simulation. Retrieved from Proquest Dissertations and Theses.

14 DEBRIEFING FOR MEANINGFUL LEARNING Active Learning Approach Form of clinical teaching Constructivist learning Promotes active learning Incorporates Guided Reflection Schon s work Reflection in/on-action Dreifuerst added thinking beyond-action Dreifuerst, K.T. (2010). Debriefing for meaningful learning: Foster development of clinical reasoning through simulation. Retrieved from Proquest Dissertations and Theses.

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17 Forneris, S. G., Crownover, J. G., Dorsey, L. E., Leahy, N., Maas, M. A., Wong, L., Zabriskie, A., and Zavertnik, J. E. (2012).

18 HEALTH SCIENCES REASONING TEST (HSRT) Measures high-stakes reasoning and decision-making processes Form of the California Critical Thinking Test Designed broadly for health professions students Health Sciences Reasoning Test HSRT Test Manual. Insight Assessment

19 HEALTH SCIENCES REASONING TEST (HSRT) General Information Type of Instrument Available Date of Publication Languages Reliability Administration Information Time to Administer Administration Types Self-administered, rating scale 2006, 2008, & 2011 Arabic, Chinese Simplified or Traditional Characters, Dutch, English, Farsi, Korean, Spanish minutes Online or Paper-and-Pencil Results Total score of critical thinking scales; and 5 scale scores Analysis and Interpretation Inference Evaluation and Explanation Deductive Reasoning Inductive Reasoning

20 DEBRIEFING ASSESSMENT FOR SIMULATION IN HEALTHCARE- STUDENT VERSION (DASH-SV) DASH used by peer-faculty to evaluate quality of debriefing DASH-SV reports quality of debriefing evaluated from a student perspective Retrieved, Feb 13,

21 General Information Type of Instrument Available Date of Publication 2009, 2010 Language DEBRIEFING ASSESSMENT FOR SIMULATION IN HEALTHCARE-STUDENT VERSION (DASH-SV) Reliability 0.82 Administration Information Time to Administer Administration Types Self-administered, multiple choice English, German minutes Paper-and-Pencil Results 6 elements of effective debriefing: engaging learning engaging context engaging organization in-depth discussion promoting reflection identify areas of weakness and why Identify areas for improvement and why

22 Teaching Thinking: Using Simulation Effectively Part 2: Operationalizing simulation and debriefing to enhance clinical reasoning

23 RESEARCH QUESTIONS Does the use of the DML debriefing strategy positively impact the development of clinical reasoning skills in undergraduate nursing students compared to usual and customary debriefing? Do nursing students perceive a difference in the quality of debriefing when the DML strategy is used compared to usual and customary debriefing? Change in clinical reasoning as measured by improved scores on the HSRT exemplifies meaningful learning from the simulation experience.

24 METHODOLOGY Quasi-experimental, pre-test-post-test, repeated measure research design HSRT and DASH-SV curriculum requirements Students randomly assigned to traditional debriefing vs. DML debriefing Change in clinical reasoning as measured by improved scores on the HSRT exemplifies meaningful learning from the simulation experience.

25 RESEARCH QUESTION #1 Does the use of the DML debriefing strategy positively impact the development of clinical reasoning skills in undergraduate nursing students compared to usual and customary debriefing? RESEARCH QUESTION #1: MAYBE.

26 POST-SCORE t-test: Two-Sample Assuming Equal Variances HSRT Paired T-Tests TREATMENT t-test: Paired Two Sample for Means Control 25 Treatment Mean Variance Observations Pooled Variance Hypothesized Mean Difference 0 df 151 t Stat P(T<=t) one-tail t Critical one-tail <-- This is another way to look at the data. This says the treatment group post scores are significantly different than P(T<=t) two-tail the control group. t Critical two-tail Pre Post Mean Variance Observations Pearson Correlation Hypothesized Mean Difference 0 df 77 t Stat P(T<=t) one-tail t Critical one-tail <-- This says that students in the treatment group have a statistically significant improvement in their P(T<=t) two-tail scores. t Critical two-tail Control Treatment Pre Post Pre Post 0 Control Treatment

27 RESEARCH QUESTION #2 Do nursing students perceive a difference in the quality of debriefing when the DML strategy is used compared to usual and customary debriefing? RESEARCH QUESTION #2: YES

28 DASH-SV Paired T-Tests t-test: Two-Sample Assuming Equal Variances Treatment Control Mean Variance Observations Pooled Variance Hypothesized Mean Difference 0 df 148 t Stat P(T<=t) one-tail t Critical one-tail <-- This means the difference is significant at P(T<=t) two-tail the 0.05 level t Critical two-tail Control Treatment Difference Control Treatment

29 WHAT DO THE RESULTS REALLY TELL US: Dreifuerst s raw scores illustrated a positive change in clinical reasoning skills with use of the DML debriefing model. Statistically significant N=238 MCNER full scale study findings illustrated a positive change in the raw scores in clinical reasoning, Statistically significant not strong N= 153

30 FACULTY DEVELOPMENT Learning Objectives for faculty Perform a head-to-toe physical assessment and use the following assessment tools: SPICES and Confusion Assessment Method (CAM). Identify and discuss critical assessment findings:( elevated blood pressure and confusion) and relate which findings are commonly found in the older adult patient. Recognize geriatric syndrome(s) present in simulation: urinary incontinence and confusion. Assuring Consistency

31 FACULTY DEVELOPMENT Assuring Consistency

32 Teaching Thinking: Using Simulation Effectively Part 3: Building Expertise

33 HOW EASY IS IT FOR YOU TO MAKE TRANSITIONS IN YOUR TEACHING? 1. Piece of cake. 2. I need the details and some control. 3. I trust everything to others. 4. I would rather die than change.

34 WHAT INITIAL REACTIONS DO YOU HAVE TO THE PHRASE ACTIVE LEARNING 1. This will mean more work for me. 2. I will have difficulty giving up some of the classroom control. 3. I am not sure I am comfortable with students directing the learning. 4. I ll have to prepare for the unexpected questions.

35 LET S MEET MILLIE!

36 Faculty Nutshell: Millie Larsen has been newly admitted to the care unit after an overnight observation in the ED due to new confusion. The focus of the simulation: students recognition of confusion, use correct assessment tools (SPICES, CAM), determine source of confusion, differentiate geriatric syndromes, specifically differentiate confusion as delirium and not dementia.

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38 Learning Objectives for faculty Perform a head-to-toe physical assessment and use the following assessment tools: SPICES and Confusion Assessment Method (CAM). Identify and discuss critical assessment findings:( elevated blood pressure and confusion) and relate which findings are commonly found in the older adult patient. Use SBAR techniques when communicating with other members of the health care team. Recognize geriatric syndrome(s) present in simulation: urinary incontinence and confusion.

39 MILLIE LARSEN SCENARIO 1

40 LET S WATCH A DEBRIEFING USING A TRADITIONAL DEBRIEFING MODEL

41 DEBRIEFING ASSESSMENT FOR SIMULATION IN HEALTHCARE (DASH) STUDENT VERSION

42 LET S WATCH A DEBRIEFING USING DEBRIEFING FOR MEANINGFUL LEARNING

43 DEBRIEFING ASSESSMENT FOR SIMULATION IN HEALTHCARE (DASH) STUDENT VERSION

44 Teaching Thinking: Using Simulation Effectively Discussion: What is your reaction to this debriefing method in comparison to U/C debriefing

45 WHAT DOES IT MEAN TO THINK LIKE A NURSE WHAT DOES THIS LOOK LIKE?

46 Theoretical Perspectives What does it mean to be critical? Freire Mezirow Brookfield Schon Argyris Tennyson More than just a composite of knowledge, skills, abilities Emphasis on reflective dimension of critical thinking Focus on being critical; use of context in constructing knowledge Dynamic nature of critical thinking and the link to thinking in practice

47 TOWARDS A CONCEPTUAL UNDERSTANDING OF THINKING IN PRACTICE: Forneris, S. G. (2004). Exploring the attributes of critical thinking: A conceptual basis. International Journal of Nursing Education Scholarship, 1(1, Article 9), 1-18.

48 6 months into practice when guided in their thinking Theme: Critical thinking as intentional, reflective thinking

49 TEACHING THINKING More than: Articulating content knowledge Organization of tasks Time management Demonstrating competencies More of: Dialogue Critical questioning Thinking out loud Connecting thinking and doing

50 TEACHING THINKING

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53 NOW IT S YOUR TURN LET S WATCH ANOTHER SIMULATION AND GIVE YOU THE CHANCE TO STRATEGIZE HOW YOU MIGHT TEACH THE STUDENTS TO THINK LIKE A NURSE

54 Faculty Nutshell: Millie Larsen has sustained a fall following her admission. While her cognition is improving, from a safety standpoint, she requires assistance with ambulation. The key focus of this simulation is for students to recognize the need for accurate assessments of patient s level of function and use of proper assessment skills and screening for safety and transition from acute care.

55 Simulation Learning Objectives for faculty Perform a head-to-toe physical assessment and use the following assessment tools: SPICES, Confusion Assessment Method (CAM), Katz Index of Independence, and Hendrich II Fall Risk Model. (Identify changes in cognition from simulation scenario #1 (cognition has improved) Recognize conflict between daughter and client regarding discharge plan and communicate therapeutically with patient and daughter. Identify issues related to the transition of care specific to the patient in this simulation. (risks and benefits of discharge to home) Identify and discuss geriatric syndromes evident in the simulation: fall risk, confusion, incontinence. Safely administer medications.

56 MILLIE LARSEN SCENARIO 2

57 SMALL GROUP WORK HOW WOULD YOU GUIDE THE THINKING?

58 ROLE CALL It s your turn show us your thinking

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61 WHAT WE LEARNED Achieving Learning Outcomes

62 WHAT WE LEARNED Curriculum Enhancements

63 WHAT WE LEARNED Enhanced Teaching Strategies Educational strategies need to focus on enhancing clinical reasoning through a learner-centered approach that guides thinking through the use of reflection & dialogue to make an inferential link between thinking & doing. (Forneris & Peden-McAlpine, 2007, 2009)

64 CHALLENGES AND OPPORTUNITIES FOR CHANGE Faculty Development

65 CHALLENGES AND OPPORTUNITIES FOR CHANGE Clinical Partner Development

66 CHALLENGES AND OPPORTUNITIES FOR CHANGE Improving Patient Care Outcomes

67 FACULTY RESOURCES Faculty Development Hartford Institute for Geriatric Nursing NLN ACES NLN SIRC (Simulation Innovation Resource Center) urces/aces/index.htm

68 Barton, A. J., Armstrong, G., Preheim, G., Gelmon, S. B., & Andrus, L. C. (2009). A national Delphi to determine developmental progression of quality and safety competencies in nursing education. Nursing Outlook, 57, doi: /j.outlok Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55, doi: /j.outlook Facione, N. C., & Facione, P. A. (2006). The Health Sciences Reasoning Test. Millbrae, CA: The California Academic Press. Forneris, S. G., Crownover, J. G., Dorsey, L. E., Leahy, N., Maas, M. A., Wong, L., Zabriskie, A., and Zavertnik, J. E. (2012). Integrating QSEN and ACES: An NLN simulation leader project. Nursing Education Perspectives, 33(3), Forneris S.G. & Peden-Mcalpine C. (2007). Evaluation of a reflective learning intervention to improve critical thinking in novice nurses. Journal of Advanced Nursing 57(4), Forneris S.G. & Peden-Mcalpine C. (2009). Creating context for critical thinking in practice: the role of the preceptor. Journal of Advanced Nursing 65(8), Insight Assessment. Health Science Reasoning Test (HSRT). Retrieved February 19, 2012, from Reasoning-Test-HSRT Jeffries, P. R. (2007). Simulation in nursing education. From conceptualization to evaluation. New York, NY: National League for Nursing. National League for Nurses (2013). Simulation Innovation Resource Center. Retrieved from Reese, C. R. (2010). ACES Case #1: Millie Larsen. Developed by the National League for Nursing, Simulation Team Advancing Gerontological Education Strategies (STAGES). Retrieved from

69 Dreifuerst, K.T. (2010). Debriefing for meaningful learning: Foster development of clinical reasoning through simulation. Retrieved from Scholarworks.uipui.edu 5/2459

70 THANK YOU FOR YOUR KIND ATTENTION!!!

71 QUESTIONS?????