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.

The introduction of an interactive teaching and learning activity (TLA) in class and its relationship to students’ learning-outcomes

In the university education arena, it is becoming apparent that traditional methods of conducting classes are not the most effective ways to achieve desired learning outcomes. The traditional class/method involves the instructor verbalizing information for passive, note-taking students who are assumed to be empty receptacles waiting to be filled with knowledge. This method is limited in its effectiveness, as the flow of information is usually only in one direction. Furthermore, “It has been demonstrated that students in many cases can recite and apply formulas in numerical problems, but the actual meaning and understanding of the concept behind the formula is not acquired (Crouch & Mazur)”. It is apparent that memorization is the main technique present in this approach. A more effective method of teaching involves increasing the students’ level of activity during, and hence their involvement in the learning process. This technique stimulates self- learning and assists in keeping these students’ levels of concentration more uniform. In this work, I am therefore interested in studying the influence of a particular TLA on students’ learning-outcomes. I want to foster high-level understanding and critical thinking skills using active learning (Silberman, 1996) techniques. The TLA in question aims to promote self-study by students and to expose them to a situation where their learning-outcomes can be tested. The motivation behind this activity is based on studies which suggest that some sensory modalities are more effective than others. Using various instruments for data collection and by means of a thorough analysis I present evidence of the effectiveness of this action research project which aims to improve my own teaching practices, with the ultimate goal of enhancing student’s learning.

STEM futures and practice, can we teach STEM in a more meaningful and integrated way?

Integrating Science, Technology, Engineering and Mathematics (STEM) subjects can be engaging for students, can promote problem-solving and critical thinking skills and can help build real-world connections. However, STEM has long been an area of some confusion for some educators. While they can see many of the conceptual links between the various domains of knowledge they often struggle to meaningfully integrate and simultaneously teach the content and methodologies of each these areas in a unified and effective way for their students. Essentially the question is;how can the content and processes of four disparate and yet integrated learning areas be taught at the same time? How can the integrity of each of the areas be maintained and yet be learnt in a way that is complementary? Often institutional barriers exitin schools and universities to the integration of STEM. Organizationally, at a departmental and administrative level, the teaching staff may be co-located, but when it comes to classroom practice or the teaching and learning of these areas they are usually taught very separately. They are usually taught in different kinds of spaces, in different ways (using different pedagogical approaches) and at different times. But is this the best way for students to engage with the STEM areas of learning? How can we make learning more integrated, meaningful and engaging for the students?

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

Theme Paper for Curriculum innovation and enhancement theme AIM: This paper reports on a research project that trialled an educational strategy implemented in an undergraduate nursing curriculum. The project aimed to explore the effectiveness of ‘think aloud’ as a strategy for improving 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 (Lasater, 2007). Nursing students are expected to develop and display clinical reasoning skills in practice, but may struggle articulating reasons behind decisions about patient care. The ‘think aloud’ approach is an innovative learning/teaching method which can create an environment suitable for developing clinical reasoning skills in students (Banning, 2008, Lee and Ryan-Wenger, 1997). This project used the ‘think aloud’ strategy within a simulation context to provide a safe learning environment in which third year students were assisted to uncover cognitive approaches to assist in making effective patient care decisions, and improve their confidence, clinical reasoning and active critical reflection about their practice. MEHODS: In semester 2 2011 at QUT, third year nursing students undertook high fidelity simulation (some for the first time), commencing in September of 2011. There were two cohorts for strategy implementation (group 1= used think aloud as a strategy within the simulation, group 2= no specific strategy outside of nursing assessment frameworks used by all students) in relation to problem solving patient needs. The think aloud strategy was described to students in their pre-simulation briefing and allowed time for clarification of this strategy. All other aspects of the simulations remained the same, (resources, suggested nursing assessment frameworks, simulation session duration, size of simulation teams, preparatory materials). Ethics approval has been obtained for this project. RESULTS: Results of a qualitative analysis (in progress- will be completed by March 2012) of student and facilitator reports on students’ ability to meet the learning objectives of solving patient problems using clinical reasoning and experience with the ‘think aloud’ method will be presented. A comparison of clinical reasoning learning outcomes between the two groups will determine the effect on clinical reasoning for students responding to patient problems. 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.

'Women on a Wiki’ : the role of interactive websites in reflective learning practices for undergraduate women’s health students

Aim Our pedagogical research addressed the following research questions: 1) Can shared ‘cyber spaces’, such as a ‘wiki’, be occupied by undergraduate women’s health students to improve their critical thinking skills? 2) What are the learning processes via which this occurs? 3) What are the implications of this assessment trial for achieving learning objectives and outcomes in future public health undergraduate courses? Methods The students contributed written, critical reflections (approximately 250 words) to the Wiki each week following the lecture. Students reflected on a range of topics including the portrayal of women in the media, femininity, gender inequality, child bearing and rearing, domestic violence, mental health, Indigenous women, older women, and LGBTIQ communities. Their entries were anonymous, but visible to their peers. Each wiki entry contained a ‘discussion tab’ wherein online conversations were initiated. We used a social constructivist approach to grounded theory to analyse the 480 entries posted over the semester. (http://pub336womenshealth.wikispaces.com/) Results The social constructivist approach initiated by Vygotsky (1978) and further developed by Jonasson (1994) was used to analyse the students’ contributions in relation to four key thematic outcomes including: 1) Complexities in representations across contexts; 2) Critical evaluation in real world scenarios; 3) Reflective practice based on experience, and; 4) Collaborative co-construction of knowledge. Both text and image/visual contributions are provided as examples within each of these learning processes. A theoretical model depicting the interactive learning processes that occurred via discussion of the textual and visual stimulus is presented.

Influencing pre-service teachers, skills and attitudes towards diversity. Is DOL the Answer?

Abstract: This paper reports on a preliminary investigation into the success of an undergraduate course, in helping preservice teachers at a regional university develop the skills and attitudes necessary to design inclusive learning environments that cater for, and celebrate, difference. The study is particularly relevant given recommendations by the Education Queensland Ministerial Taskforce (Queensland Government, 2004) that all pre-service teacher education programs must ensure that inclusive education is a pervasive theme. The paper starts by providing an overview of inclusive contexts and a rationale for inclusive education including critical elements. This leads into an overview of the undergraduate course EDED11400 Managing Diversity and discussion, based on feedback from the teaching team, on the capacity for the course to help pre-service teachers develop inclusive curriculum and pedagogical practices. The pedagogical framework Dimensions of Learning* is then discussed, with consideration given to whether this framework with its focus on critical thinking and habits of mind, might improve future learning outcomes in the course EDED11400 Managing Diversity. (*Dimensions of Learning is a pedagogical framework designed to teach thinking skills (Marzano et al., 1988). It explores five types of thinking represented in the framework by five dimensions of learning.)

Enhancing capacity for 'systematic' thinking in public health

The concept of being evidence based or evidence informed is widely acknowledged as an important component of decision-making. It is perhaps most universally referred to in medicine, however has extended into many other disciplines over the past decade, including public health. Evidence-based public health has been defined as the ‘conscientious, explicit and judicious use of current best evidence in making decisions about the care of communities and populations in the domain of health protection, disease prevention, health maintenance and improvement (health promotion)’.1 More recent literature favours the use of the term evidence informed over evidence based to acknowledge the varying influences on decisions in this complex field.2,3 Evidence-informed activities in any discipline require a specific set of skills in critical thinking. These skills include identifying the questions to be resolved, collecting relevant evidence, and assessing, synthesizing and distilling evidence in a way that can inform the set of activities to be undertaken as a result.

Embedding metacognitive skills in spatial design

Metacognitive skills are considered to be essential for graduates from higher education institutions. In teaching spatial design, a fundamental aspect of student learning is the ability to ‘frame’ problems, generate solutions and explore possibilities of different solutions. This article proposes an innovative approach to design education through the implementation of strategies into the design process. The externalisation of implicit and tacit learning through metacognition connects theoretical concepts to interior design process and practice, as well as allowing students to engage and critically analyse issues surrounding theory and practice, thus equipping them with the skills as future design professionals.

Teacher educators embrace philosophy: reflections on a new way of looking at preparing pre-service teachers

Over the last decade in Australia, the role of the teacher has changed. Teachers are now expected to model and foster in their students a wide range of skills such as critical thinking, self-regulated learning, knowledge of self and others and lifelong learning. These changes are having a significant impact on the design of pre-service teacher education programmes, with university educators re-evaluating the teacher training curriculum and embedded pedagogical processes in order to consider how they might develop these skills in pre-service teachers. One approach is to consider the processes and practices inherent in philosophical inquiry. This paper reports on three participants’ reflections of a 12-week philosophy programme that was conducted for teacher educators at Queensland’s University of Technology (QUT) in 2008. The programme was facilitated by teachers from Buranda State School who have been teaching philosophy in their P-7 school for more than ten years. This paper provides insight into teacher educators’ reflections on the philosophy programme and the associated changes and challenges of implementing such a programme in pre-service teacher education degrees.

Implementation of an integrated, technology-based, discovery mode assessment item involving an incubation period to enhance learning outcomes for engineering maths students

In this paper we discuss our current efforts to develop and implement an exploratory, discovery mode assessment item into the total learning and assessment profile for a target group of about 100 second level engineering mathematics students. The assessment item under development is composed of 2 parts, namely, a set of "pre-lab" homework problems (which focus on relevant prior mathematical knowledge, concepts and skills), and complementary computing laboratory exercises which are undertaken within a fixed (1 hour) time frame. In particular, the computing exercises exploit the algebraic manipulation and visualisation capabilities of the symbolic algebra package MAPLE, with the aim of promoting understanding of certain mathematical concepts and skills via visual and intuitive reasoning, rather than a formal or rigorous approach. The assessment task we are developing is aimed at providing students with a significant learning experience, in addition to providing feedback on their individual knowledge and skills. To this end, a noteworthy feature of the scheme is that marks awarded for the laboratory work are primarily based on the extent to which reflective, critical thinking is demonstrated, rather than the amount of CBE-style tasks completed by the student within the allowed time. With regard to student learning outcomes, a novel and potentially critical feature of our scheme is that the assessment task is designed to be intimately linked to the overall course content, in that it aims to introduce important concepts and skills (via individual student exploration) which will be revisited somewhat later in the pedagogically more restrictive formal lecture component of the course (typically a large group plenary format). Furthermore, the time delay involved, or "incubation period", is also a deliberate design feature: it is intended to allow students the opportunity to undergo potentially important internal re-adjustments in their understanding, before being exposed to lectures on related course content which are invariably delivered in a more condensed, formal and mathematically rigorous manner. In our presentation, we will discuss in more detail our motivation and rationale for trailing such a scheme for the targeted student group. Some of the advantages and disadvantages of our approach (as we perceived them at the initial stages) will also be enumerated. In a companion paper, the theoretical framework for our approach will be more fully elaborated, and measures of student learning outcomes (as obtained from eg. student provided feedback) will be discussed.

Literacy models across nations : literacy and critical literacy in teacher training programs in India

The thrust towards constructivist learning and critical thinking in the National Curricular Framework (2005) of India implies shifts in pedagogical practices. In this context, drawing on grounded theory, focus group interviews were conducted with 40 preservice teachers to ascertain the contextual situation and the likely outcomes of applying critical literacy across the curriculum. Central themes that emerged in the discussion were: being teacher centred/ learner centred, and conformity/autonomy in teaching and learning. The paper argues that within the present Indian context, while there is scope for changes to pedagogy and learning styles, yet these must be adequately contextualised.

Cognitive skills required in contemporary workplaces

This paper discusses some of the changes occurring in contemporary workplace practices, and the implications these have for the types of knowledge and skills required to work in such environments. Increasingly, workers need to be multi-skilled to function effectively in contemporary work environments. The nature of multi-skilling is explained in terms of cross-skilling, up-skilling and higher-order thinking skills, and the relevance of multi-skilling in today's workplaces is examined. Finally, the paper explores some factors affecting the acquisition of these desired skills in light of current work practices.

Development and evaluation of an integrated clinical learning model to inform continuing education for acute care nurses

Background Significant ongoing learning needs for nurses have occurred as a direct result of the continuous introduction of technological innovations and research developments in the healthcare environment. Despite an increased worldwide emphasis on the importance of continuing education, there continues to be an absence of empirical evidence of program and session effectiveness. Few studies determine whether continuing education enhances or develops practice and the relative cost benefits of health professionals’ participation in professional development. The implications for future clinical practice and associated educational approaches to meet the needs of an increasingly diverse multigenerational and multicultural workforce are also not well documented. There is minimal research confirming that continuing education programs contribute to improved patient outcomes, nurses’ earlier detection of patient deterioration or that standards of continuing competence are maintained. Crucially, evidence-based practice is demonstrated and international quality and safety benchmarks are adhered to. An integrated clinical learning model was developed to inform ongoing education for acute care nurses. Educational strategies included the use of integrated learning approaches, interactive teaching concepts and learner-centred pedagogies. A Respiratory Skills Update education (ReSKU) program was used as the content for the educational intervention to inform surgical nurses’ clinical practice in the area of respiratory assessment. The aim of the research was to evaluate the effectiveness of implementing the ReSKU program using teaching and learning strategies, in the context of organisational utility, on improving surgical nurses’ practice in the area of respiratory assessment. The education program aimed to facilitate better awareness, knowledge and understanding of respiratory dysfunction in the postoperative clinical environment. This research was guided by the work of Forneris (2004), who developed a theoretical framework to operationalise a critical thinking process incorporating the complexities of the clinical context. The framework used educational strategies that are learner-centred and participatory. These strategies aimed to engage the clinician in dynamic thinking processes in clinical practice situations guided by coaches and educators. Methods A quasi experimental pre test, post test non–equivalent control group design was used to evaluate the impact of the ReSKU program on the clinical practice of surgical nurses. The research tested the hypothesis that participation in the ReSKU program improves the reported beliefs and attitudes of surgical nurses, increases their knowledge and reported use of respiratory assessment skills. The study was conducted in a 400 bed regional referral public hospital, the central hub of three smaller hospitals, in a health district servicing the coastal and hinterland areas north of Brisbane. The sample included 90 nurses working in the three surgical wards eligible for inclusion in the study. The experimental group consisted of 36 surgical nurses who had chosen to attend the ReSKU program and consented to be part of the study intervention group. The comparison group included the 39 surgical nurses who elected not to attend the ReSKU program, but agreed to participate in the study. Findings One of the most notable findings was that nurses choosing not to participate were older, more experienced and less well educated. The data demonstrated that there was a barrier for training which impacted on educational strategies as this mature aged cohort was less likely to take up educational opportunities. The study demonstrated statistically significant differences between groups regarding reported use of respiratory skills, three months after ReSKU program attendance. Between group data analysis indicated that the intervention group’s reported beliefs and attitudes pertaining to subscale descriptors showed statistically significant differences in three of the six subscales following attendance at the ReSKU program. These subscales included influence on nursing care, educational preparation and clinical development. Findings suggest that the use of an integrated educational model underpinned by a robust theoretical framework is a strong factor in some perceptions of the ReSKU program relating to attitudes and behaviour. There were minimal differences in knowledge between groups across time. Conclusions This study was consistent with contemporary educational approaches using multi-modal, interactive teaching strategies and a robust overarching theoretical framework to support study concepts. The construct of critical thinking in the clinical context, combined with clinical reasoning and purposeful and collective reflection, was a powerful educational strategy to enhance competency and capability in clinicians.