Using ‘think aloud’ as a strategy for learning clinical reasoning in high fidelity case-based simulation for undergraduate nursing students

AIMS This paper reports on the implementation of a research project that trials an educational strategy implemented over six months of an undergraduate third year nursing curriculum. This project aims to explore the effectiveness of ‘think aloud’ as a strategy for learning clinical reasoning for students in simulated clinical settings. BACKGROUND Nurses are required to apply and utilise critical thinking skills to enable clinical reasoning and problem solving in the clinical setting [1]. Nursing students are expected to develop and display clinical reasoning skills in practice, but may struggle articulating reasons behind decisions about patient care. For students learning to manage complex clinical situations, teaching approaches are required that make these instinctive cognitive processes explicit and clear [2-5]. In line with professional expectations, nursing students in third year at Queensland University of Technology (QUT) are expected to display clinical reasoning skills in practice. This can be a complex proposition for students in practice situations, particularly as the degree of uncertainty or decision complexity increases [6-7]. The ‘think aloud’ approach is an innovative learning/teaching method which can create an environment suitable for developing clinical reasoning skills in students [4, 8]. This project aims to use the ‘think aloud’ strategy within a simulation context to provide a safe learning environment in which third year students are assisted to uncover cognitive approaches that best assist them to make effective patient care decisions, and improve their confidence, clinical reasoning and active critical reflection on their practice. MEHODS In semester 2 2011 at QUT, third year nursing students will undertake high fidelity simulation, some for the first time commencing in September of 2011. There will be two cohorts for strategy implementation (group 1= use think aloud as a strategy within the simulation, group 2= not given a specific strategy outside of nursing assessment frameworks) in relation to problem solving patient needs. Students will be briefed about the scenario, given a nursing handover, placed into a simulation group and an observer group, and the facilitator/teacher will run the simulation from a control room, and not have contact (as a ‘teacher’) with students during the simulation. Then debriefing will occur as a whole group outside of the simulation room where the session can be reviewed on screen. The think aloud strategy will be described to students in their pre-simulation briefing and allow for clarification of this strategy at this time. All other aspects of the simulations remain the same, (resources, suggested nursing assessment frameworks, simulation session duration, size of simulation teams, preparatory materials). RESULTS Methodology of the project and the challenges of implementation will be the focus of this presentation. This will include ethical considerations in designing the project, recruitment of students and implementation of a voluntary research project within a busy educational curriculum which in third year targets 669 students over two campuses. CONCLUSIONS In an environment of increasingly constrained clinical placement opportunities, exploration of alternate strategies to improve critical thinking skills and develop clinical reasoning and problem solving for nursing students is imperative in preparing nurses to respond to changing patient needs. References 1. Lasater, K., High-fidelity simulation and the development of clinical judgement: students' experiences. Journal of Nursing Education, 2007. 46(6): p. 269-276. 2. Lapkin, S., et al., Effectiveness of patient simulation manikins in teaching clinical reasoning skills to undergraduate nursing students: a systematic review. Clinical Simulation in Nursing, 2010. 6(6): p. e207-22. 3. Kaddoura, M.P.C.M.S.N.R.N., New Graduate Nurses' Perceptions of the Effects of Clinical Simulation on Their Critical Thinking, Learning, and Confidence. The Journal of Continuing Education in Nursing, 2010. 41(11): p. 506. 4. Banning, M., The think aloud approach as an educational tool to develop and assess clinical reasoning in undergraduate students. Nurse Education Today, 2008. 28: p. 8-14. 5. Porter-O'Grady, T., Profound change:21st century nursing. Nursing Outlook, 2001. 49(4): p. 182-186. 6. Andersson, A.K., M. Omberg, and M. Svedlund, Triage in the emergency department-a qualitative study of the factors which nurses consider when making decisions. Nursing in Critical Care, 2006. 11(3): p. 136-145. 7. O'Neill, E.S., N.M. Dluhy, and C. Chin, Modelling novice clinical reasoning for a computerized decision support system. Journal of Advanced Nursing, 2005. 49(1): p. 68-77. 8. Lee, J.E. and N. Ryan-Wenger, The "Think Aloud" seminar for teaching clinical reasoning: a case study of a child with pharyngitis. J Pediatr Health Care, 1997. 11(3): p. 101-10.

A communitarian theory of the education rights of students with disabilities

There is a lack of writing on the issue of the education rights of people with disabilities by authors of any theoretical persuasion. While the deficiency of theory may be explained by a variety of historical, philosophical and practical considerations, it is a deficiency which must be addressed. Otherwise, any statement of rights rings out as hollow rhetoric unsupported by sound reason and moral rectitude. This paper attempts to address this deficiency in education rights theory by postulating a communitarian theory of the education rights of people with disabilities. The theory is developed from communitarian writings on the role of education in democratic society. The communitarian school, like the community within which it nests, is inclusive. Schools both reflect and model the shape of communitarian society and have primary responsibility for teaching the knowledge and virtues which will allow citizens to belong to and function within society. Communitarians emphasise responsibilities, however, as the corollary of rights and require the individual good to yield to community good when the hard cases arise. The article not only explains the basis of the right to an inclusive education, therefore, but also engages with the difficult issue of when such a right may not be enforceable.

Reasonable adjustment and the assessment of students with disabilities: Australian legal issues and trends

Student assessment is particularly important, and particularly controversial, because it is the means by which student achievement is determined. Reasonable adjustment to student assessment is of equal importance as the means of ensuring the mitigation, or even elimination, of disability related barriers to the demonstration of student achievement. The significance of reasonable adjustment is obvious in the later years of secondary school, and in the tertiary sector, because failure to adjust assessment may be asserted as the reason a student did not achieve as well as anticipated or as the reason a student was excluded from a course and, as a result, from future study and employment opportunities. Even in the early years of schooling, however, assessment and its management are a critical issue for staff and students, especially in an education system like Australia’s with an ever increasing emphasis on national benchmarks testing. This paper will explain the legislation which underpins the right to reasonable adjustment in education in Australian schools. It will give examples of the kinds of adjustment which may be made to promote equality of opportunity in the area of assessment. It will also consider some of the controversies which have confronted, or which, it may be speculated, are likely to confront Australian education institutions as they work towards compliance with reasonable adjustment laws.

Ethical decision making and health care managers : developing managerial profiles based on ethical frameworks and other influencing factors

Whether the community is looking for “scapegoats” to blame, or seeking more radical and deeper causes, health care managers are in the firing line whenever there are woes in the health care sector. The public has a right to question whether ethics have much influence on the everyday decision making of health care managers. This thesis explores, through a series of published papers, the influence of ethics and other factors on the decision making of health care managers in Australia. Critical review of over 40 years of research on ethical decision making has revealed a large number of influencing factors, but there is a demonstrable lack of a multidimensional approach that measures the combined influences of these factors on managers. This thesis has developed an instrument, the Managerial Ethical Profile (MEP) scale, based on a multidimensional model combining a large number of influencing factors. The MEP scale measures the range of influences on individual managers, and describes the major tendencies by developing a number of empirical profiles derived from a hierarchical cluster analysis. The instrument was developed and refined through a process of pilot studies on academics and students (n=41) and small-business managers (n=41), and then was administered to the larger sample of health care managers (n=441). Results from this study indicate that Australian health care managers draw on a range of ethical frameworks in their everyday decision making, forming the basis of five MEPs (Knights, Guardian Angels, Duty Followers, Defenders, and Chameleons). Results from the study also indicate that the range of individual, organisational, and external factors that influence decision making can be grouped into three major clusters or functions. Cross referencing these functions and other demographic data to the MEPs provides analytical insight into the characteristics of the MEPs. These five profiles summarise existing strengths and weaknesses in managerial ethical decision making. Therefore identifying these profiles not only can contribute to increasing organisational knowledge and self-awareness, but also has clear implications for the design and implementation of ethics education and training in large scale organisations in the health care industry.

Multicultural training experiences as predictors of psychology students’ cultural competence

The psychologists in the western world, including Australia, are required to be culturally competent due to the cultural diversity of these societies. Previous studies conducted in North America and Europe have found multicultural teaching, clinical experience with culturally diverse clients, and discussion of multicultural counselling issues in supervision to be related to the practitioner’s cultural competency. The present study examined factors contributing to trainee psychologists’ perceived level of cultural competence. It was hypothesised that multicultural teaching, clinical experience and supervision would be related to students’ level of cultural competence. One hundred and twenty seven postgraduate clinical psychology students completed an online survey battery that included demographic information, a social desirability measure, and the Multicultural Mental Health Awareness Scale (Khawaja, Gomez & Turner, 2009). This hypothesis was partially supported. Clinical experience and supervision focusing on multicultural issues were found to be related to participants’ perceived cultural competence, however, multicultural teaching was not. These results provide insight into how universities around Australia can facilitate future psychologists’ competence in working with clients from different cultural backgrounds.

University students’ depression : a cross-cultural investigation

Australian, Iranian and Portuguese university students (N = 967) completed University Students Depression Inventory (USDI; Khawaja & Bryden, 2006) in English, Persian, and Portuguese languages respectively. A series of MANOVA were used to examine differences in depression symptoms as an effect of the country and demographic variables. Interactions were also examined. The results indicated that country, gender, and year level had some impact on the depressive symptoms of the university students. Australian students were more depressed than the Iranian and Portuguese students, while Iranian students were more depressed than the Portuguese students. Subscales of USDI: Lethargy, Motivation, and Cognitive/Emotional were also used to compare the depressive symptoms of students. The Australian female students reported a significantly higher level of lethargy than their male counterparts. Similarly, the first year male students from Iran were significantly more lethargic than the first year Iranian female students. Iranian and Portuguese male students, compared to the female students of these countries, experienced a lower level of motivation. The Australian and Iranian students, compared to the Portuguese students, reported a significantly higher level of cognitive and affective symptoms. The scores on the Cognitive/Emotional subscale increased with the year level. Differences among students’ depression are described and implications discussed.

Cyberbullying : a threat to student mental health and wellbeing

Cyberbullying is a threat to student mental health and wellbeing. As predicted the consequences of cyberbullying have been shown to be more detrimental to students than traditional bullying because of the wider audience and the 24/7 nature of this form of bullying. It is becoming an increasingly vexatious problem for victims, students who bully, educators and parents. Parents and the community are turning to schools to provide preventative strategies and to manage incidents of cyberbullying. Some sections of the community believe there is a technological solution to the problem, or that the law should be overhauled to address the problem more effectively. However, bullying is a deeply embedded social relationship problem, of which cyberbullying is one form. Therefore, planned prevention and intervention strategies need to be considered in the context of the social relationships in the whole school community.

Self-Government and the fashioning of resilient personae : legal education, criminal justice, and the government of mental health

This paper explores attempts to shape resilient personae through relations of self-government, and highlights the way that this features as part of advanced liberal forms of rule. As an example of this process, it focuses on the way that undergraduate law students are encouraged to fashion resilient personae throughout their legal studies, so as to avoid, or effectively respond to, experiences that may have a detrimental effect on their mental health. This paper argues that the production of such resilience relies on students being encouraged to take up psychologically- and biomedically-infused subject positions, becoming well-disciplined subjects, entrepreneurs of the self, and even virtuous persons. It highlights that the fashioning of resilient personae in this way involves extensions to the targets and practices of self-government and reinforces advanced liberal government. The paper then suggests how insights into fashioning resilience in this context can inform further research on resilience, particularly resilience produced within criminal justice professionals.

Chaos or complex systems? Identifying factors influencing the success of international and NESB graduate research students in Engineering and Information Technology Fields

The paper explores the results an on-going research project to identify factors influencing the success of international and non-English speaking background (NESB) gradúate students in the fields of Engineering and IT at three Australian universities: the Queensland University of Technology (QUT), the University of Western Australia (UWA), and Curtin University (CU). While the larger study explores the influence of factors from both sides of the supervision equation (e.g., students and supervisors), this paper focusses primarily on the results of an online survey involving 227 international and/or NESB graduate students in the areas of Engineering and IT at the three universities. The study reveals cross-cultural differences in perceptions of student and supervisor roles, as well as differences in the understanding of the requirements of graduate study within the Australian Higher Education context. We argue that in order to assist international and NESB research students to overcome such culturally embedded challenges, it is important to develop a model which recognizes the complex interactions of factors from both sides of the supervision relationship, in order to understand this cohort‟s unique pedagogical needs and develop intercultural sensitivity within postgraduate research supervision.

Educational stress scale for adolescents : development, validity, and reliability with Chinese students

This article describes the development and initial validation of a new instrument to measure academic stress—the Educational Stress Scale for Adolescents (ESSA). A series of cross-sectional questionnaire surveys were conducted with more than 2,000 Chinese adolescents to examine the psychometric properties. The final 16-item ESSA contains five latent variables: Pressure from study, Workload, Worry about grades, Self-expectation, and Despondency, which together explain 64% of the total item variance. Scale scores showed adequate internal consistency, 2-week test–retest reliability, and satisfactory concurrent validity. A confirmatory factor analysis suggested the proposed factor model fits well in a different sample. For researchers who have a particular interest in academic stress among adolescents, the ESSA promises to be a useful tool.

Ingroup and role identity influences on the initiation and maintenance of students' voluntary attendance at peer study sessions for statistics

Background: Although class attendance is linked to academic performance, questions remain about what determines students’ decisions to attend or miss class. Aims: In addition to the constructs of a common decision-making model, the theory of planned behaviour, the present study examined the influence of student role identity and university student (in-group) identification for predicting both the initiation and maintenance of students’ attendance at voluntary peer-assisted study sessions in a statistics subject. Sample: University students enrolled in a statistics subject were invited to complete a questionnaire at two time points across the academic semester. A total of 79 university students completed questionnaires at the first data collection point, with 46 students completing the questionnaire at the second data collection point. Method: Twice during the semester, students’ attitudes, subjective norm, perceived behavioural control, student role identity, in-group identification, and intention to attend study sessions were assessed via on-line questionnaires. Objective measures of class attendance records for each half-semester (or ‘term’) were obtained. Results: Across both terms, students’ attitudes predicted their attendance intentions, with intentions predicting class attendance. Earlier in the semester, in addition to perceived behavioural control, both student role identity and in-group identification predicted students’ attendance intentions, with only role identity influencing intentions later in the semester. Conclusions: These findings highlight the possible chronology that different identity influences have in determining students’ initial and maintained attendance at voluntary sessions designed to facilitate their learning.

The SurfAid International Schools Program : opportunities for HPE and senior health education

SurfAid International is a humanitarian organisation that has been delivering a range of evidence based health promotion initiatives, primarily for people living on Nias and the Mentawai Islands off the west coast of Sumatra, Indonesia since 2000. The SurfAid Schools Program launched in 2007, providing opportunities for the development of global awareness, cultural knowledge, empathy and active citizenship among students living in Australia, New Zealand, North America and the United Kingdom. This session will commence with an overview of the work of SurfAid International and resources provided by the SurfAid International Schools Program. The social justice orientation of the Queensland Health Education Senior Syllabus and the HPE Essential Learnings will be reviewed along with a consideration for affective learning through attitudes and values. Participants will be given time to consider how units with a health of specific populations focus could be conceptualised, developed and managed. Opportunities for co-curricular applications will also be discussed.

‘Show Me Your Wiki and I’ll Show you Mine’: Using Online Interactive Media to Improve Academic Writing and Research in a Public Health Under-Graduate Cohort

The number of Internet users in Australia has been steadily increasing, with over 10.9 million people currently subscribed to an internet provider (ABS, 2011). Over the past year, the most avid users of the Internet were 15 – 24 year olds, with approximately 95% accessing the internet on a regular basis (ABS, Social Trends, 2011). While the internet has been described as fundamental to higher education students, social and leisure internet tools are also increasingly being used by these students to generate and maintain their social and professional networks and interactions (Duffy & Bruns 2006). Rapid technological advancements have enabled greater and faster access to information for learning and education (Hemmi et al, 2009; Glassman and Kang, 2011). As such, we sought to integrate interactive, online social media into the assessment profile of a Public Health undergraduate cohort at the Queensland University of Technology (QUT). The aim of this exercise was to engage students to both develop and showcase their research on a range of complex, contemporary health issues within the online forum of Wikispaces (http://www.wikispaces.com/) for review and critique by their peers. We applied Bandura’s Social Learning Theory (SLT) to analyse the interactive processes from which students developed deeper and more sustained learning, and via which their overall academic writing standards were raised. This paper outlines the assessment task, and the students’ feedback on their learning outcomes in relation to the Attentional, Retentional, Motor Reproduction, and Motivational Processes outlined by Bandura in SLT. We conceptualise the findings in a theoretical model, and discuss the implications for this approach within the broader tertiary environment.