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.

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 qualitative think aloud study of the early Neo-Piagetian stages of reasoning in novice programmers

Recent research indicates that some of the difficulties faced by novice programmers are manifested very early in their learning. In this paper, we present data from think aloud studies that demonstrate the nature of those difficulties. In the think alouds, novices were required to complete short programming tasks which involved either hand executing ("tracing") a short piece of code, or writing a single sentence describing the purpose of the code. We interpret our think aloud data within a neo-Piagetian framework, demonstrating that some novices reason at the sensorimotor and preoperational stages, not at the higher concrete operational stage at which most instruction is implicitly targeted.

Longitudinal think aloud study of a novice programmer

Recent research from within a neo-Piagetian perspective proposes that novice programmers pass through the sensorimotor and preoperational stages before being able to reason at the concrete operational stage. However, academics traditionally teach and assess introductory programming as if students commence at the concrete operational stage. In this paper, we present results from a series of think aloud sessions with a single student, known by the pseudonym “Donald”. We conducted the sessions mainly over one semester, with an additional session three semesters later. Donald first manifested predominately sensorimotor reasoning, followed by preoperational reasoning, and finally concrete operational reasoning. This longitudinal think aloud study of Donald is the first direct observational evidence of a novice programmer progressing through the neo-Piagetian stages.

Content validity of the Illness Perception Questionnaire-Revised for people with Type 2 Diabetes: A Think-Aloud study

Objectives: To access the cognitions of adults with type 2 diabetes whilst completing items on the Illness Perceptions Questionnaire – Revised (IPQ-R). To determine whether these cognitions are congruent with the meaning of items and subscales as interpreted by researchers and clinicians using the IPQ-R and to identify the nature and extent of problems that individuals experience when completing the IPQ-R.
Design: Participants (n=36) were recruited from a primary care diabetes clinic and a hospital diabetes clinic. They were asked to complete the IPQ-R using a ‘think-aloud’ methodology.
Main Outcome Measures: Transcripts were analysed to identify instances where participants expressed problems with item completion, or where there was inconsistency between verbal and written responses.
Results: The most problematic subscales were those of ‘personal control’ and ‘consequences’.
Conclusion: Generally, participants found the IPQ-R unproblematic. However, participants had problems with the concept of ‘cure’ and ‘symptoms’ in the context of type 2 diabetes, and with the negative phrasing used in some items. These findings have important implications for the interpretation of IPQ-R scores, particularly when the IPQ-R is used as the basis for individualised interventions among people with type 2 diabetes.

Première validation d'une situation clinique de soins infirmiers en vue d'une intervention éducative de type "think aloud"

Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal

Exploring self-rated health among adolescents : a think-aloud study

BACKGROUND: Despite extensive use of self-rated health questions in youth studies, little is known about what such questions capture among adolescents. Hence, the aim of this study was to explore how adolescents interpret and reason when answering a question about self-rated health. METHODS: A qualitative study using think-aloud interviews explored the question, "How do you feel most of the time?", using five response options ("Very good", "Rather good", "Neither good, nor bad", "Rather bad", and "Very bad"). The study involved 58 adolescents (29 boys and 29 girls) in lower secondary school (7th grade) and upper secondary school (12th grade) in Sweden. RESULTS: Respondents' interpretations of the question about how they felt included social, mental, and physical aspects. Gender differences were found primarily in that girls emphasized stressors, while age differences were reflected mainly in the older respondents' inclusion of a wider variety of influences on their assessments. The five response options all demonstrated differences in self-rated health, and the respondents' understanding of the middle option, "Neither good, nor bad", varied widely. In the answering of potential sensitive survey questions, rationales for providing honest or biased answers were described. CONCLUSIONS: The use of a self-rated health question including the word 'feel' captured a holistic view of health among adolescents. Differences amongst response options should be acknowledged when analyzing self-rated health questions. If anonymity is not feasible when answering questions on self-rated health, a high level of privacy is recommended to increase the likelihood of reliability.

The Use of Think-Aloud Strategies to Solve Word Problems

In this action research study of my sixth grade mathematics class, I investigated how students’ use of think-aloud strategies impacts their success in solving word problems. My research reveals that the use of think-aloud strategies can play an important role in the students’ abilities to understand and solve word problems. Direct instruction and modeling of think-aloud strategies increased my students’ confidence levels and the likelihood that they would use the strategies on their own. Providing students with a template to use as they solve a word problem helps students to better focus in on the think-aloud strategies I had been modeling for them.

What do people think about when they answer theory of planned behaviour questionnaires? A 'think aloud' study

Two studies aiming to identify the nature and extent of problems that people have when completing theory of planned behaviour (TPB) questionnaires, using a cognitive interviewing approach are reported. Both studies required participants to 'think aloud' as they completed TPB questionnaires about: (a) increasing physical activity (six general public participants); and (b) binge drinking (13 students). Most people had no identifiable problems with the majority of questions. However, there were problems common to both studies, relating to information retrieval and to participants answering different questions from those intended by researchers. Questions about normative influence were particularly problematic. The standard procedure for developing TPB questionnaires may systematically produce problematic questions. Suggestions are made for improving this procedure. Copyright © 2007 SAGE Publications.

What do IPAQ questions mean to older adults? Lessons from cognitive interviews

Background Most questionnaires used for physical activity (PA) surveillance have been developed for adults aged ≤65 years. Given the health benefits of PA for older adults and the aging of the population, it is important to include adults aged 65+ years in PA surveillance. However, few studies have examined how well older adults understand PA surveillance questionnaires. This study aimed to document older adults’ understanding of questions from the International PA Questionnaire (IPAQ), which is used worldwide for PA surveillance. Methods Participants were 41 community-dwelling adults aged 65-89 years. They each completed IPAQ in a face-to-face semi-structured interview, using the “think-aloud” method, in which they expressed their thoughts out loud as they answered IPAQ questions. Interviews were transcribed and coded according to a three-stage model: understanding the intent of the question; performing the primary task (conducting the mental operations required to formulate a response); and response formatting (mapping the response into pre-specified response options). Results Most difficulties occurred during the understanding and performing the primary task stages. Errors included recalling PA in an “average” week, not in the previous 7 days; including PA lasting ≤10 minutes/session; reporting the same PA twice or thrice; and including the total time of an activity for which only a part of that time was at the intensity specified in the question. Participants were unclear what activities fitted within a question’s scope and used a variety of strategies for determining the frequency and duration of their activities. Participants experienced more difficulties with the moderate-intensity PA and walking questions than with the vigorous-intensity PA questions. The sitting time question, particularly difficult for many participants, required the use of an answer strategy different from that used to answer questions about PA. Conclusions These findings indicate a need for caution in administering IPAQ to adults aged ≥65 years. Most errors resulted in over-reporting, although errors resulting in under-reporting were also noted. Given the nature of the errors made by participants, it is possible that similar errors occur when IPAQ is used in younger populations and that the errors identified could be minimized with small modifications to IPAQ.

Consumer’s persistence in solving their own problem with self‐service technology

An increasing range of technology services are now offered on a self-service basis. However, problems with self-service technologies (SSTs) occur at times due to the technical error, staff error, or consumers’ own mistakes. Considering the role of consumers as co-producers in the SST context, we aim to study consumer’s behaviours, strategies, and decision making in solving their problem with SST and identify the factors contributing to their persistence in solving the problem. This study contributes to the information systems research, as it is the first study that aims to identify such a process and the factors affecting consumers’ persistence in solving their problem with SST. A focus group with user support staff has been conducted, yielding some initial results that helped to conduct the next phases of the study. Next, using Critical Incident Technique, data will be gathered through focus groups with users, diary method, and think-aloud method.

Exploring Problem Decomposition in Conceptual Design

Design embraces several disciplines dedicated to the production of artifacts and services. These disciplines are quite independent and only recently has psychological interest focused on them. Nowadays, the psychological theories of design, also called design cognition literature, describe the design process from the information processing viewpoint. These models co-exist with the normative standards of how designs should be crafted. In many places there are concrete discrepancies between these two in a way that resembles the differences between the actual and ideal decision-making. This study aimed to explore the possible difference related to problem decomposition. Decomposition is a standard component of human problem-solving models and is also included in the normative models of design. The idea of decomposition is to focus on a single aspect of the problem at a time. Despite its significance, the nature of decomposition in conceptual design is poorly understood and has only been preliminary investigated. This study addressed the status of decomposition in conceptual design of products using protocol analysis. Previous empirical investigations have argued that there are implicit and explicit decomposition, but have not provided a theoretical basis for these two. Therefore, the current research began by reviewing the problem solving and design literature and then composing a cognitive model of the solution search of conceptual design. The result is a synthetic view which describes recognition and decomposition as the basic schemata for conceptual design. A psychological experiment was conducted to explore decomposition. In the test, sixteen (N=16) senior students of mechanical engineering created concepts for two alternative tasks. The concurrent think-aloud method and protocol analysis were used to study decomposition. The results showed that despite the emphasis on decomposition in the formal education, only few designers (N=3) used decomposition explicitly and spontaneously in the presented tasks, although the designers in general applied a top-down control strategy. Instead, inferring from the use of structured strategies, the designers always relied on implicit decomposition. These results confirm the initial observations found in the literature, but they also suggest that decomposition should be investigated further. In the future, the benefits and possibilities of explicit decomposition should be considered along with the cognitive mechanisms behind decomposition. After that, the current results could be reinterpreted.

Analyse comparative de l’utilisation des ouvrages de référence chez des étudiants bilingues en traduction et en droit dans le domaine du droit pénal

L’objectif principal du présent mémoire est d’observer le processus de traduction d’un texte de nature juridique mis en oeuvre par deux groupes d’étudiants, cinq étudiants inscrits au baccalauréat en traduction et quatre inscrits au baccalauréat en droit. Tout d’abord, nous analyserons les différences qui existent entre les deux groupes dans leur utilisation des ouvrages de référence. Nous observerons entre autres la diversité générale des ouvrages consultés et la connaissance antérieure des ouvrages papier, la répartition par type d’ouvrages (dictionnaire bilingue, monolingue ou autres), la répartition par support d’ouvrages (électronique ou papier), l’utilisation des correcteurs, l’intensité des recherches effectuées et, finalement, le premier ouvrage consulté selon le type et le support. Ces données seront recueillies grâce à la méthode de verbalisation à voix haute et à l’enregistrement de l’écran d’ordinateur, au moyen du logiciel WebEx. Ensuite, nous évaluerons la qualité des traductions en faisant une distinction entre deux types d’erreurs, soit les erreurs de traduction et les erreurs de langue. Nous tenterons par la suite d’établir des liens entre l’utilisation des ouvrages de référence et la qualité des traductions. Nous observerons que les deux groupes utilisent les ouvrages de référence différemment et que les traducteurs ont semblé mieux outillés que les juristes pour remettre une traduction de qualité.

L’exercice du raisonnement clinique d’infirmières du programme SIPPE lorsqu’elles priorisent leurs interventions auprès de familles qui vivent en contexte de vulnérabilité.

Cette recherche qualitative avait pour but d’explorer le raisonnement clinique d’infirmières de première ligne en CSSS/CLSC lorsqu’elles priorisent leurs interventions auprès de familles vivant en contexte de vulnérabilité dans le cadre du programme des Services intégrés en périnatalité et pour la petite enfance (SIPPE). Il s’agit d’une étude de cas qui comporte un échantillon intentionnel de sept épisodes de soins impliquant deux infirmières auprès de sept familles en période postnatale lorsqu’elles priorisent leurs interventions. La collecte de données a procédé par méthode think aloud, suivie d’entretiens semi-dirigés auprès des infirmières. Une analyse qualitative des données a été effectuée selon des méthodes interprétatives et par comptage de catégories. Ces dernières ont été formulées et mises en relation en s’inspirant de la modélisation du processus de raisonnement clinique de Tanner (2006) ainsi que des stratégies de raisonnement clinique proposés par Fonteyn (1998). Au terme de cette étude, le processus de raisonnement clinique ne semble pas être différent selon le type de priorité d’intervention auprès de familles en contexte de vulnérabilité, particulièrement lorsque nous distinguons la priorité selon un degré d’urgence (prioritaire ou secondaire). Aussi, nous constatons qu’il existe peu de diversité dans les processus de raisonnement clinique mobilisés à travers les sept épisodes de soins; et qu’un processus narratif de raisonnement est fréquent. Si une famille exprime un besoin urgent, l’infirmière y répond prioritairement. Par ailleurs, lorsque des conditions suggèrent un potentiel accru de vulnérabilité des familles, un mode de raisonnement clinique plus systématique, qui comporte une collecte et une mise en relation d’informations afin de formuler une proposition pour soutenir le passage à l’action, semble être mobilisé pour prioriser l’intervention. Il en est ainsi s’il s’agit d’un premier bébé, que la famille n’utilise pas d’autres ressources formelles de soutien. Autrement, s’il s’agit d’un deuxième bébé et que les familles utilisent d’autres ressources, les infirmières tendent plutôt à appliquer une routine d’intervention SIPPE. Aussi, cette recherche témoigne de l’engagement soutenu des infirmières auprès de familles vivant d’importants défis. Il importe toutefois de soutenir le développement d’un répertoire plus varié de processus de raisonnement clinique afin de renforcer leur capacité de prioriser leur intervention qui se déroule dans un contexte de multiples contraintes organisationnelles et interpersonnelles.

Using neo-Piagetian theory, formative in-Class tests and think alouds to better understand student thinking : a preliminary report on computer programming

It is acknowledged around the world that many university students struggle with learning to program (McCracken et al., 2001; McGettrick et al., 2005). In this paper, we describe how we have developed a research programme to systematically study and incrementally improve our teaching. We have adopted a research programme with three elements: (1) a theory that provides an organising framework for defining the type of phenomena and data of interest, (2) data on how the class as a whole performs on formative assessment tasks that are framed from within the organising framework, and (3) data from one-on-one think aloud sessions, to establish why students struggle with some of those in-class formative assessment tasks. We teach introductory computer programming, but this three-element structure of our research is applicable to many areas of engineering education research.