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 business of fashion : entrepreneurship and enterprise learning for the new ‘creative’ global marketplace – the Australian case study [Abstract]

While the fashion industry is normally first to recognise trends and embrace creativity, fashion designers are sometimes the last to acknowledge that business acumen and entrepreneurial skills are needed. However, fashion designers and entrepreneurs are now all members of the new ‘creative’ global marketplace with its inherent need to sell globally and be competitive with international brands. For the Australian industry, this tension creates enormous pressures due to Australia’s small population (and market/s), the decreasing textile and manufacturing base, the increase of ‘creative’ micro businesses and with this the increasing number of young Australians wanting to start their own fashion business. This paper highlights the current size of the Australian fashion industry, the trend for small business models, the ‘career portfolio’ entrepreneur and strategies Australian universities are undertaking to address students wishing to enter the business of fashion. It also identifies case studies where enterprise learning pedagogy has been successfully implemented into the business education of an Australian fashion program and concludes with recommendations for an enterprise pedagogy that creates authentic learning, while working with industry and community stakeholders in flexible university formats.

Swapping as the "Hello World" of relational reasoning : replications, reflections and extensions

At the previous conference in this series, Corney, Lister and Teague presented research results showing relationships between code writing, code tracing and code explaining, from as early as week 3 of semester. We concluded that the problems some students face in learning to program start very early in the semester. In this paper we report on our replication of that experiment, at two institutions, where one is the same as the original institution. In some cases, we did not find the same relationship between explaining code and writing code, but we believe this was because our teachers discussed the code in lectures between the two tests. Apart from that exception, our replication results at both institutions are consistent with our original study.

Some empirical results for neo-Piagetian reasoning in novice programmers and the relationship to code explanation questions

Recent research on novice programmers has suggested that they pass through neo-Piagetian stages: sensorimotor, preoperational, and concrete operational stages, before eventually reaching programming competence at the formal operational stage. This paper presents empirical results in support of this neo-Piagetian perspective. The major novel contributions of this paper are empirical results for some exam questions aimed at testing novices for the concrete operational abilities to reason with quantities that are conserved, processes that are reversible, and properties that hold under transitive inference. While the questions we used had been proposed earlier by Lister, he did not present any data for how students performed on these questions. Our empirical results demonstrate that many students struggle to answer these problems, despite the apparent simplicity of these problems. We then compare student performance on these questions with their performance on six explain in plain English questions.

Mining a data reasoning model for personalized text classification

It is a big challenge to acquire correct user profiles for personalized text classification since users may be unsure in providing their interests. Traditional approaches to user profiling adopt machine learning (ML) to automatically discover classification knowledge from explicit user feedback in describing personal interests. However, the accuracy of ML-based methods cannot be significantly improved in many cases due to the term independence assumption and uncertainties associated with them. This paper presents a novel relevance feedback approach for personalized text classification. It basically applies data mining to discover knowledge from relevant and non-relevant text and constraints specific knowledge by reasoning rules to eliminate some conflicting information. We also developed a Dempster-Shafer (DS) approach as the means to utilise the specific knowledge to build high-quality data models for classification. The experimental results conducted on Reuters Corpus Volume 1 and TREC topics support that the proposed technique achieves encouraging performance in comparing with the state-of-the-art relevance feedback models.

The enterprise information security policy as a strategic business policy within the corporate strategic plan (extended abstract)

Information security has been recognized as a core requirement for corporate governance that is expected to facilitate not only the management of risks, but also as a corporate enabler that supports and contributes to the sustainability of organizational operations. In implementing information security, the enterprise information security policy is the set of principles and strategies that guide the course of action for the security activities and may be represented as a brief statement that defines program goals and sets information security and risk requirements. The enterprise information security policy (alternatively referred to as security policy in this paper) that represents the meta-policy of information security is an element of corporate ICT governance and is derived from the strategic requirements for risk management and corporate governance. Consistent alignment between the security policy and the other corporate business policies and strategies has to be maintained if information security is to be implemented according to evolving business objectives. This alignment may be facilitated by managing security policy alongside other corporate business policies within the strategic management cycle. There are however limitations in current approaches for developing and managing the security policy to facilitate consistent strategic alignment. This paper proposes a conceptual framework for security policy management by presenting propositions to positively affect security policy alignment with business policies and prescribing a security policy management approach that expounds on the propositions.

Food and interaction design [Extended Abstract]

Food and interaction design presents an interesting challenge to the HCI community in attending to the pervasive nature of food, the socio-cultural differences in food practices and a changing global foodscape. To design for meaningful and positive interactions it is essential to identify daily food practices and the opportunities for the design of technology to support such practices. This workshop brings together a community of researchers and practitioners in human-food interaction to attend to the practical and theoretical difficulties in designing for human-food interactions in everyday life. Through a practical field study and workshop we explore themes of food experiences, health and wellbeing, sustainability and alternative food cultures.

Bending and blurring blended learning boundaries [Extended Abstract]

This presentation presents a blended learning model that provides greater opportunity for learning to be self-managed and personalized.

History behind the egg: Women's comprehensive histories and IVF outcomes, Australia, 2008-2009 [abstract]

The individual history of infertile women, as well as their age, may influence their response to in vitro fertilisation (IVF) cycles. This study examined the associations between women’s histories and two IVF outcomes: eggs aspirated (EA) and proportion with normal, two-pronuclei (2PN), fertilisation. This is a cross-sectional survey of infertile women (n=141, 27-46 years) from a multi-centre clinical sample. Participants completed a survey of socio-demographic, relationship, lifestyle, reproductive and fertility factors, medical conditions and recurrent symptoms. Among participants with heterosexual partners (n=122), associations between women’s histories and EA or 2PN fertilisation were analysed using linear and logistic modelling, respectively, adjusted for age at EA and accounting for multiple IVF cycles (n=313 cycles). Participants aged 35+ years had reproductive histories of miscarriage only (16.9%), termination only (9.9%) or birth+termination (5.6%) that were 2-, 3- and 4-fold higher, respectively, than those aged <35 years (7.1%, 2.9%, 1.4%). More years of oral contraceptive use were associated with a lower mean EA: never used, 14.6 EA; 0-2 years, 11.7 EA; 3-5 years, 8.6 EA; 6þ years, 8.2 EA (p=.04). Participants with polycystic ovary syndrome had a higher mean EA (11.5) than those without the condition (8.3 EA, p<.01). Participants in trade or service occupations had lower proportions of 2PN fertilisation (51.7%) than participants in other occupations (professional, 58.6%; manual/other, 63.6%, p<.02). Increasing women’s age and prolonged used of oral contraceptives were associated with lower EA from IVF cycles; PCOS was associated with higher EA. Occupational exposures may have a detrimental effect on normal fertilisation rates.

History behind the IVF egg: Are women's comprehensive histories associated with the number of eggs collected, or fertilised normally, from repeated IVF cycles? [abstract]

Most studies of in vitro fertilisation (IVF) outcomes use cycle-based data and fail to account for women who use repeated IVF cycles. The objective of this study was to examine the association between the number of eggs collected (EC) and the percentage fertilised normally, and women’s self-reported medical, personal and social histories. This study involved a crosssectional survey of infertile women (aged 27-46 years) recruited from four privately-owned fertility clinics located in major cities of Australia. Regression modeling was used to estimate the mean EC and mean percentage of eggs fertilised normally: adjusted for age at EC. Appropriate statistical methods were used to take account of repeated IVF cycles by the same women. Among 121 participants who returned the survey and completed 286 IVF cycles, the mean age at EC was 35.2 years (SD 4.5). Women’s age at EC was strongly associated with the number of EC: <30 years, 11.7 EC; 30.0-< 35 years, 10.6 EC; 35.0-<40.0 years, 7.3 EC; 40.0+ years, 8.1 EC; p<.0001. Prolonged use of oral contraceptives was associated with lower numbers of EC: never used, 14.6 EC; 0-2 years, 11.7 EC; 3-5 years, 8.5 EC; 6þ years, 8.2 EC; p=.04. Polycystic ovary syndrome (PCOS) was associated with more EC: have PCOS, 11.5 EC; no, 8.3 EC; p=.01. Occupational exposures may be detrimental to normal fertilisation: professional roles, 58.8%; trade and service roles, 51.8%; manual and other roles, 63.3%; p=.02. In conclusion, women’s age remains the most significant characteristic associated with EC but not the percentage of eggs fertilised normally.

Infertility resolved with or without fertility treatment in Australian women aged 31-36 years: A prospective, population-based study [abstract]

Birth outcomes during a three year period were compared for women with a history of infertility who did or did not use fertility treatment with hormones and/or in vitro fertilisation. Participants in the Australian Longitudinal Study on Women’s Health born in 1973-78 were randomly selected from the universal public health insurance database and completed up to five mailed surveys (1996-2009). Participants reported on their infertility and use of treatment at age 28-33 years (survey 4 (S4) in 2006) and 31-36 years (survey 5 (S5) in 2009). The odds of resolved infertility at S5 were estimated using logistic regression with adjustment for age, area of residence, private health insurance and male infertility. Among 7280 women who responded to both S4 and S5, 18.6% (n=1378) reported infertility. More than half (n=804, 56.8%) of these women did not use treatment and 43.9% (n=347) gave birth between S4 and S5. Compared to infertile women who did not use treatment, women who used treatment were more likely at S5 to have recently given birth (odds ratio (OR) = 1.59, 95% CI 1.26-2.00) or be pregnant (OR = 1.77, 1.27-2.46). Further, women who used treatment were more likely to have twins (3.37, 1.18-9.62), premature births (1.52, 0.95-2.43), or low birthweight babies (1.83, 0.70-2.53) compared to women who gave birth without using treatment. Many women aged up to 36 years with a history of infertility can conceive naturally over a three year period without the use of treatment.Women who have never had a prior birth may need to use treatment to resolve their infertility but they are at higher risk of poorer perinatal outcomes, such as premature or low birthweight babies.

Ruptures in the production of girlhood : teenage flows and multiplicities [Abstract]

This paper examines the paradoxical and ubiquitous nature of Butler’s heterosexual matrix, and opens it up to an alternative Deleuzian analysis. Drawing on stories and art works produced in a collective biography workshop on girls and sexuality this paper extends previous work on the subversion of the heterosexual matrix undertaken by Renold and Ringrose (2008). The paper moves, as they do, from a molar to a molecular analysis, but extends that work by re-thinking the girl/subject in terms of Deleuze and Guattari’s endlessly transforming multiplicities where “the self is only a threshold, a door, a becoming between two multiplicities” (Deleuze and Guattari, 1987: 249)

The Cyndi Lauper affect : bodies, girlhood and popular culture [Abstract]

Using a collective biography method informed by a Deleuzian theoretical approach (Davies & Gannon, 2009), this paper analyses embodied memories of girlhood becomings through affective engagements with resonating images in media and popular culture. In this approach to analysis we move beyond an impasse in some feminist cultural studies where studies of popular culture have been understood through theories of representation and reception that retain a sense of discrete subjectivity and linear effects. In these approaches, analysis focuses respectively on decoding and deciphering images in terms of their normative and ideological baggage, and, particularly with moving images, on psychological readings (Coleman, 2011; Driscoll, 2002). Understanding bodies and popular culture through Deleuzian notions of ‘becoming’ and ‘assemblage’ opens possibilities for feminist researchers to consider the ways in which bodies are not separate to images but rather, are known, felt, materialised and mobilised with/through images (Coleman, 2008, 2009, 2011). We tease out the implications of this new approach to media affects through two memories of girls’ engagements with media images, reconceived as moments of embodied being within affective flows of popular culture that might momentarily extend upon the ways of being and doing girlhood.