Future health care demands predict the need for higher level ...... understanding student nurse perceptions important to nursing education (Benner, 2001).
CRITICAL THINKING TEACHING AND LEARNING STRATEGIES AS PERCEIVED BY A.D.N. NURSING STUDENTS by Caree Updyke Copyright 2016
A Dissertation Presented in Partial Fulfillment of the Requirements for the Degree Doctor of Education in Educational Leadership with a Specialization in Curriculum and Instruction
University of Phoenix
ABSTRACT The purpose of this study was to delve into the perceptions of senior-level associate degree program student nurses about specific teaching strategies and how these strategies affected individualized critical thinking learning. Qualitative methodology and phenomenology were the desired method and design. Through the interview process, student nurse perceptions provided key points about the three specific strategies, and how these strategies influenced individualized critical thinking learning. Results from this study provided the researcher with solid perceptive feedback about the three strategies. Future research study may provide expanded results about the subject and is recommended. Perceptive responses by the sample population encourage academic leaders to re-evaluate currently used strategies. Information pertinent to the effectiveness of the strategies, student nurse learning, critical thinking, and application to practice was obtained through this study. Predictions about the future of healthcare suggests greater patient case complexity, so by exploring already existing tactics, and newer potential improvised ideas, nursing education leaders are charged with developing possible solutions toward change. Results from this study provided insight in to potential answers toward necessary change. Future health care demands predict the need for higher level thinking nurses to care for complexly ill patients. Using the interview process, perception guide questions, and qualitative methodology, the study provided useful insight into the value of the three strategies and the directionality of the future of nursing education.
Keywords: Nursing, undergraduate, critical thinking, critical reasoning
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DEDICATION I would like to dedicate this to all those that struggle with such a tremendous task. This journey requires daunting dedication, perseverance and tenacity for accomplishing what some may dismiss as unachievable. The final product is a culmination of years of concentrated study and tremendous depth of learning. I never believed I would be here, at this point in time. Thanks to everyone who made this dream possible. To my beloved grandson Michael Patrick Galle for being born, for loving his “Ammie”, and giving me the interval strength to finish.
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ACKNOWLEDGEMENTS Nelson Mandela (1918-2012) said this best: “It always seems impossible, until it’s done”. That is what I felt I lived for the past 6 years, and that saying helped me stay focused; constantly in sight of this dream. I would like to acknowledge my friends and family for all their support during this long process. In addition to family, I would like to thank my university support; my mentor and committee members. Specifically, I would like to thank my committee members: Dr. Stephen Mercer, Dr. Stephen Northam, and Dr. Diane Breckenridge. I am grateful to all members of my committee for supporting me, encouraging me, and helping me professionally. Dr. Stephen Mercer, you were simply the best chair person I could have asked for. Knowing you were always available made me feel supported in every way imaginable. I never felt abandoned or forgotten. In special appreciation, I need to thank several people. Without these people, I would never have accomplished this goal. First and foremost, I’d like to thank Dr. Jillian Skelton. Dr. Skelton gave me enthusiasm and encouragement that gave me the steam to purge forward every time I wanted to quit. Believe me, there were many times I wanted to quit. I would tell her, she was my rock. I would have quit if she were not a phone call away. She would talk me “down to earth” when I was upset. Although I never met you in person, your calming voice gave me strength. You are truly beautiful. I want to thank my husband Stephen. Without your support, this journey could never have been accomplished. Your patience and understanding throughout the process vi
allowed me to spend time studying and writing, rather than spending my time on other things. My beautiful grandson Michael Patrick, who was born on June 21, 2011, the year I went to my first year residency. Michael, your life has been a driving force for my completing this journey. Your beautiful smile and humor were always refreshing in times of my stress and despair. I’d like to than my colleagues at Montgomery County Community College in Blue Bell Pennsylvania and Abington Jefferson Health in Abington Pennsylvania for supporting my dream. Specifically, I’d like to thank Dr. Linda Roy, Ruth Benfield, Pamela Roberts, Martina Ware, Nancy Moran, Gail Hanson, Ruth Ann Kiefer, Stephanie Sanders and Anita Fennessy. I might have not officially told all of you, but your support was greatly appreciated. There were things you all did for me that allowed me to finish. Your support was priceless. Thank you to Mr. Rick Fizz, Robert Gentile, and Miguel Wong at the University of Phoenix.
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TABLE OF CONTENTS Contents
Pages
List of Tables ...................................................................................................................... xii List of Figures ................................................................................................................... xiii Chapter 1: Introduction ........................................................................................................ 1 Critical Thinking Ability of Nurses.......................................................................... 3 Scope of the Study .................................................................................................... 7 Problem Statement ................................................................................................... 7 Statement of Purpose ................................................................................................ 9 Nature of the Study................................................................................................. 10 Research Questions ................................................................................................ 15 Research Methodology ........................................................................................... 16 Definitions .............................................................................................................. 18 Demographic Variables .......................................................................................... 19 Conceptual Framework .......................................................................................... 20 The Three Strategies ............................................................................................... 24 Assumptions ........................................................................................................... 26 Limitations.............................................................................................................. 26 Delimitations .......................................................................................................... 27 Summary ................................................................................................................ 28 Chapter 2: Review of the Literature ................................................................................... 29 Title Searches, Articles and Journal ....................................................................... 30 Historical Overview of Critical Thinking in Nursing ............................................ 36 viii
History of Nursing Academia................................................................................. 38 Nursing Leadership ................................................................................................ 43 National League for Nursing .................................................................................. 48 National Councils State Boards of Nursing ........................................................... 49 American Nurses Credentialing Center .................................................................. 50 Diversity in Nursing ............................................................................................... 51 Future Goals and Vision ......................................................................................... 54 Benner’s Theory of Novice to Expert .................................................................... 55 Applied Critical Thinking ...................................................................................... 57 Theory into Practice ............................................................................................... 61 Integration into Practice ......................................................................................... 62 The Three Strategies ............................................................................................... 63 Journaling ................................................................................................... 63 Seminar (case study) .................................................................................. 70 Simulation .................................................................................................. 72 Current Findings ..................................................................................................... 76 Gaps in the Literature ............................................................................................. 81 Summary and Conclusion ...................................................................................... 82 Chapter 3: Research Method and Design ........................................................................... 84 Research Method .................................................................................................... 86 Appropriateness of the Study ................................................................................. 90 Rationale for the Study ........................................................................................... 93 Sample Population .................................................................................................. 95 ix
Demographic Variables .......................................................................................... 96 Trustworthiness ...................................................................................................... 96 Geographic Location .............................................................................................. 98 Ethical Consideration ............................................................................................. 99 Data Collection ....................................................................................................... 99 Analysis ................................................................................................................ 101 Confidentiality ...................................................................................................... 102 Preventing Bias..................................................................................................... 103 Conclusion ............................................................................................................ 104 Chapter 4: Findings .......................................................................................................... 105 Data Collection Process........................................................................................ 105 Descriptive Findings and Themes ........................................................................ 109 Research Question 1 ................................................................................. 109 Research Question 2 ................................................................................. 109 Please share your feelings about what case study (seminar) means to you. ........................................................................................... 110 Please share your feelings about what journaling means to you .. 111 Please share your feelings about what simulation means to you. 114 When I mention the term “critical thinking,” please share what that means to you ................................................................................. 117 Please share with me your perceptions and your feelings about which strategy you may or may not prefer and why. ................... 119 Time Impact ......................................................................................................... 121 x
Instructor Impact .................................................................................................. 123 Personal Impact .................................................................................................... 125 Cost considerations............................................................................................... 127 Summary .............................................................................................................. 127 Chapter 5: Discussion ....................................................................................................... 128 Research Question One ........................................................................................ 128 Research Question 2 ............................................................................................. 129 Instructor Impact .................................................................................................. 130 Case Study ............................................................................................................ 131 Journaling ............................................................................................................. 132 Simulation ............................................................................................................ 134 The Impact of Time .............................................................................................. 135 Bridging the gap between theory and practice ..................................................... 136 Decision making ....................................................................................... 137 Case Study ................................................................................................ 138 Journaling ................................................................................................. 138 Simulation ................................................................................................ 139 Conclusions and Recommendations ......................................................... 139 References ........................................................................................................................ 141 Appendix A: Student Perception Interview Guide …...………………………………....166 Appendix B : An Invitation for Senior Student Nurses………………………………….168 Appendix C: Request to Perform Study ........................................................................... 169 Appendix D : Consent to Participate…………………………………………………….170 xi
LIST OF TABLES Table 1: Table of Literature................................................................................................ 31 Table 2: NVIVO codes and sub-codes ............................................................................. 108 Table 3: Word Frequency ................................................................................................. 122
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LIST OF FIGURES Figure 1: Integration into Practice (McHugh & Lake, 2010) ............................................. 62
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Chapter 1 Introduction Teaching and learning strategies commonly used in nursing programs across the country include journaling, case study, and simulation (Billings & Halstead, 2009). Academic environments, such as nursing, include program evaluation as a means to understand strategy intricacies, effectiveness, and applicability as best practices for enhancing learning (Billings & Halstead, 2009). Students are individuals who have perceptions about individualized learning that are invaluable for academic environment program improvement and student success (Davies, 2007). Student nurses’ insightfulness and perspective can provide objectivity about teaching and learning activities that lead to student success (Davies, 2007; Fairris, 2012). According to Mundy (2008), evidence exists suggesting that academic program faculty members continually strive to assess effectiveness of programs as active participants in the evaluation process. One identified area of weakness is the effectiveness of teaching critical thinking paradigms (Benner, Sutphen, Lenord, & Day, 2010; Mundy, 2008). Students should have ideas about personal individualized learning, and in this case, critical thinking learning. Students should also be encouraged to express concepts about individualized learning as a means to improve program curriculum concentrations (ACEN, 2013; Fairris, 2012; Haleem et al., 2010). The healthcare industry is calling for dramatic change by 2020, including changes directly effecting the nursing educational paradigm (IOM, 2011; NLN, 2011; PSNA, 2010). For this proposed study, program curriculum concentrations include the critical thinking concept and nurses’ expanding role responsibilities, which are integral parts of 1
the change process (Benner et al., 2010; IOM, 2011; NLN, 2011; PSNA, 2010). Proposed changes reflect the current state of nursing education and the desired direction of change. The healthcare industry’s focus on changes is not a new one; however, 2020 is approaching quickly, so changes need to be rapid and meaningful. Problem identification and process changes are complicated processes that take time to solidify. Because healthcare is designed to be a collaborative environment, nursing education must align with the recommended initiatives and goals to improve overall healthcare delivery and patient outcomes (IOM, 2011; NLN, 2011) In recent years, the involvement of students within the assessment process has demonstrated that evaluation initiatives can reveal strengths and weaknesses in any academic program (Fairris, 2012). Understanding student perspectives about the three strategies may help provide some direction for potential change. Some schools provide students with the ability to assess the broader aspect of a school’s curriculum: the teachers, the program, the objectives, and the environment (ACEN, 2013; MCCC, 2011). Students serve as important stakeholders, exemplifying student nurse input as both valuable and important to a program’s integrity (Billings & Halstead, 2009). Assessment and evaluation of teaching and learning strategies should be open and collaborative to enhance and promote critical thinking learning (Billings & Halstead, 2009). This relationship among student nurses, the institution, and educators will foster inquisitiveness and discovery. According to Fairris (2012), program evaluation by students is a growing initiative, which improves academic institutions quality initiatives, quality improvement goals, and perpetuates a culture that supports evidenced based teaching pedagogies. 2
The choice to concentrate on the three strategies is simple: all three strategies are commonly used in nursing educational curricula across the country (Billings & Halstead, 2009). The researcher asked nursing students for their individualized perspectives as a means to understand assertions about the strategies and how these strategies affect critical thinking learning. Nursing programs strive to develop critically thinking professional nurses through nursing education strategies such as simulation, journaling, and case study. By assessing student perceptions of the three strategies, this study may help enhance individualized critical thinking learning. Critical Thinking Ability of Nurses In healthcare, understanding the depth and importance of teaching critical thinking concepts to student nurses is fundamental and imperative (Benner et al., 2010; Billings & Halstead, 2006; Tanner, 2006, 2007, 2010). Critical thinking concepts encompass all professions; however, the fundamental understanding of how and why individuals think, act, and react is unique to many professional venues (Facione & Facione, 2007). In healthcare, acquisition of critical thinking and reasoning skills is paramount for understanding the complexities of patient populations. Facione and Facione (2007) emphasized critical thinking as meta-cognition; a concept of problem solving, thus procuring a hypothesis, and further acting on the end assessment findings. This metacognitive form of problem solving is applicable to any profession. Critical thinking is merely one of many components necessary to elicit change and improve care delivery, especially in the nursing profession. The researcher in this study concentrated on critical thinking concepts for the education of nursing students, as perceived by the student nurses sought for this study. Despite academia’s attempt at 3
understanding the concept of critical thinking, Facione and Facione (2007) declared people have been learning to think critically for thousands of years without formal study to capture the essence of what it means to think critically. The prospect of critical thinking integration most certainly aligns with future changes in nursing and the healthcare system. The healthcare industry requires substantial change to improve the delivery of care and provision of healthcare delivery. A leader in the nursing industry, the National League for Nursing (NLN), has called for a review of current strategies used to teach critical thinking principles (NLN, 2003, 2011). This call includes expanding, innovating, and developing current strategies to meet predicted future changes in healthcare (NLN, 2003, 2011). The three strategies concentrated within the proposed study are commonly used and are therefore concentric to the issue. According to Benner, Hughes, and Sutphen (2008), the definition of critical thinking by nurses has evolved over many years. Critical thinking skills are necessary to provide safe, high quality care that is dependent upon the nurse’s ability to think, problem solve, make sound judgments, and demonstrate logical reasoning (Benner, Hughes, & Sutphen, 2008, 2010; NLN, 2011; Tanner, 2010). Given projected healthcare reform demands, predictions include that workforce numbers may decline, resulting in expanded expectations of active working nurses. Therefore, this need to understand and perfect critical thinking skills has become more urgent. Nurse theory experts Benner (2001), Benner et al. (2008), and Tanner (2006, 2007, 2010) confirmed the evidentiary application of critical thinking concepts used by nurses and student nurses is difficult to validate within the learning process. Furthermore, teaching the concepts of critical thinking as a strategy is both difficult to measure and validate, thereby making 4
understanding student nurse perceptions important to nursing education (Benner, 2001). Developing a deeper understanding of how and why the strategies work or do not work was concentric to this proposed study. Tanner, Benner, Chesla, and Gordon (1993) and Tanner (2006) emphasized the importance of critical thinking in self- reflective practices. Self-reflective practices are valuable for internalizing learning because narrative versions of self- reflective experience help substantiate learned concepts. Learned concepts are incurred through experience and situational awareness. The internalization of information gathered during experience is retained after repeated exposure to similar situations. Tanner (2006) explained that beginning nurses reason analytically as an extension of the refinement and adjustments of textbook knowledge. Both Benner (2001) and Tanner (2006) emphasized intuition as an integral part of critical thinking and situational awareness. Tanner (2006) characterized intuition as a feeling of apprehension that overwhelms the learner and is triggered by knowledge from previous experience. Benner (2001) reflected that critical thinking is difficult to teach, assess, and even more difficult to validate. Collectively, nursing professionals agree that reflective processes often help, but often the experiences have already occurred, so memories of events are recalled retrospectively and might not be accurate. While clinical learning is an effective strategy, it is not the only method; nursing curricula offers other strategies by which to teach critical thinking, including journaling, case study, and simulation. These strategies are commonly used in nursing education (Billings & Halstead, 2009). The researcher in this study investigated student nurse perceptions about the three strategies in relation to individualized critical thinking learning. The importance of improving critical 5
thinking skills is a consistent theme throughout the nursing literature and is considered imperative to the future of healthcare practice and nursing care delivery (AACN, 2014; IOM, 2011; NLN, 2003, 2011; PSNA, 2010) Critical thinking is necessary for every profession. Embedded within the profession of nursing is the concept of critical thinking that is considered paramount to every educated nurse’s practice (Bodin, 2012). Bodin (2012) revealed national nurse leaders have not only raised concerns about registered nurses’ critical thinking skills but also identified the lack of intact critical thinking skills in nursing staff. According to Clark and Aiken (2003), lack of solid critical thinking skill acquisition is the leading cause for failure to rescue. Failure to rescue is a term coined by Clark and Aiken (2003) and used within nursing and medicine that reflects the inability to recognize signs of patient compromise and the lack of implementation of corrective measures derived by thinking critically. Critical thinking is one of the most important assessment concepts for nurses in daily work. For nurses, critical thinking is the difference between possessing valuable information and knowing what to do with that information (Mulnix, 2012). The National League for Nursing (2011) has defined critical thinking as a practice within the discipline of nursing that incorporates specific reflective reasoning that guides nurses in generating, implementing, and evaluating approaches toward resolving client and professional concerns. As early as 2003, the National League for Nursing has called for nursing academia, leadership, and faculty to help evaluate, design, and innovate current systems. This process is necessary to meet future changes and help reshape nursing practices (NLN, 2003).
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Teaching tangible critical thinking skills has remained a challenge for nurse educators and leaders because critical thinking is an abstract concept and is difficult to measure (Benner et al., 2010; Berkow, Virkstis, Stewart, & Aronson, 2011). Tanner et al. (1993) explained critical thinking as “knowing” the individual as an entire entity, including historical facts. By “knowing” integral aspects of the patient, the nurse may be able to predict responses to care, interventions, and treatments (Tanner, Benner, Chesla, & Gordon, 1993). Even more complicated is the part of critical thinking learning that pertains to arriving at reasonable and justifiable conclusions that help an individual make appropriate judgments (Mulnix, 2012). Scope of the Study The scope for this study involved investigating the three specific strategies as perceived by senior level associate degree student nurses. By understanding the lived educational experiences of the senior level nursing students, the value of each strategy in relation to individualized critical thinking learning emerged. Lived experiences are important because students are able to place evaluative assessments of the impact that educational strategies have on personal critical thinking learning. Problem Statement By 2020, health care leaders estimate that the demand for skilled, qualified nurses will increase from roughly two million in 2010 to approximately three million (BLS, 2013; HRSA, 2013). The United States healthcare industry is projecting an acute shortage of nurses (RNs) for many reasons. One reason is many nurses are baby boomers who are planning to retire by 2020 (AACN, 2014). Other reasons include
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proposed and current changes in the healthcare system and predicted healthcare demands (AACN, 2014). According to the Bureau of Labor Statistics’ Employment Projections Report (2013) for years 2012-2022, registered nursing is listed among the top occupations for projected job growth as the nation approaches year 2022 (BLS, 2013). The RN workforce is expected to expand from 2.71 million in 2012 to 3.24 million in 2022 (AACN, 2014); this statistic equates to a 19% increase in that time span. Currently, the state of the nursing industry reflects an aging workforce slated to retire in the next decade; BLS projects the need for approximately 525,000 necessary replacements in the workforce (BLS, 2013). In summary, the total number of open jobs for nurses equates to 1.05 million by 2022 (BLS, 2013). The increased number of newly licensed nurses predicted to join the workforce by or after 2020 will require result in a mass influx of nurses who will require acquisition of critical thinking skills. Predictions allude to patients with increasingly complex issues, necessitating more astute critical thinking skills for seamless intelligent care for sick patients (HRSA, 2013; IOM, 2011; PSNA, 2011). Faced with healthcare reform demands and patients with complex ailments, nurses are increasingly responsible for improving patient outcomes, patient knowledge and understanding, and overall patient health (NLN, 2011). A nurse’s ability to analyze clinical findings, patient presentation, and clinical picture along with subtleties in patients’ conditions is paramount (Harjai & Tiwari, 2009). Patients’ illnesses are profoundly more complicated and are compounded by multifaceted maladies (Benner et al., 2010). Berkow, Virkstis, Stewart, and Conway (2008) published the results of a nurse-executive leadership survey examining readiness 8
of newly graduated and recently hired nurses. Of surveyed nurses’ executives, only 10.4% considered new graduates as equipped or prepared to provide safe and effective nursing care (Berkow et al., 2008). The remainder of those surveyed expressed a need to do better (Berkow et al., 2008). Benner et al. (2010) also supported this belief and discovered a significant gap between current nursing practice and the provided education that should reflect current nursing practice. Understanding the profound uncertainty of nursing’s future, the Institute of Medicine (IOM) (2011) called for improved, efficient, and relevant competency, better preparation, and higher workforce numbers. Nursing education must help develop innovative ways for nurses to fulfill their potential as primary care providers and to practice to the full extent of their education and training (IOM, 2011). Nursing education must develop nurses with higher levels of critical thinking to fill the void created by the proposed nursing shortage (IOM, 2011; PSNA, 2010). The relationship of nursing education to the predicted problem aligns well with the desire to understand strategies that will help nurses fulfill professional, ethical, and legal responsibilities. For this proposed study, student nurse perceptions about journaling, seminar (case study), and simulation revealed some specifics that will potentially guide nursing education and mold curricular foundations related to the critical thinking concept. Statement of Purpose The IOM, in conjunction with other leaders in healthcare, called for dramatic changes in all aspects of healthcare by 2020 (IOM, 2011; NLN, 2011; PSNA, 2010). One initiative is to improve upon the educational delivery and outcomes for the nursing workforce (IOM, 2011; NLN, 2011; PSNA, 2010). Nurses are currently committed to 9
delivering exceptional quality care designated by current regulatory, industrial, and organizational conditions. The call for change related to all aspects of care includes all aspects of nursing, and specifically nursing education (IOM, 2011; NLN, 2003; 2011). Collaboratively, healthcare leaders have called for transforming the health care system to provide competent, seamless, and affordable quality care for future healthcare delivery. Nursing education and the nursing industry are integral to this process (NLN, 2003, 2011). Nurses are expected to contribute to a patient-centered, evidence-based system that contributes to improved health outcomes (IOM, 2011; NLN, 2011; PSNA, 2010). The purpose of the proposed qualitative, phenomenological study is to understand how nursing students’ perceive the three teaching strategies (simulation, seminar (case study), and journaling) as they influence “individualized critical thinking learning” in an associate nursing program located in Southeast Pennsylvania. Understanding the impact that journaling, case study, and simulation have on individualized critical thinking may help schools create a curriculum that develops better trained, critically thinking students who produce safer, higher quality patient care as eventual registered nurses. By understanding the dynamic of the impact that strategies have on critical thinking learning, nursing education can entertain ideas on how to innovate, improve upon, and perhaps change the way strategies are introduced into nursing curricula. Nature of the Study This qualitative, phenomenological study included participants from an associate degree nursing program at the senior level (second year). Montgomery County Community College approved a formal invitation for this proposed study. Information about this proposed study was available exclusively to senior level nursing students 10
shortly before the onset of the semester. Students were able to choose specific times and dates for private interviews that fit their schedule. Interviewing was the chosen method for gathering information. Interviews were conducted in a private, naturalistic setting that was conducive to inquiry. The interview process took place using a perception guide adapted from Breckenridge (1997). A naturalistic setting provides for a familiar atmosphere that is natural to those individuals participating in a research study and that will help promote relaxation (Moustakas, 1994; Polit & Hungler, 1997). In this proposed study, interviews were conducted on college campus in a quiet room. Individualized, quiet, calming, and familiar surroundings contributed to a conducive interview process. During the interviews, themes and patterns about the three strategies were identified through the expressed perceptive experiences of student nurses during the education process. Gray and Aspland (2011) emphasized these points by explaining that qualitative inquiry involves precepts concerned with what people are saying and doing. Confidentiality was preserved by use of pseudonyms instead of student nurse formal names. The interviews were conducted in a naturalistic setting and were concentric to the three critical thinking teaching strategies. The three strategies to be included in this proposed study are case study, journaling, and simulation. A digital audio recording device was used to store interview data. Breckenridge’s Perception Guide (1997) and adapted questions were used to guide the specific inquiry pertinent to this study. Themes, concepts, and key points were derived for this study using digital audio-taped structured interviews in a naturalistic setting. Polit and Beck (2010) explained that the interview process is the most common form of data collection in a qualitative study. The use of a qualitative, phenomenological design was appropriate 11
for this study because results are based on individual student nurse experiences. Generated results revealed common perceptions; common perceptions are the premise for qualitative forms of study (Moustakas, 1994). The phenomenological aspect of this study included the perceptions of the educational experiences of the student nurses (Chenail, 2011). These perceptive experiences purport the essence of being as meaningful or not meaningful by the person experiencing a phenomenon (Husserl, 1931). In nursing, these experiences explain meaningful concepts as individuals live them in the everyday world (Tatano-Beck, 2011). The precepts behind phenomenological forms of study are to unveil important points about the three strategies as perceived by the student nurses who have experienced all three strategies during nursing school (Burns & Grove, 2011). A quantitative form of study was not appropriate for this proposed study because a quantitative study would only yield specific numerical data regarding a preferred method. Quantitative results would not reveal the expressive perceptive reasons why a certain strategy is preferred or not preferred. Quantitative studies do not explore themes, beliefs, perceptions, and feelings associated with specific phenomena (Hanson, Balmer, & Giardino, 2011). This form of inquiry would only serve to delineate which of the strategies is least or most effective but would not tell the researcher why a specific strategy is considered less or more effective. Husserl (1931) first identified the concept of phenomenology by describing it as the science of the essence of being (essential being). The essence of being is measurable through perceptive experiences and transcendental phenomena (Husserl, 1931). Phenomenology aims exclusively at understanding the knowledge of essences, not 12
established facts, and aims to investigate the judging of thoughts pertaining to a particular phenomenon (Husserl, 1931). In this case, the desired outcomes for measurement are the perceptions about the three strategies as experienced and perceived by senior level student nurses. There are no facts to measure in phenomenological research, only feelings and perceptions. Qualitative study was appropriate for this study because qualitative study involves the use of descriptive information to help explain the value of experiences. Phenomenology deepens the understanding of those experiences by soliciting descriptive, feelings, and perceptions prescribing a perceived value for those experiences (Munhall & Oiler, 1986). By providing value-based descriptive perceptions about the three strategies, industry leaders may be able to develop a better understanding of the impact of the strategies on personal critical thinking learning. Munhall and Oiler (1986) idealized the use of a phenomenological study for an individual’s perceptions as the rationalization for the methodology as perceiving, interpreting, being, and living those experiences. The lived experiences reflect the purpose for the use of phenomenology in this proposed study because student nurses use all three strategies as a part of daily and weekly assignments (Munhall & Oiler, 1986). These experiences initiate feelings, ideas, and perceptions that translate into levels of importance and value derived from the lived experiences (Munhall & Oiler, 1986). “Perception is defined as access to truth, and the foundation of all knowledge” (Munhall & Oiler, 1986, p.55). Husserl (1931) described the essence of being that directly relates to experiences in relation to the particular phenomena and further divided the understanding of 13
empiricism as factual ( quantitative) or idealistic (qualitative). In simpler terms, Husserl described empiricisms as facts or essences. Phenomenology is theoretically based and does not generate empirically generated deductions (Husserl, 1931). Included within this premise are the experiences that refer to awareness that resulted from actual experiences. For this study, the perceptive experience allowed the individual (nursing student) to arrive at conclusions about the usefulness of the three strategies in relation to individualized critical thinking learning. Through the nursing education process, the student nurse lives the experiences of performing activities such as journaling, case study, and simulation to facilitate critical thinking and reasoning. Tatano-Beck (2011) explained the implications for the use of qualitative phenomenological forms of research in nursing as important for the descriptive findings. Phenomenology is a better conceptual fit with the clinical aspects of nursing because of the kinds of research questions that arise from experiences. These experiences explain more closely the implications to nursing practice through quantitative methods than do quantitative methods (Tatano-Beck, 2011). These experiences describe the essence of being as explained by Husserl (1931). The phenomenon of how each strategy enhances critical thinking in student nurses is both personal and individualized through generated themes, beliefs, and feelings (Hanson et al., 2011). Individual preference means the value of each strategy has personal value to each student simply because each method either facilitates or does not facilitate individualized critically thinking skills. While considering that individuals can present very different points of view, the personal perceptive experience about the value of the
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three aforementioned strategies became the target for understanding the inferred value of the phenomena as related to individualized critical thinking learning. For this proposed study, the strategies experienced by the student nurses during integral learning experiences involved the three strategies: journaling, case study, and simulation. Twelve senior level student nurses from an associate degree nursing program from the mid-Atlantic region participated in this study. The purpose of the current phenomenological, qualitative study was to explore the perceptions, experiences, feelings, and beliefs of 10-15 senior level student nurses to determine individual views on critical thinking. Research Questions This qualitative research study included using specific, open-ended research questions as a guide to the interview process in a naturalistic setting. Open-ended questions encourage individual expression and therefore are appropriate forms of inquiry in phenomenological research (Groenewald, 2004). Using scripted, open-ended questions, the interviewer delved into student nurses’ insightful perceptions about the effectiveness of the three strategies as they related to individualized critical thinking ability. The research study inquiry provided insight the researcher needed to understand the meaning of the strategies as perceived by the student nurses. The experiences of the student nurses provided the researcher with information about each phenomenon and helped satisfy answers to inquiry (Polit & Beck, 2010; Tatano-Beck, 2011). Qualitative research explores the how, what, and why principles associated with a specific phenomenon (Creswell, Hanson, Clark & Morales, 2007; Groenewald, 2004). For this
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reason, questions are typically open-ended, thus inviting and encouraging of expression of feelings and perceptions. The specific problem the researcher investigated was understanding how the three strategies impact critical thinking learning as perceived by senior-level associate degree program nursing students in relation to the facilitation of individualized critical thinking learning. The following research questions guided this study: RQ1: What are the lived experiences of nursing students at an associate degree nursing program in Southeast Pennsylvania? RQ2: How do nursing students perceive the three teaching strategies (simulation, seminar (case study), and journaling) as each influences individualized critical thinking learning? Research Methodology This study was performed with a qualitative design using a phenomenological methodology through one-on-one interview in a naturalistic setting. Phenomenology refers to the essence of being as described by Husserl (1931). The relationship of the phenomena to the idealism of the person experiencing the phenomena is phenomenological and is measurable through the perceptions of the person exposed to the phenomena (Husserl, 1931). The term lived experiences was derived from sources including Husserl (1994), Kumar (2004), and Van Manen (1990, 2002), the lived experience context refers to an individual’s experiences with a certain phenomenon on a routine basis. This study was qualitative in design, phenomenological in method, and naturalistic in setting. Van Manen (1990, 2002) explained that phenomenology identifies 16
life experiences as learning paradigms, presenting incidents that explain a phenomenon. In this case, the study represented the student nurses’ experiences and perceptions of the three strategies as related to individualized critical thinking learning. Van Manen’s (1990, 2002) description of phenomenology included insightful experiences and situations as perceived by individuals. All three strategies are routinely used within the curricular contexts of schools of nursing and are commonly employed critical thinking teaching educational tools. The researcher’s specific rationale for using this method was to help extrapolate statements expressed by student nurses regarding the three different teaching strategies. A database for housing or extrapolating these themes can be used with computerized systems. An example instrument suited for this purpose includes NVivo 10 (2015). NVivo 10 (2015) isolates common themes and not only provides clarity on the student nurse perceptions, but will also aid in data saturation recognition. NVivo 10 offers a variety of ways to present information in a collage or cluster formation, bringing common themes to the forefront. Because the researcher is the instrument in qualitative forms of study, other ways of extracting perceptive themes can be achieved through journaling and anecdotal note taking. The final sample size was 12 student nurses. According to Langford (2001) and Moustakas (1994), sample sizes in qualitative research tend to be small, using selective purposive samples of individuals who share and experience a particular phenomenon. In this study, the choice included senior-level student nurses who have experienced the three teaching strategies during the education process. The design included a student perception interview questions guide adapted from Breckenridge’s Perception Interview Guide (1997; 2002; 2011). Sampling was 17
purposeful and theoretical. Johnson (2010) adapted Breckenridge’s perception interview guide for senior year student nurses in her dissertation research studying transformational leadership. For the purpose of this study, the theories surrounding critical thinking (Benner, 2001; Tanner, 2006) integrated well with the questions posed and are aligned with Breckenridge’s Perception Interview Guide. Breckenridge’s Perception Interview Guide was used to standardize interview questions while remaining focused on specific questions developed for this proposed study (Fawcett, 1999). Successful interviews are evident when the researcher allows for open reflection in a relaxed, informal environment aimed at creating an inviting, trusting atmosphere (Moustakas, 1994). Breckenridge’s Perception Interview Guide (1999) served to provide structure to the question paradigm preventing distraction and diversion from the proposed subject matter in question (Appendix A). Definitions For the purposes of this proposed study, the researcher used the following definitions: Case study: Teaching strategy used to help students learn to think critically about a situation or phenomenon that contain complex interrelated concepts (Jackson, Ignatavicious, & Case, 2006). Competence: The expected level of skill and performance resulting from the application of knowledge, judgment, and skill (ANA, 2007). Critical Thinking: A process by which an individual arrives at conclusions about a situation using judgment, reasoning, and thought (Facione &Facione, 2007). 18
Failure to Rescue: The inability to recognize signs of patient compromise and the lack of implementation of corrective measures derived by thinking critically (Clark & Aiken, 2003) Healthcare: Industry for delivery of care, treatment, and medicinal practices for individuals and families Journaling: Reflective thought about a phenomenon or situation (Husserl, 1931). Nursing Student: An individual over the age of 18 who is enrolled in an associate degree program nursing program (MCCC, 2011). Perceptions: A conclusion based on individual experience; evaluative appraisal. An individual’s description of an object or situation (Moustakas, 1994) Simulation: Teaching strategy often used in nursing as a substitute for real life experience using actual patients. Faux situations made to look, feel, and resemble that of real situations (NLN, 2011) Strategy: tactical method; plan of action (NLN, 2011) Demographic Variables The demographic variables in this study involved the age of the students. Diverse learning ability is specifically considered in this proposed study because age is proven to impact learning ability. Because nursing programs accept a wide variety of age groups, from post- high school to well over age 35, age is a potential factor when assessing teaching and learning. Charles (2012) explained the current mean age for registered nurses in 2012-2013 is 48 years of age, making age a definitive issue in nursing education. For this proposed study, a purposeful sample was used: senior level nursing students in an associate degree nursing program. Gender was not a factor in the male 19
nursing student population. Sampling was on a voluntary basis. With respect to sampling, gender was not a differentiating factor in any of the response outcomes. Conceptual Framework Many facets pertain to the concept of learning to think critically, and for the purpose of this proposed study, one major theory was explored: the concept of critical thinking. Nursing theory and education complement the concept of critical thinking; thus, all three aforementioned strategies have been chosen as important to substantiate points of interest. In this study, the researcher used Benner’s critical thinking framework and the theory of novice-to-expert (Benner, 2001). Theories of nursing and how individuals learn and process information were extremely pertinent for this study. Nursing theory explains what nurses need and should understand as professional thinkers and problem solvers. Nursing embodies knowledge that is perpetual, conceptual, and dynamic. Patients, physicians, and others rely on the basic skills nurses provide while caring for patients. A strong, convincing body of knowledge is necessary in the healthcare environment, and confirms Benner’s theories about nursing, critical thinking, and reasoning. Critical thinking is an overall goal for teaching and achieving effective learning for student nurses. Benner et al. (2010) generally described critical thinking as the ability to recognize subtle changes in clients while using acquired critical thinking skills that eventually evolve into critical reasoning mastered skills. To highlight this concept, Benner’s (2001) novice-to-expert theory (Benner, 2001) was integrated throughout the proposed study. Benner’s (2001) novice-to-expert model was adapted from the Dreyfus Model. Benner (2001) used the adaptation to build a foundation for her nursing theories.
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The Dreyfus Model of Skill Acquisition was developed by Stuart and Herbert Dreyfus in 1980. The theory is the basis for Benner’s adapted model that is currently used nursing academia. Dreyfus and Dreyfus (1980) introduced the skill acquisition theory as the theory related to experiences derived from performance and exposure. Dreyfus and Dreyfus (1980) documented the five stages of expertness as a sequential journey that can be applied to any professional continuum. Benner (1991) expanded on the theory and adapted the theory to the profession of nursing. According to the theory, students move through a learning continuum of five stages of expertness: novice, advanced beginner, competent, proficient, and expert (Dreyfus & Dreyfus, as cited in Benner, 1991). Integrated in the theory are three precepts. The first precept is a person’s reliance on movement from abstract rationales to the use of past concrete experiences. The second precept is a simulacrum. For simplification, a precept simulacrum exemplifies a change of student perception of a particular situation as a culmination of subparts rather one concentric issue. The third precept applies to students’ movement from disengaged observer to involved participant (Benner, 2001; Dreyfus & Dreyfus, 1980). Using the Dreyfus Model as the basis for the theory, Benner explained through exemplars how nurses begin to generate ideas and hypotheses about situations involving patients. The critical thinking paradigm is a difficult concept to teach in a classroom for preparedness of students in the patient environment. Benner’s theories about how nurses gather information, formulate conclusions, and move from awkward beginner to seasoned, skilled practitioner were extremely relevant for this proposed study.
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Spencer (2008) defined critical thinking as this concept applies to the paradigm of nursing practice. Spencer (2008) highlighted critical thinking as applicable in clinical simulation and within the classroom. According to Spencer (2008), “Students can share their individual perspectives of situations while enhancing individualized critical thinking learning, and comparing to that of their peers” (p.89). Another example lies within the constructs of a study performed by Burke (2010). Burke (2010) discussed the developmental importance of simulation and case study within entry-level nursing, but encouraged improvements through the employment of student evaluation and validation. Critical thinking and the dynamics of teaching the critical thinking concept have perplexed nursing educators for decades. Benner (1990), Benner et al. (2010), and Tanner (2006) concurred with this dilemma in nursing education. The problem inherently lies in the abstractness of the critical thinking concept. According to Guhde (2010), one main challenge faced by nursing educators is facilitating critical thinking in students so these students may make “good clinical judgments” (p. 275). The path to achieving critical thinking skills is the overarching goal for nursing programs all over the United States. As addressed within Benner’s (2001) Dreyfus Model adaptation of Novice to Expert, Guhde (2010) also reinforced learning to think critically is not an innate intuitive process, but rather a process that occurs over time and is enhanced by experience. Guhde (2010) further affirmed that student nurses commonly situate between the early stages of analysis of personal thought while not actualizing formal critical thinking. This belief was also mirrored by Hill (2010). Critical thinking skills are necessary for higher- level problem-solving skills and must be developed over time (Benner, 2001; Guhde, 2010; Hill, 2010). Making the journey from beginning problem solver to expert occurs 22
gradually with education, skill acquisition, and practice. An experienced nurse might assess a patient in the same way as an inexperienced nurse; however, both nurses may end of with very different plans for care delivery and intervention (Hill, 2010). Critical thinking acquisition at any level cannot be achieved by any singular means and requires reinforcement for knowledge attainment. Investigating how student nurses feel about learning is important, and the input and feedback from these students can help guide future teacher practices about critical thinking. Concentration on the value of the three strategies, as perceived by student nurses for the intake and application of critical thinking learning, was crucial for this proposed study. Journaling, reflective writing, and case study are strategies supported by the evidence and supported by nursing professionals; however, where students believe these strategies are effective is the question the researcher attempted to answer in this study. Simulation is a relatively new practice currently used across the country. The uses of technology in nursing education practice should not be underestimated; however, combined with reflective journaling and case study, technology does promote critical thinking as viewed by the student nurse. The choice to study these three strategies as they relate to critical thinking learning stems from the common use of all three in nursing programs across the country. Because these are commonly used, the rationale for studying the effectiveness of the three strategies as perceived by students becomes important. Positive and negative attributes are associated with each teaching strategy. In a study performed by Gibbs, Trotta, and Overbeck (2014), student nurse feedback revealed that case study and simulation were desirable, but they were not without disadvantages.
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Benner’s (2001) beliefs regarding a nurse’s personal growth center around experiences attained through any one of the teaching strategies: reflective journaling, case study, or simulation. Student nurses should feel comfortable voicing opinions about what helps substantiate individual learning goals and critical thinking growth. Chan (2010) discovered the large number of factors that contribute to the critical thinking paradigm require further investigation to understand what helps to enhance the concept. Faculty misunderstanding of critical thinking as a definition is a real concern for nurse leaders and raises concerns regarding the skill of individuals teaching critical thinking concepts to students. Confusing perspectives, lack of knowledge, student anxiety, and student cultural and learning styles all directly affect the implementation of program objectives regarding critical thinking pedagogies and strategies (Chan, 2013). Understanding student perspectives may help facilitate an improved faculty understanding of which strategy works best isolated or combined. The Three Strategies The researcher’s choice to study these specific strategies correlated with commonality of the use of these three strategies in nursing programs across the country. The findings of the study provided insight and a better understanding of perceptions of student nurses’ critical thinking learning. By listening to the interviewed students, the researcher gained a better perspective on how strategies impact learning. Burrell (2014) explained that the concept of reflective thought (journaling) has been used for years in many educational realms, including nursing. Journaling is used as an avenue to facilitate critical thinking and is often used in conjunction with clinical rotations (Burrell, 2014). Case study has also been a commonly used strategy in nursing education as a means to 24
trigger thought and provoke enhanced critical thinking. Gibbs et al. (2014) recently compared the use of case study and simulation. Decisively, Gibbs et al. found both are complimentary strategies; however, the researchers concluded that more study is necessary to understand how both can be used conjointly to facilitate the critical thinking educational needs of nursing students. The use of simulation is currently being researched to improve efficacy in deployment as a solid teaching strategy (NCSBN, 2014). For this qualitative study, the researcher sought to uncover student nurse perceptions about three teaching learning strategies as each relates to critical thinking learning by the student nurses during nursing education. Predictions made by industry leaders urge nurse educators to investigate current, past, and future innovative strategies to assist in developing the intellect and critical thinking patterns of future practicing nurses (NCSBN, 2014). The premise of industry predictions is inclusive of commonly used strategies such as journaling, case study, and simulation. The recent study performed by the National Council State Boards of Nursing (NCSBN) (NCSBN, 2014) spotlights the potential use of simulation as an alternative strategy for teaching critical thinking to be expanded upon; however, existing literature does not completely support the use of simulation as the only avenue to accomplish the task (NCSBN, 2014). Currently, no single strategy for teaching critical thinking has universal support from nursing educators, revealing flaws that make leaders indecisive about making permanent changes to curriculum and pedagogy (NCSBN, 2014). Developing a better understanding of the current chosen strategies as perceived by the student nurses may prove insightful to nurse leaders. The researcher chose the three
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strategies that were at the center of this study because of the commonality in which they are used in nursing programs across the country. Assumptions For research studies, certain assumptions can be made, such as the belief that student nurses are interested in expressing honest and sincere perceptions about nursing education. In understanding the three strategies have been experienced by every participant once they reach the senior level, assumptions were made that each student understood and participated in each strategy as part of the nursing program curriculum experience. Another assumption associated with this research effort was student nurses were interested and willing to share personal experiences during the time while attending nursing school. By performing the study, the results provided improved insight about the three strategies as perceived by senior level nursing students in an associate degree nursing school program. Limitations Limitations for this study included the availability of students to participate in the study and the number of participants enrolled within the study. Many factors such as student workload, work schedules, family life, children, affected this research study. Nursing program class schedules also affected participation. No incentive was offered for participation in this study, which may have influenced participation. Student geography and time elements were also limitations. These limitations were avoided by performing interviews in a space made available at the community college and providing a succinct schedule with specific times and dates for one to one interviews. Providing a succinct schedule made participation more feasible for students. 26
Delimitations Delimitations of any qualitative study are items not performed or excluded by the researcher. Generally, delimitations are things that can be controlled by the researcher but are purposely not changed, thus providing clarity for the reader about why certain exclusions were apparent and necessary (Creswell, 2007; Ellis & Levy, 2009; Pajares, 2007). Limiting the topics of study to the specified three strategies (journaling, simulation, and case study) was purposeful because all three levels include the three succinct curricular strategies within the frameworks of the nursing program at the chosen college as well as other programs across the country. The perception guide used in this study included customized standardized probe questions that focused the interview about the three strategies and prevented distractions (Breckenridge, 1997). The final participant sample size was 12 senior level nursing students. The sample size for this study was appropriate because qualitative research studies typically have smaller sample sizes because of the complex nature of gathering information and quantifying answers (Moustakas, 1994). The qualitative data collection process determined the actual number of participants once data saturation was achieved. Data saturation was inferred once themes became repetitive and familiar. The perception guide used in this study (Breckenridge, 1997) included probe questions that focus the interview on the three strategies only, and, if students strayed from the central three strategies, the researcher redirected students to the three main strategies and the perception guide questions. Any extraneous themes not central to the three strategies were noted but did not contribute to proposed data saturation. Any
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extraneous themes will be mentioned as notable during the conclusion and findings remarks. Summary This proposed study used a qualitative method with a phenomenological design through interviews in the participants’ nursing school. The purpose of this study was to explore the student nurse perceptions about the three strategies through the experiences of student nurses and how these strategies compliment their abilities to learn and think critically. Critical thinking was the focus of this study because of the difficulty in the establishment of critical thinking learning Chapter 2 includes the literature and evidentiary review that is concentric to critical thinking principles. Chapter 2 also includes definitions of the three teaching strategies and explanations of the evolution of nursing academia, the importance of nursing leadership, and the theoretical framework of Benner’s novice-to-expert.
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Chapter 2 Review of the Literature Nursing education, with respect to being a profession, carries specific characteristics within a body of knowledge and postulates responsibilities that are crucial to favorable patient outcomes. One of these attributes is critical thinking ability. A considerable amount of literature was available on the concept of critical thinking. Benner (2001) and Tanner (2006) both explained critical thinking concepts as intuitive processes that effect and enable nurses to grow professionally. Facione and Facione (1996, 2007) described the value of critical thinking as the concept applies to many professions. Critical thinking is difficult to teach, measure, and standardize, but very necessary for problem solving ability (Facione & Facione, 2007). The purpose of this study was to explore journaling, case study, and simulation through the experiences of student nurses and how these strategies complimented their ability to learn and think critically. Examining the three strategies is meaningful because schools of nursing across the country commonly use them to ensure nursing students are developing critical thinking abilities a part of the curriculum and education of future nurses. Critical thinking learning acquisition is difficult to quantify and may be a subjective measure (Benner et al., 2001; Tanner, 2006). Each individual learns at a personal pace, and learning is a personal journey by which individuals achieve attainment of knowledge through lessons and experience. Nonetheless, critical thinking is a vital part of making correct choices in patient care. According to Tanner (2006), clinical judgment is synonymous with critical thinking and is complex and complicated. In nursing practice, 29
clinical judgment comes from the ability to understand salient subtleties in a patient’s clinical picture. The ability to recognize changes and form hypotheses as well as formulate actions, conclusions, and responses are all parts of the ability to think critically (Tanner, 2006). Good, sound, and competent clinical judgments come from a nurse’s ability to sort out the facts and observations, both pathophysiologic and diagnostic. Chan (2013), Burrell (2014), and Gibbs et al. (2014) surmised common themes exist in the ability to think critically. The general critical thinking process includes gathering, organizing, interpreting, and understanding information about patients. This process is comparable to the nursing process adapted by Callista-Roy (2009) and includes verbiage that is similar to Faciones & Facione’s (2007) previously mentioned critical thinking process. This chapter contains review of peer reviewed literature gathered to understand the dynamics and definition of critical thinking, current perceptions of teaching. This chapter includes a review of the peer-reviewed literature, articles, journals, books, and other professional materials related to the three strategies in the teaching and learning paradigm, critical thinking concepts in nursing education, and further attempts to understand the appraisal of such experiences as corroborated by student nurses. Title Searches, Articles and Journal A literature review was conducted using various electronic and manual searches. Search methods included secondary sources such as books and primary sources such as peer- reviewed journals and other research documents. Documents were discovered mostly through germinal material while other journals articles were obtained through keyword search. These keywords and associated nomenclature included the following: 30
journaling, reflection, critical reflection, clinical reflection, and nursing critical reflection. Phrases used included exploring feelings about clinical nursing and learning, critical thinking in nursing, students’ perceptions of journaling, students’ perceptions of case study, and students’ perception of simulation. Search engines used for this purpose included Google Scholar Search, EbscoHost, Medline, ProQuest, Gale Power search, JSTOR, and Ovid. Academic and professional institutions used to support these searches include the University of Phoenix library, Montgomery County Community College, La Salle University, and Abington Memorial Hospital aka Abington Health. Professional and peer reviewed journals from the following will serve to enhance the information in this study: Teaching and Learning in Nursing, Nurse Educator, and Journal of Nursing Education. The literature review includes four main sections: Table of Literature, Historical Overview, Current Findings, and Gaps in the Literature. Table 1 Table of Literature Key Term Searched
Database Peer Reviewed Research s and Articles and Documents reference Books location
Clinical EbscoHos Jackson et al. Reasonin t (2006) g Books Benner et al. In nursing Google (2008) Scholar Benner et al. ProQuest (2010) Cerullo et al. (2012) Gierach et al. (2010) Harjai et al. (2009)
Gierachet;al (2010)
31
Scientific / Scholarly Journals
Kuiper et al. (2004)
Sources found/ Sources utilized
Huckabay (2009) Roy et al. (1999) Rubenfeld et al. (2007) Tanner (2006)
Critical thinking
Benner (2001) Paans et al. EbscoHos Benner et al. (2012) t (2008) Bodin (2012) Medline Benner et al. Mulnix(2012) (2010) Berkow et al. (2008) Cain et al. (2012) Cerullo et al. (2012) Facione(2007) Marchigiano et al. (2011) Saintsing et al. (2011) Tanner (2006,2007,20 10) Tanner et al.(1993)
Critical Dreyfus et thinking EbscoHos al.(1980) in nursing t Guhde (2010) Hill(2010) Kaddoura (2011) McHugh et al.(2010) Tanner (2006) Tanner (2007) Taylor(2002) Journaling Barnes(2010) use in EbscoHos Billings(2006)
Cruz et al. (2009) Kuiper et al(2004)
Fero et al. (2010)
Kaddoura(20 11)
Barnes(2011) Epp (2008)
Blake(2005) Kennison
32
nursing
t Medline
Charles(2010) Cirocco(2006) Haslip (2010) Hayman et al.,2012) Hendrix et al (2012) Ironside,(2001) Kuo et al. (2011) Lasater (2007) Marchigiano et al. (2011) Yildirim et al. (2011) Case study Gray et al. use in EbscoHos (2011) nursing t Harrison (2012) Medline Jackson et Sage al.(2006) Woods (2012) Yildirim et al.(2011) Simulation Burke (2010) use in EbscoHos Clapper(2010) nursing t Durham(2008) education Medline Gierach et al(2010) Guhde (2010) Howard et al. (2011) Hyland et al. (2012) Jefferies (2005,2012) Table Lasater continued (2007a,2007 b, : 2011) Lusk et al. (2013) Weaver (2011) Nursing Benner et al. education EbscoHos (2010) and t Egenes (need critical Books date;2009)
McMillanCoddington(20 13) Wald et al. (2010)
Lachasseur et al. (2011)
Feroet;al(2010 ) Gierach et al. (2010) Suling(2008) (presentation)
Egenes,2009) Fitzpatrick,(20 09) Lachasseur et 33
(2012)
Gray et al. (2011) Lauver et al. (2009)
thinking
Novice Nurses
Davis (1991) Gibbs (2014 Guhde (2010) Haslip (2010) Kalauz et al.(2008) Luchetti (1998) Marchigiano et al.(2011) McDonald (2013) Tanner(2006)
al. (2011) Bodin (2012) Borglin(2012) Halstead(2012 ) IOM,2010) Schneckel(201 0) Sullivan(2012) Xi Wu (2013) Valiga(2009)
Benner (2001) EbscoHos Bob(2009) t Day(2009) Books Fairris (2012) Saintsing et al.(2011) Sorenson (2008)
Student EbscoHos Breckenridge et Nurse t :al (2012) Demogra phics Nursing AACN(2009) Workforc EbscoHos AACN(2013) e t AACN(2014) Google Adams et al. Scholar (2011) JSTOR ANA(2013) BLS (2013) Buerhaus et al.(2009) Breckenridge(2 006) Davis et al. (2010) Scovil(1914)
Bednarz,et al. (2010) Buerhaus et al. (2009) Halloran (2012) Juraschek et al. (2012) HRSA(2012) Lensburg et al. (2009) Noone(2008)
34
Lynn& Redman, 2006 Barnett et al. (2012)
Nursing shortage
Teaching AACN,2013) and EbscoHos Breckenridge in learning t Fawcett(1999) Strategies Books Fawcett(2000) Howard et al. (2011) Kaddoura (2011) Learning Bandura(1994) theory EbscoHos Benner (2001) t Chan(2010) Kelley et al. (2012) Knowles 1980,1984,199 Table 0 Continued Lev et al (2000) Research Charalambous qualitativ EbscoHos et al.(2008) e tools t Chenail (2011) Creswell (2007) Creswell et al. (2007) Gray et al. (2010) Groenewald(20 04) Husserl(1931) Ironside (2001) Lincoln & Guba (1985) Moustakas(199 4) Polit et al. (2007) Polit et al. 1997) Sandelowski (2000) Whittemore(20 12)
Stayacova (2012) Roy (2014)
Gloudemans et Townsend et al. (2013) al. (2011)
Al Yateem (2012) Breckenridge (1997) Campbell et al. (2011) Chenail (2011) Gray et al(2010) Hanson et al.(2011) Houghton et al. (2013) Kaiser (2009) Mays (1995)
35
Chenail(201 1) Hanson et al. (2011) Kaiser (2009) Pannucci et al. (2010) Pratt(2012) Converse(20 12) Salmon (2012) Qu et al.(2012)
Patient/Student Perception Interview Guide Creswell’s criteria Qualitative study Phenomenologi cal
Historical Overview of Critical Thinking in Nursing Nurses are integral to the healthcare industry. Understanding the entire clinical picture is often underestimated by the bedside nurse, and according to Tanner et al. (1993), nurses perceive their personal understanding of their patients’ clinical picture as “knowing” their patients. “Knowing” is synonymous with understanding the patient and their responses to interventions and treatments (Tanner et al., 1993). Although “knowing” is difficult to quantify, Tanner et al. (1993) explained the concept is not. Benner (2001) and Benner et al. (2010) also corroborated the premise of knowing the patient as understanding the patient’s clinical presentation as well as the patient’s needs, conditions, and subsequent treatment regimens. “Knowing” the patient’s case helps the nurse formulate a plan of care for individualizing responses and interventions (Tanner et al., 1993). This concept is crucial in understanding the concepts of critical thinking and clinical judgment (Tanner et al., 1993). Nurse leaders within the industry correlate critical thinking concepts to care of patients at the bedside. Through a literature search, ample information was available about critical thinking by nurses. Critical thinking is an abstract linear process that leads to critical reasoning (Benner et al., 2010; Harjai & Tiwari, 2009; Tanner et al., 1993). Critical reasoning is an end result of the fine-tuned culmination of experiential knowledge and exposure to situations that require critical thinking skills (Benner, 2001). Both critical thinking and critical reasoning are highly individualized, challenging to teach, and difficult to measure (Benner, 2001). Literature from 2010 to 2012 acknowledges the critical thinking abilities of nurses to be a top priority, and substantiates the need to improve the nurse education system (IOM, 2011; NLN, 2011; PSNA, 2010). The importance of critical thinking should not to 36
be underestimated. Accuracy in the recognition of patient issues should precede decisionmaking in the formulation of a solution (Harjai & Tiwari, 2009). Competence is the overall goal of nurse educators for nursing staff members and students. Competence is defined in a multitude of ways. The American Nurses Association (ANA) defined competence as a level of performance that integrates skill, knowledge, judgments, and abilities (ANA, 2013). The Institute of Medicine defined competence as using communication that is judicial and habitual while integrating skill, expertise, knowledge, emotional intelligence, technical skill, reflection, values, and clinical reasoning on a daily basis while caring for patients (IOM,2011). Fitzpatrick (2009) acknowledged that competence is needed in acute care institutions, and critical thinking is a skill that leads to competence. Competence is measurable, can be defined, and is evaluated (ANA, 2013). The critical thinking ability of nurses is imperative as the healthcare industry faces anticipated challenges in the near future (Berkow et al., 2011; Chan, 2013). In 2011, the Institute of Medicine and the Robert Wood Johnson Foundation launched a two-year initiative to transform the profession of nursing to improve care and patient quality outcomes. The joint venture produced a publication titled The Future of Nursing: Leading Change, Advancing Health, which contains recommendations from the industry’s top leaders, including nurses (IOM, 2011). Nurse educator leaders are called upon to review current nursing education pedagogy, tactics, and strategies to promote seamless academic processes (Halloran, 2012). According to Mundy (2008), nursing educators must strive to instill critical thinking information into students and provide opportunities to develop and master effective critical thinking skills. Development of skill
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mastery is derived from purposeful thought, conscious awareness, dedicated time, active engagement, and fine-tuned reflexive skills (Benner et al., 2010; Mundy, 2008). Patient safety is a continuous priority for the future of the healthcare industry. Nursing organizations, nursing agencies, and educational organizations are being challenged with implementing programs for improving patient safety and competence in clinical practice (Lenburg, Klein, Rahman, Spencer, & Boyer, 2009). Chan (2013) explained critical thinking for patient outcomes is essential in nurses’ daily practice. This assertion is supported by other nursing industry leaders within the healthcare realm (Benner, 2001, 2010; Hill, 2010; IOM, 2011; McHugh & Lake, 2010; NLN, 2011; PSNA, 2010) Competence is defined as the expected level of skill and performance because of the culmination of, application of knowledge, judgment and skill (ANA, 2007). Competence is enhanced through evidenced-based practices that are mindful, careful, and purposeful. Because of the increased need for evidence-based patient centered care, critical thinking enhancement is necessary because patients are more complex than ever before, and the healthcare environment is more demanding of nurses’ skills (Chan, 2013). History of Nursing Academia The literature on the history of nursing as a profession is abundant. Until the 1960s though, thinking critically as a nurse was not a professional expectation, so most of the literature about critical thinking in nursing can be found after the 1980s. Prior to the 1980s, very little literature examined nurses as independent thinkers. Without question, early nurses practiced by following the orders set in place by a physician. Nurses also did not possess any sense of autonomy until the mid- to the latter part of the 21st century. 38
The work of Florence Nightingale demonstrated a move toward transformation of nurses from servant to a thinking clinician. Ms. Nightingale is considered the first role model in the nursing profession and contributed abundantly to the profession (Selanders, Crane, & Patrick, 2012). Florence Nightingale and her history are cornerstones of the profession of nursing, and her work continues to resonate through the body that is nursing. Her understanding of the basics of wellness, illness, cleanliness, malaise, and how they connected are all pivotal to how a nurse thinks. Nightingale’s lifetime of work and her relentless journey toward improving the healthcare system provided the embodiment of nursing with a philosophical foundation for sound practice (Selanders, Crane, & Patrick, 2012). However, Nightingale understood the gravity of nursing as a science and a profession, and expressed that education was an extreme necessity in nurse preparation (Selanders, Crane, & Patrick, 2012). According to Scovil (1914), “No training is of any use unless one can learn to feel and to think out things for one-self and if we have not the true religious feeling and purpose, hospital life, the highest of all things with these, without them becomes a mere routine and bustle” (p. 17). Critical thinking ability is a part of the pedagogical and practical part of the nursing profession. The story of women in medicine transcends decades. Many women were healers and midwives who later transformed into nurses (Luchetti, 1998). The beginning of elemental nursing education is traceable to Croatia with the first evidence of organized care and nurses training noted as early as 1854 (Kalauz et al., 2008). By the turn of the 20th century, nurses had begun to make a mark for the nursing profession, and internationally, nursing was growing, but not with ease. Women were often not
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recognized as potential physicians, so most medical schools, colleges, and universities forced women into the midwifery and nurse categories (Mann, 1998). Florence Nightingale and the nursing profession date as far back as the Crimean War, circa 1854. Florence Nightingale and her successes, contributed to making nursing a respected, scientific profession. After the war had ended, she returned to England hailed as a hero and was given the opportunity to advance and display her experiences (Egenes, 2009a). The first-nursing school in England is credited to Nightingale and her dream. The St. Thomas Hospital first opened its doors in 1860. Located in England, the St Thomas Hospital school established the promise of subsequent nurse education legacies in both England and America (McDonald, 2013). Considered a pioneer in the field of nursing, Nightingale worked together with doctors, engineers, and architects to build the St. Thomas School of Nursing (McDonald, 2013). Nightingale and the St. Thomas School of Nursing pioneered evidenced based care, community nursing care concepts, innovative labor rules, nurses’ code of conduct, scheduled time off, and rest time (McDonald, 2013). As decades have passed, the nursing profession has changed tremendously. The nursing profession in current times is a relatively young profession and continues to evolve in current times (McDonald, 2013). Nursing in America evolved progressively after the turn of the century. American nurses’ training developed during the Civil War. More than 3,000 women served as battlefield nurses to care for the wounded, worked in field hospitals, or even cared for the sick in their own homes (Egenes, 2009a). During this time, more women became nurses; however, most of the nurses’ efforts went without pay. During the war, nurses’ efforts were also scrutinized for their lack of experience and were closely 40
monitored by surgeons and general physicians because these volunteer nurses were not trusted or respected as knowledgeable clinicians (Egenes, 2009a). Despite primary training efforts, even those who were skilled and considered competent experienced difficulty being accepted. During this era, nursing as a profession was not respected and was considered laughable. Respect for what nurses stood for was essentially nonexistent. Near the end of the Civil War, however, those untrained nurses eventually gained the respect of some army physicians, in addition to the soldiers they had treated compassionately during the war (Egenes, 2009a). Because of the reputation of these volunteer nurses, Dorthea Dix was appointed as Superintendent of Female Army Nurses (Egenes, 2009a). Dix’s expectations were so high that most aspiring nurses were unable to meet them and never prospered. The first documented United States school for nurse training is credited to the New England Hospital for Women and Children, located in Connecticut (Davis, 1991). The very first nurse to graduate nurse’s training from this school was Linda Richards in 1873. According to Davis (1991), the present status of nursing education and pedagogy developed into different levels of education, training, and preparedness. The first permanent recognized and credible school of nurses’ training in the United States was Woman’s Medical Hospital of Philadelphia and was founded mainly by female physicians. Woman’s Medical Hospital is credited with having the first-official curriculum that was modeled after Florence Nightingale’s model for nurses training (Egenes, 2009a). The hospital provided prospective trainees with board, equipment, paid instructors, and library services. Most training schools during this time in nursing were
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hospital based where nurses earned on-the-job training with an eventual certificate in training or a diploma in nurses training. Many schools of nursing during this era in nursing were run by physicians, and the nurses were supervised by and practiced under the direction of doctors. Nurses were considered bedside caregivers only and had little knowledge of medical concepts (Egenes, 2009b). Physicians across the country were against any formal training for nurses; however, by 1873, change occurred. During this time, three more nurses’ training schools were built: Bellevue Hospital Training School, located in New York City; Connecticut Training School, located in New Haven Hospital; and Boston Training School, located in Massachusetts General Hospital. The significance of the schools is that laywomen rather than physicians founded these three schools. By 1883, the total number of nurse training schools in the U.S. had grown to 35 (Egenes, 2009b). By the turn of the century, the number of nursing schools increased to well over 432, but this included sanitariums, tuberculosis clinics, and other specialty forms of hospitals (Egenes, 2009b). Only a select few of any nursing school graduates were offered hospital supervisorial positions and most were assigned to the bedside to provide direct care to patients. Nurses of that era were expected to follow physician orders strictly and had little to no decision-making ability. They followed orders and for legal purposes remained under the supervision of a physician. Nurses did not have autonomy to think or act independently. Despite the rigidity in duty and resistance of physicians to support the growth of nursing, the profession expanded in medicine and science development. The development of the microscope, antiseptic agents, procedural advancements, and disease recognition had improved the science of medicine. Because of the complex growth and 42
development of medicine and the recognition and treatment of disease, physicians began to recognize the need for nurses as trained professionals (Egenes, 2009b). The first official self-reported associate degree nursing program in the United States State University of New York (SUNY). SUNY, officially called the Orange County Community College, opened its doors as an official nursing program in 1952 (SUNY Orange, 2013). Within the program, an official curriculum, college credits, and a certificate award were developed for program completion. Despite encouraging expansion in nursing education, nursing leaders struggled with developing better education with comprehensive pedagogical frameworks in nursing. Schools of nursing and community colleges across the country varied in length of training, consistency in curricular foundations, entrance examinations, and the pedagogical content. The length of these programs was also an issue because programs ranged from several months to three years (Egenes, 2009b). Nursing Leadership Between 1901 and 1923, a tremendous amount growth occurred within nursing education. Goldmark Report in 1923 recommended that all schools of nursing develop and maintain educational standards including pedagogical and academic objectives rather than skill application (Egenes, 2009b). Despite the development of community collegebased nursing programs, already established nursing programs offered nothing more than hospital-based diploma schools (Egenes, 2009b). By the 1940s, nursing leaders were looking toward expansion of nursing education to a higher level of academic preparedness to improve delivery of patient care. Ester Brown and other leaders strived to change the body of nursing and the educational 43
system that supported it. Brown advocated improved quality of education, quality delivery, and appropriate pedagogy specific to nursing and science (Egenes, 2009b). The result was the Brown Report, which is a substantial hallmark in nursing education history. The report made recommendations for official educational avenues to prepare registered nurses at institutions of higher learning (Scheckel, 2009). Brown’s contribution to nursing has her credited with recent evolutionary changes in nursing that helped conceptualize the associate degree nurse. In 1949, the Ginzberg Report recommended hospitals move to eliminate diploma schools of nurse training and begin two-year college level courses for registered nurse education. However, by 1950, the Nursing Schools at Mid-Century Report countered this recommendation, finding that most college schools of nursing were not training prospective nurses adequately (Schneckel, 2009). Diploma schools of nursing were still considered the best approach to nurse training at the time (Schneckel, 2009). Mildred Montag is credited with the official conception of the associate degree nurse (Egenes, 2009b). The associates nurse degree has helped nursing education expand from skilled laborer to a thinking clinician. In 1959, Montag developed the Community College Education for Nursing document that officially established the associate degree level registered nurse and the training that is currently associated with the degree (Schneckel, 2009). By 1965, the government established guidelines that graduates from nursing programs become educationally prepared in college-level institutions or other institutions of higher learning (Schneckel, 2009). As nursing pedagogy continued to grow, the higher levels of education emerged, and now include the baccalaureate, masters, and doctoral levels of education. 44
Nursing pedagogy currently consists of a broad-based delivery of knowledge that surrounds the premise of reasoning ability. A major contribution to the pedagogy of nursing education was the development of the nursing process in 1967. The concept of the nursing process was considered the first initiative toward the thinking nurse (Rubenfeld & Scheffer, 1999). The process includes four stages: assessment, diagnosis, planning, implementation, and evaluation. Considered the first step in critical thinking to nursing education, the nursing process begins with an assessment of the client and ends with evaluation of the care provided (Callista-Roy, 2009). Diagnosis denotes nursing judgment about what the patient requires based on what the nurse can provide and does not denote clinical diagnosis of a physical condition (Rubenfeld & Scheffer, 1999). This organized process helps nurses expand their clinical reasoning capabilities (Rubenfeld & Scheffer, 1999). The steps embedded within the nursing process closely mirror the model developed by Facione (1990). Facione’s six critical thinking skills include interpretation, analysis, evaluation, inference, explanation, and self-regulation. Each step is similar in concept to the nursing process as adapted by Callista-Roy (2009). Callista-Roy’s adaptation of the nursing process included the following steps: assessment, diagnosis, planning, implementation, and evaluation. These steps signify the journey toward understanding critical thinking is an easily envisioned process, but hard to actualize as an educational strategy (Benner et al., 2010). In the latter part of the 1970s, nursing scholars such as Helen Yura and Barbara Carper made tremendous attempts at applying science to the nursing profession. Helen Yura and Mary B. Walsh in 1973 were credited with enhancing scholarship within the 45
systematic nursing process, and Barbara Carper, in the late 1970s, was credited with the four fundamental patterns of knowing. Both were inspirational to the building of a nursing pedagogy (Xi Wu, 2013). Carper’s (1978) work pertained to the four elements of knowing: empirical science of nursing, the art of nursing, the component of the body of knowledge in nursing, and the ethical and moral components of nursing. Both nurse scholars contributed to the concepts necessary for the enhancement of basic critical thinking skills in nurses within the work they have accomplished (Xi Wu, 2013). Nurse scholars believe that nurses should be able to examine a clinical situation, weigh the assessments, follow certain rules, and come to a conclusion about what to do and how to proceed toward treatment and resolution (Rubenfeld & Scheffer, 1999). Through review of the literature, clarity is increasingly evident regarding nurse leaders’ positions on the development of enhanced critical thinking skills. Current schools and colleges of nursing have struggled with the application of teaching critical thinking with consistent results. Therefore, nurse leaders agree on initiatives toward realizing critical thinking enhancement in nursing education as a current goal and future goal. Nurse leaders are charging nursing educational leaders to investigate, improve upon, innovate, create, and develop succinct avenues to teach the concepts of critical thinking that will resonate over time (Chan, 2013; NCSBN, 2014; NLN, 2003,2011). The Carnegie Study, performed by Benner et al. in 2010, resulted in recommendations for transformative initiatives in nursing education to prepare nurses to work in demanding future healthcare environments. Although the study concentrated on the improvement efforts using simulation, a generic call for transformative efforts surfaced because of the study (Benner et al., 2010). Nurse leaders advocated for nursing education to investigate and develop 46
new and improved ways to emphasize, enhance, and incorporate critical thinking practices into daily assessment and care of the patient (Harjai &Tiwari, 2009). Yildirim and Ozsoy (2011) concluded that more research is needed to evaluate methods that enhance critical thinking because the concept is not defined concretely. National nurse leaders, such as the ANCC (2013), NCSBN (2014), and the ACEN (formally known as NLNAC) (2011), currently advocate for the improvement of critical thinking teaching strategies to improve patient care, patient outcomes, and safety. The IOM, the Centers for Medicare and Medicaid Services, and other branches of the government are collaborating to investigate options to optimize delivery of care, assessment, and treatment to improve patient outcomes. The nurse is directly in the middle of this equation and is integral to the process of healthcare improvement initiatives, including nursing education (IOM, 2010; NLN, 2011). Several pieces of literature suggest that a revaluation or examination of current curricular design, development, and maintenance is warranted (Roy & Jones, 2007). The purposefulness of understanding current processes increases awareness that curriculum should be designed and developed to help make nurses better thinkers. Within nursing academia and colleges of nursing, disunity exists in nursing academics because there are three-entry levels that currently exist: diploma, associate, and baccalaureate. According to the American Nurses Association Position paper of 1965, some nursing leaders argue there should be one-entry level degree into nursing: the baccalaureate degree (NLN, 2013; PSNA, 2011).
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National League for Nursing The National League for Nursing Education (NLN) evolved in 1893 and has remained the steadfast standard for schools of nursing across the United States (Egenes, 2009). The NLN focused on elevating the standards for nursing education across the entire country, attempting to make nursing education uniform and consistent. In nursing academia, the NLN remains the main organization for nursing education at the undergraduate level and beyond. The NLN remains steadfast in constantly seeking perpetual improvement in the body of nursing and the nursing profession. The National League for Nursing Accrediting Commission (NLNAC) is the accrediting governing body for associate degree and diploma entry-level nursing programs across the country (NLN, 2013). In 2013, the NLNAC became the ACEN (Accrediting Commission for Education in Nursing). All ACEN accrediting rules and regulations went into effect January 2014, after legal activities separating and becoming independent of the NLN’s jurisdiction and bylaws (ACEN, 2015). Baccalaureate nursing programs are governed by the Commission on Collegiate Nursing Education (CCNE). An expanded division of the American Association of Colleges of Nursing (AACN), the CCNE is the main national agency responsible for evaluating baccalaureate and graduate degree programs in nursing (AACN, 2009). Accreditation is extremely important for nursing programs. Nursing program accreditors are explicit and faculty qualifications are specific, but baccalaureate degree, masters, and doctoral programs across the country may choose to pursue accreditation by either the ACEN, the NLN, or the CCNE of the AACN. All of these accrediting agencies are respected and reputable (NCSBN, 2008)
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The NLNAC is a part of the NLN collectively but is mainly concerned with the accreditation and compliance of educational institutions across the country. The NLN specifies the standards that are necessary for nursing schools to maintain accreditation and institutions’ ability consistently to meet and maintain those standards (NLNAC, 2013). The NLNAC (ACEN) is responsible for the planning, preparation, and evaluation of accredited schools of nursing across the country. Accreditation criteria are directly to curricular planning that envelops the desire to improve critical thinking nursing in academic programs across the country. National Councils State Boards of Nursing The National Councils State Boards of Nursing (NCSBN) is the governing body for nurse licensure testing. The NCSBN’s purpose is to promote and provide organizations and learning institutions, which are governed by state boards of nursing, the ability to discuss and resolve issues of concern in nursing education (NCSBN, 2013). Because each state has individual governing capability, the NCSBN helps provide standards and information about individual state laws, testing options, and rules (NCSBN, 2013). Further, because each state is different, the NCSBN provides a clearinghouse for testing options. Prospective changes in program expectations and testing will effect what is currently taught in nursing schools. The NCLEX exam is a standardized test used for state licensure and is appropriate for each state’s mandates and laws as these apply to nursing (NCSBN, 2013). As schools change their curricula’s content and pedagogy, the NCLEX exam changes to reflect those mandates, and as the nursing profession changes, the NCSBN also changes. The NCSBN works closely with the NLN and NLNAC, as well as the CCNE and AACN, to help improve the knowledge 49
base and testing practices for individual state licensure (NCSBN, 2013). Critical thinking, prioritizing, and action are integral to the NCLEX exam and the assessment component of the nursing process. Assessment is directly related to critical thinking ability because assessment drives the rest of the process (Callista-Roy, 2009). Recently, the NCSBN performed a study to determine if simulation will serve as an acceptable substitute to clinical site unavailability, especially in the future. The NCSBN’s stance resulting from the study revealed that the effectiveness of simulation as a tool is affected by the faculty’s competence and familiarity with its use. When used properly the staff, faculty, and other educators remained consistent with the application of the strategy (NCSBN, 2014). Further, the regulatory body recommended future study to investigate the efficacy of simulation as a substitute for the decreasing availability of clinical site experiences (NCSBN, 2014). This study revealed useful information about the use of simulation, including planning, preparation, and execution. American Nurses Credentialing Center The American Nurses Credentialing Center (ANCC) is synonymous with the Magnet Designation (ANCC, 2013). Magnet designation status for any acute care institution is considered a leading force in nursing. Institutions that achieve Magnet accreditation from the ANCC are considered higher functioning, and strive for the enhancement of strong expert clinicians through nursing education and through the global delivery of nursing care. Magnet designated institutions support higher learning initiatives that empower nurses and subsequently improve the delivery of care by seeking innovative ways to improve the preparedness of nurses and change the educational entry level for bedside care delivery (ANCC, 2013). The ANCC (2013) encourages BSN, 50
MSN, and doctoral level nurses to practice at their highest of education, according to the IOM’s Future of Nursing Reports and the Pennsylvania Coalition on the Advancement of Nursing Education White Paper (IOM, 2011). The ANCC collaborates with other governing bodies to support, consult, drive, and improve the nursing profession (ANCC, 2013). Other efforts in the education of nurses’ education supported by Magnet designated institutions include obtaining certification in specialty areas. Under the Magnet label, nurses can seek certification in areas of clinical expertise, enhancing their skill sets, knowledge base, and critical thinking capabilities. Diversity in Nursing Literature published after 2000 includes predicted changes in the diversity of the profession of nursing in future decades. Nursing is more diverse than ever, and this diversity reveals there is no longer a stereotypical candidate or graduate associated with the profession of nursing. By 2042, the U.S. Census Bureau predicts there will be a shift in the population mix of minority citizens (Barren, 2009). The prediction indicates Hispanics will lead this population. Concerns are arising that minority populations are not entering the nursing workforce, which could eventually affect the projected nursing shortage (Barren, 2009). Not only does the nursing profession need to increase its population numbers, nursing needs minorities to help fill the void. These diverse issues bring challenges to nursing education and the preparedness of prospective students. Breckenridge (2006) explained the diversity of the nation has recently been currently comprised of the following underrepresented registered nurse populations: 2.9% Black, 7.2% Hispanics, and 42% Caucasian. Because these populations are underrepresented, this directly effects how students are educated currently in nursing 51
programs, and this compounds the inequality in population because of attrition in schools of nursing (Breckenridge, 2006). The cause for attrition in nursing schools is that students typically possess characteristics of the profile of a new access student, noting risk factors that may inhibit success in nursing programs (Breckenridge, 2006). Cultural diversity issues and linguistics issues can complicate the education of diverse populations and the premise of critical thinking education in nursing (Barron, 2009). Linguistic challenges should not discourage the leaders in nursing from seeking culturally diverse populations to enter nursing. Increasing the diverse populations in nursing and other health professions is not as complex as perceived; nursing needs to develop avenues to nurture and facilitate nurses from diverse populations into competent nurses who are entering the profession (Barron, 2009). Jeffreys (as cited in Bednarz, Schim, & Doorenbos, 2010) explained student diversity applies to non-traditional students, i.e. those students who are age 25 years or older, who commute to school, have children, are male, are ethnically diverse, hold a GED or high school diploma, and or speak English as a second language. In 1998, the Pew Health Professions Commission recommended the nursing profession seek to increase workforce diversity to reflect the nation’s general populous (Bednarz et al., 2010). Unfortunately, solutions to diverse issues do not come without problems. Education presumes the need to engage in problem solving and critical thinking to synthesize more complex and changing knowledge into appropriate courses of action. One main concern is how educators approach education for diverse populations. Three areas of concern include the nature of nurses’ training and education, the essence of human nature, and the nature of culture itself (Bednarz et al., 2010). Nursing education 52
needs to employ increased resources for a diverse, competent workforce. Some educators and nursing leaders identify the difficulty of tailoring nursing education to recognize and accommodate diverse student needs (Bednarz et al., 2010). Several problems have been identified by nurse faculty surrounding teaching diverse groups, but the most imperative is the ability to speak English. The fear most instructors have is that students who do not speak fluent English have difficulty keeping up in lecture and conferences about patient care. Problems with linguistics can lead to isolation and a decline in academic success (Noone, 2008). The approach to understanding concepts surrounding critical thinking is affected by the inability to comprehend completely and understand information provided by instructors (Noone, 2008). Changes are necessary and are highly recommended by nurse leaders but might be difficult to implement because of the lack of understanding of diverse populations (Noone, 2008). In addition, assumptions made by nurse leaders reveal potential difficulty in envisioning those necessary changes in educating a more diverse student population (Bednarz et al., 2010). Diversity issues may also include the gender aspects of the profession. Gender can also prove to be a challenge for educators in nursing education, and males are a recognized diverse population in current schools. Male populations are currently growing populations within schools of nursing and because men approach situations differently than women, there is a definite need to understand the thought processes of men versus women (Bednarz et al., 2010). Some cultures prefer males to care for males and females to care for females, and this can compound the need to increase male nurse workforce numbers. “Men in nursing often bring a more task-oriented, instrumental approach to the 53
profession” (p. 256). Gender diversity brings challenges for nursing faculty and approaches to education of critical thinking pathways and challenges nursing educators to increase the numbers of male nursing instructors (Bednarz et al., 2010). Nurse educators should be encouraged to view an influx of a more diverse student population as a learning opportunity. The value of an increase in diverse nursing students will be viewed as a necessity for a culturally competent future nursing workforce. Nursing education needs to embrace these challenges to fill the void and help increase the capacity for critically thinking nurses. In addition, nursing education needs to evaluate the current standards and alter, innovate, or develop new ways to meet the needs of all nursing students entering the profession (Bednarz et al., 2010). Nursing educational programs around the country must envision a more diverse, ethnically rich population of students (Davis et al., 2012). Nurse educators must seek ways to educate to harness strategies that work well and intelligently to prepare diverse student populations for healthcare decision making (Davis et al., 2012). Future Goals and Vision Finding new effective strategies and revising older strategies will help nursing achieve long-term goals for development of an effective future workforce. Current healthcare trends reveal the need for nurse leaders to prepare for future challenges in healthcare, diverse underrepresented populations, and optimal patient care (Davis et al., 2012). Valiga (2012) predicted nursing education will continue to evolve in order to develop fully engaged nursing students by using innovative and creative evidence-based techniques. Nursing education must meet this demand since the healthcare industry is 54
becoming more complex, and patients are presenting with advanced healthcare needs (Benner et al., 2010; Hill, 2010; NCSBN, 2014; Valiga, 2012). Halstead (2012) also reiterated the desired course for nurse educators and education as reported by the NLN and the IOM as connected and engaged. Nursing education leadership is currently planning for nursing’s future through structured planning and development. Four distinct goals are attached to nursing’s future. These goals include practicing to the full scope and ability of nurse practice acts and bylaws, engaging in higher educational endeavors, fully participating and contributing to healthcare reform and superior practices, and engaging in evidence-based practices to measure and improve the quality of care delivered (Halstead, 2012). General practices and trends are reflective of a changing, more diverse, and technologically competent student population (Davis et al., 2012). By understanding the directional goals of the future of nursing and nursing education, this traditional avenue of educating nurses will force nurse educators to investigate other options (AACN, 2013). Benner’s Theory of Novice to Expert Critical thinking principles are applicable to the profession of nursing. Benner’s 1984 theory of novice-to-expert captures the element of critical thinking and reasoning regarding patients, patients’ conditions, and patient care. Benner’s (1984) work on critical thinking also helped transform the profession of nursing. Benner and her theory about critical thinking are considered an extremely influential embodiment to the nursing profession. In 1984, Benner conducted a study about the decision making skills of nurses. This philosophy became known as novice to expert theory (Benner, 1991,1994). Benner’s hypothesis included the belief that nurses start out with a clean slate of knowledge and 55
skill; however, over time, the experiences of a professional career greatly enhance nurses’ thinking skills. Benner’s initial study was qualitative and involved interviews, observations, and dialog. Participants for her study included experienced nurses (51), new graduates (11), and senior level nursing students (5) at the California institution where she was employed. Conclusions from her study revealed experience equated to knowledge and skill attainment, and that these existed along a continuum. The levels Benner highlighted are the foundation for critical thinking acquisition and include the following steps or stages: novice, advanced beginner, competent, proficient and lastly, expert. One goal of the researcher’s goals in the current study was to determine what helps students begin moving from each level within the process from novice to expert. According to Benner (1991, 1994), student nurses practice based on the confines of rules and bylaws, whereas the more advanced beginner student nurse begins to use situational awareness to help formulate hypotheses and responses to those hypotheses. Competent nurses tend think in long-range type terms (Benner,1991, 1994) Competent nurses analyze situations and then formulate understanding of those situations. Proficient nurses look at the entire situation and form hypotheses based on understanding and knowledge, and act based on professionally based decisions. Expert nurses utilize intuition as a tool, and their confidence helps guide them in making care decisions. Benner’s study helped conceptualize the truth that experiences do influence action and that boundaries exist between the critical thinking skills of the nurses and the varying levels of expertise and clinical experience (Benner, 1991, 1994). The nurse who employs critical thinking skills understands the deeper complexities of the human condition, thus coming to intelligent affirmations. Student nurses can begin to learn the basics for critical 56
thinking and logical reasoning in lessons that enable them to draw conclusions. Benner’s study provided a framework in which to continue to examine the critical thinking potential in all nurses. Benner’s study has increased interest in the paradigm of logic and reason. Clinical knowledge, according to Benner (1991, 1994) is a form of specialized logic and reason, which are contextual, visionary, perceptual, and reality oriented. To understand the process of acquiring clinical knowledge, journaling, case study and simulation were chosen as avenues to achieve this correlation between nursing education and the actual profession of nursing. A basic understanding of the enhancement of critical thinking is important to the future of nursing and Benner proved this point with strong clarity. Benner’s theories provide valuable insight into the critical thinking learning paradigm that establish an important infrastructure for nursing schools, colleges, students, and faculty. Applied Critical Thinking Critical thinking is the cornerstone of what nurses do on a daily basis for their patients. All professions use embedded critical thinking concepts within a metacognitive framework to arrive at conclusions and make decisions. One general critical thinking theory containing six components to the critical thinking construct was developed by Facione, (as cited by Cain at al (1992) within the Delphi Report from Facione and Facione in 1992 (Cain, Giraud, Stedman, & Adams, 2012). The Delphi Report explained Facione’s six components of the critical thinking paradigm applicable in every pathway, including nursing reflective practices and critical thought (Cain et al., 2012). These six components include interpretation, analysis, evaluation, inference, explanation, and selfregulation (Facione, 1990). Each component is similar to the nursing process and 57
becomes pertinent in a nurse’s critical thinking pathway. A nurse’s ability to think critically can lead to improved care and patient outcomes, according to the IOM (2010). As mentioned earlier, Facione’s critical thinking explanation closely resembles that of Callista-Roy’s (2009) nursing process model. The general theme throughout nursing education’s initiatives leads to the ability of nurses to apply solid critical thinking while caring for patients. Metacognition, as emphasized by Facione and Facione (2007), is a concept in which the user creates a hypothesis about an issue, potentially arriving at a solution using experiences and rationale, and ultimately achieving an action plan. Facione and Facione (2007) corroborated Benner et al.’s (2010) conclusions in which critical thinking is an abstract learning process that is purposeful and self-regulatory. For a long time, people have been learning to think critically without formal education or coursework (Facione & Facione, 2007). Often, people are not aware they are using critical thinking to solve problems, so this adds to the inability to standardize teaching concepts (Facione & Facione, 2007). Benner et al. (2010) and Facione et al. (2007) explained the educational system would better serve students if students were taught how to solve complex issues using instinct, intuition, solid information, and reasoned judgments. Nurses must learn to think critically to solve patient concerns by arriving at conclusions that are based on assessment, knowledge base, and learned skills (Benner et al., 2010). Despite academia’s attempt at understanding the concept of critical thinking, Facione et al. (2007) deduced that people have been learning to think critically for thousands of years without formal study. Instinct and intuition are terms that are embedded within the umbrella of critical thinking. According to Gobet and Chassy 58
(2008), thinking instinctively is an action that is neither purposeful nor intentional; decisions are arrived at through previous knowledge or experience. Intuition can be defined as understanding or knowledge about a phenomenon and is synonymous with expertise (Gobet & Chassy, 2008). Benner (2001) alluded to the critical thinking phenomenon of nurses using instinct and intuition to arrive at conclusions about patients and the care they deliver. Facione and Facione (2007) explained that critical thinking is summarized as a cognitive mechanism by which reflective decision making and problem solving are used to arrive at findings and conclusions used to develop plans of action. Nurses not only need to care; they need to understand the complex nature of human beings, pathophysiology of the human body, illness, and effective treatments (Selanders, Crane, & Patrick, 2012). Over the years, nursing has grown to require education as a foundation for practice. With education comes better understanding of the science of nursing. Understanding educational challenges forces nursing education leaders to transform nursing into a thinking profession capable of more than simple tasks. The majority of the recent literature alludes to the future challenges facing all nurses, and the challenges nursing education faces in meeting the needs of an aging, retiring, and novice workforce. Nurse’s roles are expanding; they have more responsibility, more complex and complicated patients, and the increased need for cerebral, astute, knowledgeable, and critical thinking (Marchigiano, Eduljee, & Harvey, 2011). Critical thinking is defined in many ways; however, the basic premise holds that critical thinking is an intuitive judgment associated with assessments made on a clinical level and involves investigating, decision making, problem solving, and analysis of the presented problem (Benner, 2010; Wysong, 2009). Principles of critical thinking can be 59
applied to any professional arena. Although Wysong (2009) defined critical thinking in a simplistic way, trust of the nurse’s skill and evaluation of that skill competence is often decided by patient under the direct care of a nurse. Care delivery is dependent on how the nurse analyzes a situation and decides how to resolve it. Tanner (2007) also voiced that critical thinking and reasoning are the processes in which nurses evaluate situations, examine the situations, and then act to rectify the situations. According to Tanner (2006), clinical judgment is synonymous with critical thinking, which is very complex and complicated. In recent years, the concerns for faculty shortage decreased use of clinical sites, and availability of valid clinical experiences have raised questions pertinent to the expanded use and scope of simulation. The ability to recognize points, form hypotheses, and formulate actions, conclusions, and responses are all parts of the ability to think in a critical manner (Tanner, 2006). The dilemma about how to instill critical thinking skills in nurses is a continuing concern. For clarity, some experts agree that critical thinking is a culmination of common sense, instinct, intuition, and learned experiential knowledge (Benner 2001; Tanner, 2007). Nurse researchers and educators agree that the act of learning to think critically should be approached as a process versus an objective or goal to be met (Rogal, 2008). Processes are necessary in order to bring organization to how nurse educators can accomplish this task through educational initiatives, thus teaching student nurses how to confirm, validate, act, and correct situations in which they are providing care (Rogal, 2008).
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Theory into Practice Theory integration into academia and eventually into practice is applicable using Benner’s theory of novice-to-expert. Hill (2010) explained the connection is a relatively simple one because an academically prepared and experienced nurse is in the very best position to deliver the highest quality of care. Critical thinking concepts are difficult to teach, as expressed by nurse industry leaders such as the NLN, the IOM, the ANA, and the ANCC. Industry leaders emphasize there is a need to improve and to solidify critical thinking concepts through academics before nurses reach the realities of nursing. Nurses who are provided with particular skills that include critical thinking concepts can navigate patient conditions. Critical thinking and skills improvement will improve bedside care and inevitably lead to better patient outcomes (Benner, 2001, 2010; Hill, 2010; IOM, 2011; NLN, 2011). Because the journaling, case study, and simulation strategies are commonly used to facilitate the concept of critical thinking in nursing programs, the three should be examined. Examination should include validity and effectuation assessment in adequately preparing nurses for the realities and responsibilities of being at the bedside. Hill (2010) stressed the need to retain knowledgeable, experienced nurses; however, the future of nursing also depends on adequately preparing the influx of newer nurses. Improved preparation of novice-level nurses is necessary to replace those leaving the workforce. The urgency to improve preparedness of the nursing workforce is shared by industry leaders, raising the need to evaluate and re-evaluate current educational strategies and tactics (NLN, 2003, 2011). Taylor (2002) expressed that expertise and knowledge in nursing are influenced and validated by relevant experience in addition to other 61
associated factors, such as learning styles and academic preparedness. If nursing academic and industry leaders work together to understand how to prepare newer nurses for the rigors of the healthcare industry, leaders can improve, develop, and innovate strategies to help alleviate the projected nursing shortage. Figure 1 illustrates the connection between nursing education and integration into practice (McHugh & Lake, 2010). Integration into Practice
Figure 1: Integration into Practice (McHugh & Lake, 2010)
Benner, Sutphen, Leonard, and Day (2009) produced an exciting synopsis on the then-current status of nursing and nursing education: Educating Nurses: A Call for Radical Transformation. Three years later, a re-evaluation of the status of nursing found the issue of disproportionate nursing education had improved but was still unresolved (Benner et al., 2009). Figure 1 demonstrates the relationship of nursing education to nursing practice; a relationship that remains disjointed. Benner (2012) described the issue as an educational gap that may not close for another ten years and continues to remain problematic for the industry and for nursing academia. The hope remains for nurse 62
scholars and leaders to study, innovate, produce, and deliver strategies that help nurses become higher-level thinkers in a progressive, complex healthcare system (IOM, 2011; NLN, 2011). Benner (2012) also asserted that undergraduate programs and hospital based nursing programs lack pedagogies and strategies that assist nurses to move from competent levels of practice to expert levels of practice. This situation emphasizes the need for nurses to think critically, act appropriately, and anticipate the needs of a very sick patient demographic population. The correlation and relevance of nursing education to current industry practice requires a connectedness achievable only through the transformation of nursing education for current practicing nurses and future nurses entering the profession (Benner, 2012). The Three Strategies Journaling, case study, and simulation are commonly used strategies in nursing programs around the country. These three strategies, although not exclusive, are commonly employed to teach student nurses how to think critically in response to patient conditions. The subsequent sections explain each strategy. Journaling. Reflective journaling is frequently defined as a learning log or personal record of experiential learning experiences (Dwyer, 2012). According to Blake (2005), reflective practice serves as an avenue “toward self-examination in an effort to improve upon, or encourage professional growth” (p. 2). Barnes (2010) indicated the value of journaling in facilitation of critical thinking skill attainment and mastery. Facione developed a theory of critical thinking and the application of the theory to reflective practices such as journaling (Cain et al., 2012). Reflective practices combine recall, knowledge, and understanding to paradigms and may serve to help the learner 63
understand and memorize concepts. These critical thinking components included analysis of the problem, evaluation of the situation, inference, explanation, and self-regulation in learning (Facione, 1990). Journaling is a practice to record and reflect upon personal learning observations and responses to situations. Kuo, Turton, Cheng, and Lee-Hsieh (2011) explained that journaling can help students by allowing reflection from examining and re-examining experiences and feelings incurred from past events and situations. The writings allow students to make a log of the experiences by writing them down either actively or retrospectively; the students then relive those experiences and draw conclusions from them. Yildirim, Ozkahraman, and Karabudak (2011) further substantiated the concept of the journaling log by emphasizing that maintained logs can help facilitate critical thinking. Maintaining personal logs allows the student to reflect on the courses of action that led to specific decision-making actions. Nurse educators can use reflective strategies to guide students in many ways to manage, deliver, and understand the aspects of the care delivered (Billings & Kowalski, 2006; McMillan-Coddington, 2013). These experiences may be reviewed later to evaluate personal growth as well as analyze paths of thinking and contexts. Journaling is frequently used as a teaching technique when attempting to encourage critical thinking and helps to connect classroom pedagogies to the clinical forum (Billings & Kowalski, 2006; McMillan-Coddington, 2013). This form of thought process acquired during reflection is formally known as metacognition (Ruland & Ahern, 2007). Metacognition is a tool used for self-communication surmising task demands and responses before, during, and after the task (Ruland & Ahern, 2007).
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Review of this literature reveals ample studies written and published between 2005 and 2014; however, minimal evidence is available about students’ perceptions of journaling as an effective tool in undergraduate nursing education (Epp, 2008). In one recent study performed by Hendrix, O’Malley, Sullivan, and Carmon (2012), the researchers studied the perceptions of students’ journaling experiences, format, and other aspects. Four aspects of journaling were emphasized: journaling as a transformative tool for learning, to facilitate critical thinking, to promote honest reflection, and to promote discussion about experiences in a secure and trustworthy location (Hendrix, O’Malley, Sullivan, & Carmon, 2012). The results of the study revealed intricacies about journaling as perceived by student nurses. Results revealed that students valued the essence of time, confidentiality, results, feedback, and format in that order (Hendrix et al., 2012, p. 7). Interestingly, the less experienced student nurses preferred a more structured journaling format as opposed to the more experienced student nurses who preferred a free texting format (Hendrix et al., 2012). Structured journaling formats contain strict objectives and are meant to provide facts about an experience (Hendrix et al., 2012). Ruland and Ahern (2007) devised journaling modalities in RN-BSN educational pedagogy, and this modality is certainly applicable in associate degree nursing. However, Ruland and Ahern further explained the complexities of the reflection process necessitated structured requirements for the skill and not simple freehand expression. According to Ruland and Ahern, students find activities that forced reflection on personal perspectives often result in the student being uncomfortable. Instructor feedback and attention to specific goals assigned may help encourage reflection. Kennison (2012) expressed that, although journaling is a key component of many schools of nursing curriculum, downfalls to this 65
practice emerge when faculty members are “unaware of how to help students reflect, what kinds of feedback are helpful, and how to address student concerns” (p. 306). Charles (2010) explained there are many caveats to the journaling process. Many questions surrounding specific objectives and lack of encouragement in honest reflection are part of the problem. This rigidity in reflection results in students refraining from purging inner feelings about experiences that may be most meaningful. Charles also alluded to the confusion by instructors as to which objectives best promote effective and reflective practices that affect critical thinking facilitation. When performed correctly, journaling is reflective writing that helps students identify gaps in knowledge, evaluate personal interactions with colleagues and clients, acknowledge mistakes, and trigger inquisition (Kennison, 2012). Educators can make assumptions about student learning through the journaling experiences of students when students actively analyze, describe, interpret, and synthesize clinical experiences (Kuo et al., 2011). Discovering the value derived from any clinical experience is achieved by helping nursing students make sense of the experience that, in turn, enhances critical thinking (Kennison, 2012). Taylor-Haslip (2010) wrote if students are encouraged to self-reflect on clinical performance, valuable insight will be attained through the venture, fostering students to internalize concepts previously learned in theory and lecture. Taylor-Haslip (2010) further differentiated between the different forms of reflective writing. Critical reflective writing is clearly expressed rationale for “actions, decisions, and feelings during experiences, taking into further account the historical, social, and political viewpoints” (p. 71). Taylor-Haslip found correlations between student performances in the clinical environment and in the level of reflection afterward. 66
Taylor-Haslip’s conclusions about reflection pointed directly to the relationship between “valid reflection, students’ initiative to seek clarification from the instructor, and validation of intake of enhanced knowledge” (p.71). Rosenberg and Silver (2011) also explained reflective practices in which students are enabled to practice self-evaluation of personal experience through the journal process. This process allows for increased awareness and expression of personal perceptions, feelings, concepts, intellect, and emotional awareness as these apply to students’ experiences when dealing with patients. Strengths and weaknesses may also be assessed through these reflective practices, thus providing better direction for the student in future exposures to patients in the clinical area. Through deep reflection, the instructor can again guide the students and apply feedback (Rosenberg & Silver, 2011). One important caveat mentioned in Rosenberg and Silver’s article pertained to communication enhancement among the patient, the primary nurse, instructor, and student. Communication skills are necessary for every nursing student and can strengthen the nurse-patient relationship immensely. Lasater and Nielsen (2009) also expressed the importance of journaling as an effective teaching-learning modality as a long-standing hallmark in nursing education. Nurse educators have voiced concerns about meeting journaling objectives and processes related to meeting stated curricular objectives. Some literature also indicated a lack of respect for journaling as an effective teaching and learning method by some nurse educators (Charles, 2010). Epp’s (2008) review of the literature indicated there is little proof that journaling produced learning to a substantial degree. Epp’s (2008) review concluded that some educators believe journaling is redundant, excessively wordy, superficial, boring, and repetitive. Hayman, Wilkes, and Jackson (2012) identified three 67
specific challenges associated with journaling: less than optimal participation, staying focused, and feeling revealed and exposed. Honesty is a core component of the journaling concept as well as an important validating factor. Journaling is considered an abstract and interpretative strategy; however, the practice for use in nursing education remains steadfast because many educators still believe there is a connection between selfreflection and critical thinking (Charles, 2010; Yildirim, Ozkahraman, & Karabudak 2011). Older literature indicated that guidance in reflective practices can help germinate critical thinking. Reflection offers students a sustainable avenue to analyze the care provided patients and further expands on clinical judgments practiced. Recently, Wald and Reis (2010) posited that journaling can “promote effective use of feedback” by aligning with improved patient outcomes. The connection between clinical experience and self-reflection are compelling (Wald & Reis, 2010). The journaling theory adaptation can also help explain people’s beliefs about personal capability, level of performance, and influence over experiences in life (Bandura, 1993). Journaling practices serve to enhance critical thinking by allowing the students to reflect on personal experiences. Reflection on personal experiences aids the student in the realization of gathered knowledge and correlates with Benner’s Novice to Expert Theory (Benner, 2001). Knowles (1984) further supported journaling because most adults learn experientially and through problem solving techniques similar to principles involving personal growth and reflection. Journaling, as a teaching-learning strategy, is mentioned many times professionally as an effective tool; however, few studies have revealed students’ perceptions of their validity within the learning forum. Burrell (2014) advocated
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journaling and reflective practices as a conduit toward learning how to think critically; however, there are challenges to standardization and assessment by nurse educators. According to Sewell (2008), journaling serves to provide student nurses with a means of purging clinical experiences while interpreting the validity of those experiences. Journaling also serves to provide the nurse educator with insight into the progression of student nurses’ experiential learning. Sewell recommended inquisition about activities performed in the clinical area and the student nurse’s response to the activities. Openended questions about actions, formulated ideas, hypotheses, and responses serve as a means for explanation and clarification (Sewell, 2008). Sewell further advocated for the use of journaling in all nursing areas. Very little evidence within the literature mentioned the value of journaling practices. Lundberg (2008) stated strategies to improve confidence while using journaling are immensely meaningful; in fact, the instructor could use journaling as a means to boost confidence by logging the activities students believe were done correctly. Tanner (2006) posited that journaling is a reflective process that occurs as “reflection-on action” (p. 209), which documents any learning extrapolated from experience. This reflective process requires “knowledge outcomes: understanding what occurred as a result of nursing action” (p. 209) and is a part of clinical judgment (Tanner, 2006). Once this reflection-on-action is integrated into practice, the concept evolves into reflection-onpractice and becomes habitual. Noticing and responding to situations comprises clinical reasoning and leads to critical thinking. Tanner (2006) labeled this skill as “hypotheticodeductive reasoning” (p. 208) that becomes a pattern for the pathway to critical thinking.
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Educational practitioners must advocate sound, honest, reflective practices and acceptance of responsibility by student nurses in an engaged, concerned stance. Honest, responsible reflection leads to reflect-on-practice and facilitates learning; however, the difficulty inherent is developing students’ moral integrity in accepting this practice as a habit (Tanner, 2006). Once the habit is formed, nurses will perpetuate and incorporate it into practice, using reflection to validate the effectiveness of the care provided to ill patients. Seminar (case study). Seminars are often referred to as case studies in the nursing field and are defined as an activity used to trace, review, and critique aspects of specific patient cases (Lundberg, 2008). Yildirim et al. (2011) reinforced the belief that if nurse educators require student nurses to be critical thinkers, they must help students attain the skill. The use of case study produces real-life anecdotal lessons from real-life patient scenarios; however, they are complex and require time to dissect (Yildirim et al., 2011). While nursing education includes some pedagogies designed for the simple memorization of facts, critical thinking becomes the application of retained facts that are applicable to real life situations (Harrison, 2012). Case studies can bring the full experience to the classroom. These cases are real, memorable events where all aspects of the patients’ cases may be dissected and examined. Students are given opportunity to interject thoughts, ideas, solutions, and validation of facts. Gray and Aspland (2011) concluded that case based learning is the desired choice by students, encourages initiative, and helps to promote confidence, motivation, and enjoyment in learning. Postclinical conferences can serve well to emphasize this point and offer a solution where students can share stories about the clinical experience (Lundberg, 2008). 70
Debriefing and review of specific cases offers instructors tools for praise, validation of critical thinking, and promotion of confidence for actions performed by students (Lundberg, 2008). These activities assimilate the novice to expert (Benner, 2001) theory well; students learn over time and through experiences during clinical learning rotations. These experiences and the attainment of knowledge solidify foundations for the journey to becoming an expert clinician. Case studies serve this purpose well. Case studies are often a group activity that forces students to interact, problem solve, and formulate summation while presenting specific patient care situations in a team environment (Feingold et al., 2008). Wolf (2011) explained that the value of student nurse’s experiences should not be underestimated. Analysis of nursing student stories and experiences provide nursing faculty with evidence of student growth and transformation. These stories enable personal reflection on experiences, thus helping to enhance student understanding of situations in which student nurses are intimately involved. These stories also offer faculty opportunities to learn from students, thus “empowering nursing education programs to continue revitalizing strategies” used in educational programs (Wolf, 2011, p. 264). Woods (2012) also advocated case study use as an avenue of critically analyzing real life situations and deriving meaning from those experiences. Case studies developed from real-life situations serve as metaphoric lessons in patient care, clinical situations, assessment, and intervention. One negative belief about case study is that the impact of the story and the facts that go along with the story are only as good as the person recalling the actual events, facts, and timelines (Woods, 2012). Scant literature was uncovered about the value of a case study as noted by student nurses. 71
Simulation. The very first manikin appeared in 1911, invoking the inception of simulation; however, the strategy currently used as a teaching and learning tool gained momentum between 2000 and 2015. Nursing educational programs use simulation to aid student in learning skills, roles, and nurse responsibilities (Jefferies, 2012). Simulation is described as a template method by which students act out differently scripted scenarios, using knowledge derived from didactic and clinical lessons (NLN, 2011). Jefferies (2012) and Weaver (2011) emphasized that a simulation provides the ideal optimal setting for nursing students because simulated activities realistically mimic patient situations. Educational theory supports the use of simulation. An abundance of literature supports the implementation of simulation in any nursing program. The National League for Nursing (NLN) (2011) advocates for schools to invest in simulation as a sound, tested tool that seems unchallenged by other methods; however, the method may be complimented by the use of journaling and case studies. An abundance of resources is available to assist instructors in helping students learn how to think critically in a meaningful, interactive fashion. Benner’s (2001) novice-to-expert theory epitomizes this method of teaching because the growth of critical thinking can be obvious, even with the first exposure. By using simulated activities, students gain comfort in autonomous action without necessarily feeling inadequate prior to performance in the clinical environment. Some literature suggests some students are fearful of simulation of the action to act out scenarios directly alongside classmates, and this can result in discomfort and apprehension (Clapper, 2010). Experiential learners bring previous experiences, both good and bad, along with them and these experiences may directly affect student actions during simulated activities (Clapper, 2010). 72
Clapper (2010) also suggested the existence of two types of educators: teachers and facilitators. “The latter may be more conducive to learning” (Clapper, 2010, p.e8). Thus, the facilitator might be more willing to use simulation. Facilitators offer more strategies to learn during simulation and can alleviate student fear (Clapper, 2010). Simulation is considered a very strong educational pedagogy; however, potential apprehension associated with these activities can manifest in student actions because of fear and lack of confidence and experience (Clapper, 2010). Bandura (1994) suggested specific past experiences influence learning, based on feelings of self-efficacy and past negative life experience. Similar to stage fright, this fear and apprehension may inhibit student action because previous learning experiences that did not result in understanding of concepts left the learner with feelings of inadequacy. Roy (2014) performed a study in which students identified the feeling awkwardness during actual simulated activities. Students with strong confidence in their skills will acquiesce easier and demonstrate better autonomy. Simulation is described as creative, fun, and engaging. Clapper (2010) explained educators need to understand what engages the adult learner in simulation as a learning paradigm. Simulation is complex and educators need to understand what can be done to make the learning experience “the most fulfilling, creating a workforce that thrives on self-improvement and lifelong learning” (2010, p. e7). Despite this evidence of the downside to simulation, the positive effects and impact on learning are uncontested. The use of simulation closely resembles the clinical area to which students are exposed and thus remains a vital part of educational pedagogy. Benner’s Theory of Novice to Expert (2001) supported simulation as a strong avenue to skill acquisition and improved critical thinking. The use of simulation in controlled 73
settings teaches students the rudimentary skills and rationales for action, preparing them for the actual clinical area (Benner, 2001). Students then learn by performing and perfecting skills to prepare for real life experiences. The purpose of questioning the validity of such activities is to help improve the educators’ delivery, teaching method, and involvement with students during simulated lessons. Lapkin, Levette-Jones, and Work (2010) suggested that simulation use produces high satisfaction among student populations because of the ability to interact, act out, and experiment without fear of hurting anyone. Lapkin et al. (2010) also divulged evidence in which clinical simulation helped to improve three outcomes toward learning: “knowledge acquisition, critical thinking, and the ability to identify deteriorating patients” (p. e220). Another study performed by Howard, Englert, Kamegand, and Perozzi (2011) resulted in positive student perceptions and feedback on the use of simulation on learning. Suggestions from nursing leaders about the use of simulation is evident through all of the recent literature (Bambini, Washburn, & Perkins, 2009; Jefferies, 2012; Lapkin, LevetteJones, & Work (2010); Lasater, 2007a, 2011; NLN, 2011). The abundance of evidence supporting simulation outweighs its disadvantages. Faculty should continue to explore avenues to improve this paradigm and the related pedagogy. To understand the importance of student perspectives about teaching strategies, nurse leaders, educators, and faculty should explore improvement on delivery and effectiveness of teaching exercises and strategies. According to Durham and Alden (2008), simulated learning experiences allow faculty to enhance student learning in situations that they may never be exposed to during clinical site experiences. Patient simulation is a versatile teaching strategy that can be implemented in many settings 74
(Jefferies, 2012). Understanding the extraordinary value of simulation substantiates the validity of the activity as an alternative avenue in lieu of clinical site use (Durham & Alden 2008). The NCSBN (2014) showed that further study is needed to substantiate the effectiveness of simulation as the only acceptable substitution for the realities of clinical site experiences. Many studies have promoted simulation as an effective avenue in substitution of clinical experiences. However, some aspects of this strategy have proved to be unclear and challenging, so more study is recommended to help provide direction for the future of nurse education (NCSBN, 2014). Simulation is an effective avenue for teaching and learning critical thinking by emphasizing the following: physical and emotional care of the patient, prioritization, and the acquisition of skills that depend upon the situation (Hyland, Weeks, Ficorelli, & Vanderbeek-Warren, 2012). The concerns for faculty shortage, decreased use of clinical sites, and availability of valid clinical experiences have raised questions pertinent to the expanded use of simulation. According to Suling (2008), the National Councils for State Boards of Nursing (NCSBN) declared a re-evaluation of simulation to help supplement issues facing nursing education. In 2014, the NCSBN reported the results from a broad study on simulation as a strategy to replace, substitute, or supplement the decreasing availability of clinical sites. The study emphasized the positive aspects of simulation; however, it also made declarations about the downsides of the strategy. Consistent faculty preparedness, knowledge, and adaptation of simulation in lieu of clinical experiences are challenges to ensure that everyone teaches on the same level and with the same rigor (NCSBN, 2014). Recommendations from the study included exploring other aspects of simulation to ensure effective use of the modality as a full substitute for clinical site experience 75
(NSCBN, 2014). The advantages of simulation include decreasing variability and improving standardization of experiences, thereby improving student stability, encouraging critical thinking and independent thought in a controlled environment, and providing immediate feedback to students (Suling, 2008). Simulation parrots the real life experiences offered on clinical sites and provides a meaningful experience for students as a learning alternative. Roy (2014) discovered value in using simulation as a great alternative to real clinical experiences because the strategy helped students build self-efficacy. The NLN also supports this innovative teaching strategy initiative as a supplement to nursing education (NLN, 2011). Burrell (2014) and Gibbs et al. (2014) encouraged the use of simulation in conjunction with other strategies, such as the use of case study and reflective practices. Current Findings The healthcare industry expects nurse leaders to implement change through leadership and education in an effort to transform nursing as a profession (Benner et al., 2010; Chan, 2013; Halloran, 2009; NCSBN, 2014). The profession of nursing has evolved from a standardized task based profession to an abstract thinking profession. Federal agencies, such as the Centers for Medicare and Medicaid Services, The Joint Commission, the Institute of Medicine, and the Robert Wood Johnson Foundation are calling for radical healthcare change, improvement in patient safety, and competence initiatives (Halloran, 2009; IOM, 2010). Nurses are responsible for making formative assessments of patients based on data. Decisions based on inductive and deductive reasoning are subcomponents of critical reasoning and critical thinking (Cerullo & Cruz, 2012). Critical reasoning is a significant 76
theme in professional nursing practice because it helps the healthcare team provide safe, effective, and competent care to patients (Cerullo & Cruz, 2012). Kaddoura (2011) explained that the challenges in teaching nurses to think critically and act competently are complex, and the rapidly evolving healthcare system presents nurses with various complex issues that offer no clear solutions. The projected nursing shortage also presents a dilemma for nursing. Saintsing, Gibson, and Pennington (2011) alluded to the concern for the anticipated large number of retiring nurses by 2020, thus resulting in a workforce decline that will cause an urgent need to increase the workforce with competent staff. This prediction is also supported by Hill (2010) and HRSA (2009). Nursing schools will be challenged to prepare future nurses with the abilities to deal with healthcare in current times. Hill (2010) explained the loss of valuable experienced nurses will leave the profession of nursing unprepared to handle the demands of the future of healthcare. This concern resonates through the leadership and academic realms of the nursing profession because patient outcomes are a driving force in nursing quality and healthcare delivery (Hill, 2010). Nursing instructors are challenged to find the best strategies in which to develop a higher thinking nurse and provide the ability to practice nursing skills while in school (NCSBN, 2014). Complicating matters, the terms critical reasoning and critical thinking are used synonymously throughout much of the literature, causing confusion about the differences between the two. There is a difference between the two: critical thinking requires some skill acquisition and mastery that leads to critical reasoning. Critical reasoning is considered the result of developing critical thinking skills (Benner et al., 2010; Cerullo & Cruz, 2012). 77
The current state of nursing depends on competent individuals who have the ability to deconstruct patient situations with skillful thought processes. Available literature does not provide compelling evidence suggesting nursing education has considered the student nurse’s point of view about what helps facilitate critical thinking and reasoning. Once student nurses complete prospective programs and attain licensure, their preparedness for the realities of the healthcare system becomes evident. Critical thinking is a lifelong skill used throughout many professional venues including nursing, so influencing the critical thinking cascade while in school may help these nurses learn to think critically earlier, thus affecting the delivery of care (Clarke & Aiken, 2003). Nurses must learn to perform thorough assessments through scaffolding practices that build on old and new information needed to make judgments and assumptions about patients and care (Clarke & Aiken, 2003). Fairris (2012) suggested involving student nurses on an evaluative level of any program may prove advantageous and helpful by revealing strengths and weaknesses not recognized by faculty. Haleem et al. (2010) piloted a new evaluation system to improve student nurse outcomes on the NCLEX exam. Conclusions from the pilot suggested the program leaders work as a team and consider the valuable input of both students and faculty in the evaluation and in the improvement process (Haleem et al., 2010). Montgomery County Community College’s associate degree nursing program currently solicits clinical program evaluations from students after each clinical semester is completed (MCCC, 2014). Results are shared with assigned clinical instructors for process improvement and faculty awareness. Involving student nurses in program
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evaluations is not commonly documented, but student nurse involvement could potentially reveal value in doing so in the future. The literature does synthesize theories that education in nursing needs improvement and educators need to think smarter about methods to teach critical thinking concepts. Nursing education must investigate alternatives to improve the outcomes of nurses’ innate, learned, and adaptive thinking skills (NCSBN, 2014; NLN, 2011). All governing bodies for leadership in nursing are asking for improvement in the quality of education within schools of nursing (Benner et al., 2010; Cerullo & Cruz, 2012; Halloran, 2009; HRSA 2009). Cerullo and Cruz (2012) suggested evaluating one strategy is not enough. Exploring many strategies may help improve the understanding of how to develop critical thinking and reasoning. Quantitative instruments, such as the WatsonGlaser Critical Thinking Appraisal, the California Critical Thinking Skills Test, and the Cornell Critical Thinking Test may not capture the true essence of what nurses do relative to practical reality, application, and function; therefore, connections about critical thinking as a process will remain an abstract and poorly connected process (Cerullo & Cruz, 2012). Paans, Sermeus, Nieweg, Krijnen, and Van der Schans, (2012) surmised that a nurse’s disposition in relation to critical thinking and reasoning skills are extremely vital to patient outcomes. When nurses are able to compile nursing diagnoses using intact critical thinking and reasoning, the resulting interventions lead to better patient outcomes (Paans et al., 2012). Literature provides strong recommendations that nurses must possess efficient critical thinking skills that contribute to effective, efficient, and proficient care (Benner et al., 2010; Bodin, 2012). Nurses who do not possess strong critical thinking 79
skills are often deficient in recognition of important signs, symptoms, and warning signs that intervention and treatment are needed. Defining and understanding strategies that enhance critical thinking are current problems in healthcare and nursing (Harjai & Tiwari, 2009). With fewer external learning resources, nursing educators will have to resort to other means by which to teach students the intricacies of the nursing profession. Understanding how the three strategies affect, enhance, or improve the future of nursing will help educators make improvements, changes, and alterations to the curricular mold. An existing assertion between the important link of solid critical thinking skills and positive patient outcomes is evident throughout the literature. Emphasizing this point about the link in critical thinking, nurse leaders concurred that the ability to think critically is essential for nurses (Kaddoura, 2010). Harrison (2012) also reinforced the relationship between a nurse’s knowledge base and how that knowledge is used. Education is not the simple memorization of data, but the ability to use the knowledge by demonstrating the application within the clinical setting (Harrison, 2012). The application of thoughtful critical thinking skill, based on comprehensive competent assessment and response time, is the desired result. Better outcomes lead to better healthcare and delivery. Unfortunately, enhancing the critical thinking capability of nursing students is not a proven concept and as a result, has remained difficult to achieve. Sullivan (2012) reiterated that critical thinking is a process not easily learned or memorized. Nurse educators are continuously challenged to develop and discover ways to facilitate and improve the skill by using a variety of modalities and strategies. Kuiper and Pesut (2004) published information that corroborates theories about reflective critical thinking and 80
reasoning that depend on cognitive and metacognitive skill development and acquisition. Kuiper and Pesut (2004) explained that while these strategies have been used to facilitate critical thinking and reflective practice in nursing schools, they have been used in isolation. Little evidence has suggested the two are linked and come together in selfregulated learning. Within the literature, the relationship between critical thinking and reflective practice concepts is not substantial. Gaps in the Literature Gaps in the literature reveal fewer exemplary examples supportive of journaling and case study in comparison to simulation. A recent literature review found studies from Burrell (2014) and Gibbs et al. (2014) about the use of journaling as an effective pedagogy, but neither studied the perspective of journaling practices as perceived by student nurses. Ample literature has highlighted the effectiveness of these strategies, both individually and in conjunction with one another. Several examples of the literature emphasized simulation as a respected teaching method, in comparison to the other two strategies. Gaps in the literature do suggest there is little consideration regarding students’ opinions about the use and effectiveness of journaling for enhancement of critical thinking. Instructors believe they are most able to determine what works best for educating student nurses; however, the instructors may not be as expert in knowing how to implement each appropriately. The literature identifies many caveats to the successful use of each strategy, either in combination or in isolation. Little literature exists, if any, investigating the perceptions of teaching strategies as experienced by student nurses. Some information was discovered substantiating the value of the student program and curricular evaluation; however, there is nothing specific about the value of the three 81
specific strategies, or any similar studies on the effect of the strategies on students’ critical thinking learning. Few available studies have focused on student nurses’ perceptions related to the effectiveness of case study on critical thinking learning. No examples of literature substantiating the effectiveness of methods for increasing critical thinking as perceived by the student nurse were found. Professional peer-reviewed journals pertinent to critical thinking and student nurses were sparse after 2001. Again, this may be explained through lack of consideration of soliciting student nurses’ opinion because the literature offers little tangible proof. A few articles revealed evidence of the value of student evaluation, but none specifically on pedagogical strategies, including the comparison of strategies of effectiveness toward critical thinking learning. A few articles suggested student perspectives on simulation equate content with the method; however, delivery and facilitation could improve. Summary and Conclusion Clearly, many aspects of critical thinking, skill attainment, engaging students, and enhanced learning require further investigation. In an effort to secure a sound future for nursing education, nurse educational leaders must predict the future of nursing as this future relates to preparing a more diverse population of student nurses (Davis et al., 2012). Nursing leaders should consider strategies that will achieve success. In an attempt to understand how all students learn, instructors’ can infuse ideas as well as provide better advice and guidance to students. Developing an understanding and providing support and guidance can result in highly competent registered nurses. In discovering which methods complement each other, or can be used individually, nurse educators can develop pedagogy that enhances the critical thinking learning process. 82
Patient safety, optimal care, and patient outcomes depend on the path that nursing is currently taking. Current trends indicate many changes are necessary to exemplify nursing as a body of knowledge, integral profession, and leader in the future of healthcare (Benner et al., 2010; Valiga, 2012). Listening to students, conceptualizing evidencebased principles, and innovating strategies are ways to help achieve goals set forth by the leaders in the healthcare industry. The future of a stable nurse education system, that is consistent across the country, will help improve standards and make nurse education pathways more succinct, consistent, and predictable. Chapter Three contains an outline of the research process, methodology, design, study sampling, data collection, bias prevention, and confidentiality used in this study. Chapter Three is designed to aid in understanding the rationale for method and design, the reason for the study, and anticipated results.
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Chapter 3 Research Method and Design The purpose of this qualitative, phenomenological study was to unveil what students perceive to be the most effective strategy for enhancing critical thinking learning in nursing programs. The study was conducted with a purposeful sample and interview process using an interview perception guide within a naturalistic setting. Through the interview process, generated themes provided meaning and understanding relevant to discover what students perceive to be the best strategy for learning critical thinking. The following research questions guided this study: RQ1: What are the lived experiences of nursing students at an associate degree nursing program in Southeast Pennsylvania? RQ2: How do nursing students perceive the three teaching strategies (simulation, seminar (case study), and journaling) as each influences individualized critical thinking learning? Qualitative phenomenological methodology was appropriate for this study because retrieved information led to common themes about the three strategies as perceived by the student nurses involved in this study. According to Moustakas (1994), the general premise of a qualitative study is to reveal general themes, opinions, perceptions, and ideas about a targeted phenomenon. The general focus of this form of research is to explore a specific phenomenon to gain clear insight and better understanding of the aspects of phenomena (Fontana & Prokos, 2007). Burns and Grove (2011) explained that qualitative researchers attempt to unveil, explain, and predict phenomena. In this study, the phenomena included the three 84
strategies in relation to the critical thinking process as perceived by student nurses. Polit and Beck (2010) reiterated that interviewing is the most common form of data collection in a qualitative study. One-on-one interviews were audio taped, transcribed, and analyzed to optimize the quality of data obtained. Because qualitative study aligns with understanding phenomena, this approach was appropriate for this study because the phenomena was identified, described, explored, explained, and predicted (Burns & Grove, 2011; Fontana & Prokos, 2007; Moustakas, 1994). Results from this study could potentially help nurse educators develop, design, combine, or alter existing teaching strategies and other pedagogical teaching techniques. The phenomenological design within the study served to unveil revelations by student nurses about the experiences, beliefs, and perceptions of the three strategies as a means to learn critical thinking pathways and skill acquisition. Phenomenological research is appropriate for nursing studies because the premise behind phenomenological studies involves the exploration of perceptions, feelings, beliefs, and experiences, all of which are components of the caring code in nursing (Polit & Beck, 2010). Moustakas (1994) emphasized that any phenomena are building blocks that represent the basis for all knowledge, and represent an opportunity for investigation. Charalambous, Papadopolous, and Beadsmore (2008) also corroborated phenomenology is used to support health care research endeavors because of the essential components derived from terminal results. These results included an individual’s thoughts, beliefs, or values associated with an activity, strategy, or concept.
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Research Method A qualitative study approach is not a new approach in nursing. Qualitative study is predominantly used to understand concepts that are integral to the profession of nursing (Tatano-Beck, 2011). In this study, the critical thinking learning phenomenon was concentric to the comparison of the three strategies: reflective journaling, case study, and simulation. According to Polit and Hungler (1997), the purpose of qualitative study is to examine little known and poorly understood phenomena. A qualitative inquiry generates perceptions, feelings, themes, and ideas about specific topics (Groenewald, 2004). Polit and Beck (2010) emphasized that qualitative researchers extrapolate themes that emerge from the interviews that give an understanding of the probe questions of the interview guide. Phenomenological researchers seek to understand meanings, themes, descriptions, and essences of experiences as perceived by the individuals experiencing phenomena (Groenewald, 2004). Qualitative research questions are designed to seek explorative, expressive answers rather than closed-ended, yes-and-no answers (Groenewald, 2004). Phenomenological researchers search to obtain a different world view in comparison to quantitative researchers (Salmon, 2012). The use of qualitative research helps researchers delve deep into the experiences and belief systems of people who are variable, unique, and individualized (Burns & Grove, 2011; Charalambous et al., 2008; Pratt, 2012). Pratt (2012) explained that interviewing is the most commonly used qualitative approach for examining the lived experiences of individuals. In nursing research paradigms, phenomenological research is an invaluable contribution toward inquiry.
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This form of philosophical research allows investigators to understand the life experiences, perceptions, and beliefs of others in relation to a specific phenomenon. This philosophical approach requires effort, commitment, and time to achieve (Charalambous et al., 2008; Ironside, 2001; Pratt, 2012). Using Breckenridge’s (1997) interview perception guide in a naturalistic setting, participants were free to express perceptions and beliefs about the three strategies that closely follow a qualitative phenomenological approach. For this current study, the three strategies became the phenomena to be studied in relation to critical thinking learning and constituted the student nurses’ lived experience. Van Manen (1990) emphasized the assumptions made from studying individuals’ experiences brings to the surface feelings, beliefs, and understandings as these relate to the phenomena. The overall desired goal is to understand the phenomenon surrounding the three strategies as viewed by student nurses who have experienced all three strategies during a school semester. The phenomenological component of a study examines the lived experiences of individuals and their responses to those experiences (Burns & Grove, 2011; Charalambous et al., 2008; Groenewald, 2004). For this study, student nurses were interviewed. A qualitative design was chosen for this study to obtain responses that are reflective, meaningful, and could lead to topics for future study. The lived educational experiences of student nurses, including perceptions, preferences, and opinions relative to the strategies, were sought through this study. Qualitative descriptive analysis using the interview process helped unveil perceptions about the three strategies as they relate to the critical thinking learning processes taught to student nurses. “Perception is defined as access to truth and the foundation of all knowledge” (Munhall & Oiler, 1986, p.55). Critical thinking is an 87
abstract learning process that is not associated with any permanent form of concrete skill sets and is a personal process in the development in the pathways of thought (Mulnix, 2012). Unequivocally, technical skills can be taught with repetitive demonstration, but critical thinking involves more than calculable facts, which is why a qualitative study design was more appropriate for this study. Ultimately, the responses from this research study helped the researcher decide if further study is necessary. The researcher obtained information via interviews. Interviews were conducted in a private, naturalistic setting that inspired inquiry. The process included performing oneon-one interviews in a private, quiet setting. A perception guide was used to aid in the consistency and structuring of the guided inquiry. The guide was adapted for use using open-ended reflective and inviting questions. Questioning was specific to the perceived feelings associated with the three teaching strategies experienced by the students during the academic process. The researcher used a digital audio device to record entire conversations during the interview process. Immediately after each interview, the information was reviewed and transcribed by the primary researcher and a commercial company called Express Scribe (2015). Confidentiality was preserved through use of pseudonyms instead of formal names. Interviewing is the most commonly used method of data collection in qualitative forms of study (Polit & Beck, 2010). The naturalistic setting, use of the interview process and reflection are all premises concentric to qualitative forms of study (Polit & Beck, 2010; Polit & Hungler, 1997; Moustakas, 1994). Understanding the perceptive impact and lived experiences of the three strategies on the participants’ learning was the purpose of this phenomenological inquiry (Husserl, 1931). Phenomenological forms of study provide perfect alignment in nursing research 88
projects because the experiences help divulge value-based concepts as experienced by student nurses (Tatano-Beck, 2011). The value-based concepts that were obtained by performing this proposed study were explained by the individual’s interpretation of the phenomenon. Qualitative phenomenology expands the deeper understanding of the experiences as described by the individuals during the interviews. Husserl (1931), Moustakas (1994), and Polit & Beck (2010) concurred with the use of this form of study to understand the experience in relation to a phenomenon. Quantitative methodology was not the chosen design for this proposed study because results would reveal specific metrics regarding critical thinking teaching strategies and not the desired outcome to understand why the strategies may or may not be preferred by student nurses (Tatano-Beck, 2011). Open-ended questions draw the individual’s feelings to the surface and is the very reason for phenomenological inquiry. Qualitative inquiry is designed to explore the how, what and why relating to a specific phenomenon (Creswell et al., 2007; Groenewald, 2004). For this reason, questions are typically open, inviting, and encouraging of expressive dialog. Quantitative forms of research are designed for studying phenomena that have been well studied or defined, and include identification of the problem before official inquiry (Polit & Hungler, 1997). Quantitative forms of study define hypotheses that help drive inquiry; qualitative forms of study have no predicted hypotheses and no associated predictions or preconceived notions (Polit & Hungler, 1997). In this study, the problem pertained to the understanding of the three commonly used strategies in the facilitation of critical thinking (Benner et al., 2010; Burrell, 2014; Mulnix, 2012). The student nurses’ perceptions of the three strategies presented in this 89
proposed study became the phenomena for study. Moustakas (1994) explained that phenomenology attempts to eliminate any preconceived judgments and presuppositions, thus allowing for reflections that provide meaning to everyday experiences. When an individual uses internal intuition and perception, direct awareness becomes clearer due to conclusions that are derived from a particular phenomenon experienced by the individual. The reflective process along with participants’ experiences and perceptions assists with identifying specific points about a phenomenon that are idealistic, not empiric (Husserl, 1931; Moustakas, 1994). For these reasons, a qualitative study methodology, not quantitative, was more appropriate for this study. The use of phenomenological study is appropriate to extract individuals’ perceptions, interpretations, and lived experiences (Munhall & Oiler 1986; Tatano-Beck, 2011). Drawing the lived experiences from individuals may reveal feelings, ideas, and perceptions that may translate into descriptions of value created by the lived experiences (Munhall & Oiler, 1986). Appropriateness of the Study Phenomenology is one of several forms of qualitative design (Burns & Grove, 2010). Phenomenological research is applicable to nursing because this form of study uncovers the perceived experiences of individuals and, in this case, understanding the learning needs of student nurses. Nurses are social beings who must recognize the importance of individualizing interaction and knowledge about experiences that surround them. Heidegger (1962) focused on the importance of the participants’ concepts about the interview and responses to content questioning. Unlike a hypothesis, this pre-conceptual interpretation provides the basis for investigation about a certain phenomenon of interest (Converse, 2012). Special care should be taken to focus on the language, tone of a 90
response, emotional intelligence, and body language during the interview process. No individual’s response was the same as another’s, and because the interviews were conducted one on one, the participants revealed their reality during the process. Ironside (2001) emphasized the phenomenological approach to nursing research provides more than simple metrics; the methodology provides the researcher with a deeper understanding of the experiences of students and teachers. Student nurses actively and consistently participate in lessons using the three teaching strategies during the nursing program. Through active exposure to the use and familiarity of the strategies, validity to the student nurses’ perceptions of them increases (Ironside, 2001). Having had enough experience in participating in the three strategies, student nurses then develop a sense of effectiveness based on personal experience, knowledge gained, and learning achieved. Van Manen (1990) further described the individual’s experiences as equal to understanding the nature or the meaning of a phenomenon to be studied, which explains the rationale for the use of a phenomenological study in this study. Critical thinking is an abstract and non-concise concept that, as explained earlier, is difficult to teach and difficult to determine if it has been learned. Using interviews, the student nurses provided insight on the three strategies of inquiry, thus aiding the researcher to understanding of the study topic and the strategies with more clarity. The perceived experience of student nurses provided the researcher with data about each phenomenon and helped to answer the research questions (Polit & Beck, 2010). Through the intenders process, any unanticipated biases could be identified so they do not interfere with the interviewees’ ability to describe, interpret, and develop an understanding of meaning (Polit & Beck,
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2010). In this study, the perceptions of those experiences by the student nurses participating in the study related closely to the three strategies. Husserl (1931) described the transcendental phenomenological aspect of the desired study to be the understanding of the experienced phenomena as understood by the individual. This concept describes perspectives of idealism rather than pure fact (Husserl, 1931). Through the experiences, stories emerge as experienced by individuals (idealism). Themes and stories that emerge are personal interpretations of those experiences and provide supportive evidence of the common concerns and shared meanings of the experiences (Ironside, 2001). Mays and Pope (1995) avowed that qualitative forms of empirical study allow for coherent, believable, and plausible explanations about phenomena in a descriptive manner. Statistical quantitative data is not designed to provide any descriptive results and would not provide meaningful personally perceptive results. The critical thinking concepts for qualitative forms of study are abstract, individualized, and personally interpretable, necessitating a descriptive approach that can help provide insight on the studied phenomenon. Experiences provide the researcher with a clearer understanding of why something is as it is, and why something else is considered more desirable than another (Mays & Pope, 1995). This qualitative phenomenological study method provided a deeper understanding of the meaning behind the three strategies and why student nurses would choose one strategy over another strategy to enhance critical thinking. Moustakas (1994) validated this belief by advocating that an individual’s perceptions are dependable and verifiable (p. 50.) Personal experiences are comprised of mental acts that include presentations, cognition, and perceptions reflective of a specific phenomenon (Creswell et al., 2007; 92
Groenewald, 2004; Moustakas, 1994). Ironside (2001) explained that these personal experiences, themes, and perceptions provide clarity in materializing the experiences, perceptions, values, and beliefs of students and teachers. These perceptions and themes are formally known as phenomenological pedagogy. Qualitative phenomenological research is meant to explain the human experience, inclusive of personal perception (Tatano-Beck, 2011). Raw numerical data would only reveal the desired method, but not exacting reasons why the method is preferred (Ironsides, 2001; Tatano-Beck, 2011). Because learning is personal to the learner, understanding more about the studied phenomena would produce a deeper meaning, and not simple statistical facts (Husserl, 1931). Rationale for the Study This study was designed to extrapolate student nurses’ perceptions about the three teaching strategies as these strategies relate to individualized critical thinking learning and ultimately, the development of competent nurses. The future of nursing depends on the quality of graduates and their possession of solid critical thinking skills. Nursing educational leaders’ ability to embrace and prepare for upcoming changes will help improve preparation in academia and curricular delivery. Moustakas (1994) explained that populations chosen for study must have experienced those phenomena. Experience is an essential component for sample choice, which is why the researcher chose senior nursing students. In this case, the student nurses experienced each of the three strategies while in nursing school. Each student is an individual with different learning needs, skills, and experiences, and understanding how these unique needs will be met is a goal in the healthcare profession. Barnett et al. (2012) 93
explained the urgency in preparing undergraduate nurses for the challenges facing the nation is based on healthcare reform. The Pennsylvania Coalition for the Advancement of Nursing Education (PCANE) aligns with the future perspective of the National League for Nursing (NLN) and other governing bodies of nursing educational leadership. This alignment serves to help solve the predicted nursing shortage and produce competent registered nurses through seamless education (PCANE, 2012). Client populations are complicated, and hospitals are becoming increasingly overburdened with regulations and expectations, but the industry needs to fill vacant nurse positions. Nurses are expected to perform as knowledge-driven clinicians determined to help improve patient outcomes and the overall health of patients (Barnett et al., 2012). Predicted expectations will urge nurse educators to prepare student nurses for this reality as these student nurses will eventually become licensed professionals (Barnett et al., 2012). Not only are nurses expected to contribute to the transformation of the healthcare system, they are expected to serve as leaders of change to emphasize health promotion, disease prevention, patient understanding disease processes, and the comorbidities associated with disease (Barnett et al., 2012). These principles align perfectly with the Patient Protection and Affordable Care Act signed by President Barack Obama in 2010. Critical thinking is an abstract skill and understanding how individuals learn to develop the skill was the premise for the study. Because learning to think critically is an abstract science, teaching the skill is difficult to prove pedagogically and difficult to measure (Mulnix, 2012). No two individuals are alike, but understanding specifically which one of the three strategies is most effective can help provide insight about which strategy might work best. 94
This study yielded results that help nursing educators understand, possibly develop, improve, and alter strategies that enhance critical thinking in the classroom and clinical settings. The emphasis for this study was to understand, at a deeper level, the utility measure of each strategy as student nurses perceived them and the effect each strategy has toward student nurse critical thinking learning. By understanding this individualized understanding, nurse educators can support, expand, innovate, and develop newer strategies. Sample Population The population sample was senior level student nurses in an associate degree program at a local community college in southeastern Pennsylvania. No other students were solicited for this study. The demographics for this proposed study were incidental, and include, but were not limited to the following: gender, race, ethnicity, and age. Ages ranged from 20-40 years, gender was a non-factor, and participation was voluntary. Participant sample size was small. Twelve senior nursing students were solicited for this study through purposeful, purposive, and voluntary sampling (Langford, 2001; Moustakas, 1994). Polit and Beck (2010) explained that a qualitative research study incorporates smaller sample sizes to elicit in-depth information about a specific topic. Data saturation occurs at the point when no new information emerges or surfaces and generated themes begin to be repetitive and redundant. The phenomenological component of this proposal involved the perceived experiences of senior level associate degree nursing students who shared similar experiences relating to the three strategies.
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Demographic Variables The most significant demographic variable in this study was the participants’ ages. Age is important because of the relationship of age to learning ability. Nursing programs accept a wide variety of age groups, from post- high school to well over age 35; age is a potential factor when assessing teaching and learning. Charles (2012) explained the current mean age for registered nurses in 2012-2013 is 48 years of age, making age a definitive issue in nursing education. Hill (2010) corroborated this fact and emphasized the future need to fill the void of baby-boomer retirees leaving the industry, thus causing gaps in the nursing workforce. This study included a purposeful sample using 12 senior level nursing students in an associate degree nursing program. There are no other differential demographics included and no exclusions. Trustworthiness Houghton, Casey, Shaw, and Murphy (2013) stated there is an increased acceptance and recognition of the value of qualitative research in nursing. According to Lincoln and Guba (1985), previous terms such as validity and reliability have been exchanged for trustworthiness. According to Lincoln and Guba (1985), rigor in qualitative research is determined by the four distinct concepts enveloped within the trustworthiness concept. These four concepts are credibility, dependability, confirmability, and transferability. The blending of interview techniques and the qualitative design are intended to yield valuable information designed to help guide future nurse educators. Credibility is ensured through the structure of the interview process and the interview questions. Credibility for this study was attained through the believability of 96
the results, and the assurance that the intended focus for the proposed study was maintained (Whittemore, Chase, & Mandle, 2012). Moreover, credibility was achieved through conducting the research within a naturalistic setting, realistic manner, and demonstrating credibility through the results. Dependability was achieved through the stability and believability of the themes derived from the interview process (Houghton, Casey, Shaw, & Murphy, 2013; Lincoln & Guba, 1985). Confirmability was determined from the accuracy of the information obtained and how the data was obtained through using the interview technique and the pre-developed interview guide. Transferability will become evident when the information obtained through interview techniques demonstrates the ability to be transferred to a similar situation or context (Houghton et al., 2013; Lincoln & Guba, 1985). Credibility through triangulation is the most- important portion of a qualitative study, and for this proposal, triangulation occurred through involvement of the person conducting the interview, the different participants, the audiotaped interviews, the specific interview questions, and the literature (Houghton et al., 2013). In qualitative research, the researcher is considered the instrument. Credibility is determined by the procedural efforts and self-awareness on the part of the researcher (Houghton et al., 2012; Sandelowski, 2000). The interviews for this study were solely obtained by the primary researcher. All interviews were audio taped using a digital audio recorder. Interviews were conducted in a naturalistic setting that also allowed for confidentiality. Patton (1999) explained the analysis portion of a qualitative study involves managing the gathered information and conceptualizing the generating themes. The management of the related research study material helped to ensure the clarity and 97
soundness of the methods for gathering the information, analyzing the qualitative themes, and testing for validity, reliability, and triangulation. The credibility, trustworthiness, and competence of the researcher are also examined (Patton, 1999). This study followed all rules of research to reflect an honest process that yielded valuable information for future planning of nursing education. Using two outside observers confirmed the credibility of findings. Two experienced nurse educators validated the research process by reviewing the data collection and interpretive processes. The two outside observers are experienced nurse educators. Geographic Location Participants for this study were students at a community college located in Southeastern Pennsylvania. The college is county based and provides over 100 academic areas of study. The nursing program alone admits approximately 50-60 new students into the program each semester. During academic year 2011, approximately 252 students were actively enrolled in the nursing program; 60 of those in 2011 were senior level students (MCCC, 2012). For the purpose of the study, the participant sample included senior-level students. The study sample size was 12 participants. Purposeful sampling was the deliberate choice for this study because these participants can contribute to the inquiry necessary to gather data about the three strategies. Senior-level students were chosen for this study because they have experienced the three modalities during their progression throughout the program, can place personal educational value on the strategies, and are preparing to graduate. 98
Ethical Consideration An institutional review board (IRB) was solicited from a community college located in Southeastern, Pennsylvania. Proper forms and requirements were submitted to the college upon IRB approval to perform the study from the University of Phoenix and proposal committee members. All consent forms, documents, and proposal were submitted with the IRB application. Each confidential individual interview was taped and transferred as appropriate to be transcribed by the primary researcher. Informed consent was obtained from each participant. Creswell (2007) recommended all participants complete an informed consent form even if there is minimal risk from any harm or negative effect. Informed consent ensures that each participant understands the study, its rationale, and its goals. Informed consent included (a) voluntary participation clause, (b) confidentiality clause, (c) level of risk (low), (d) withdrawal clause, (e) no cost to participant, and (f) how nursing education would benefit from the study. Forms were signed and collected as appropriate, confirming the participants’ voluntary involvement as well as acknowledgement of their understanding of the participation criteria. Participation in the study posed little to no risk for participants. Data Collection Data was collected through semi-structured, digitally, audio-taped interviews. Creswell (2007) indicated that taping interviews are useful in any qualitative study. According to Al Yateem (2012), the interview technique used to collect data is a powerful way to understand people and perceptions. The main assumption in using an interview technique is that the interview technique produces realistic, accurate, and honest information (Al Yateem, 2012). Moustakas (1994) shared this view, but added 99
that when participants are in an informal, relaxed environment, they will become more expressive, open, and honest. Each interview took approximately 90 minutes and was audio taped and saved within the digital audio recorder. All interviews were conducted in a private room setting to maintain confidentiality. Participation was voluntary. Scheduled times for interviewer and interviewee availability were posted on the college’s Blackboard server site. Interview availability depended on the students’ schedules and availability. No one except the researcher and the participant were in the room. The room remained locked during the interview process, and there were no interruptions during any of the interviews. The audio information and content were the researcher’s responsibility; no person other than the researcher had access to the audio content. An interview process is the most common technique used to explore the essence and meaning of individuals’ experiences and is a powerful method to develop a deep understanding of a phenomenon (Qu & Dumay, 2011). The use of dialog and language are important for the interview process, but it is in the personalization of the technique that truly brings meaning to the research. Using a perception interview guide developed by Breckenridge in 1997, the interpretive method of inquiry can provide standardization of the interview process, thus preventing diversion from the topic of inquiry (Breckenridge, 1999). This approach for this form of research enabled participants to express information in response to a set of guided questions (Breckenridge, 1999). Phenomenological interviews tend to be informal and relaxed, thus fostering an inviting environment designed to encourage dialog (Moustakas, 1994). Broad forms of questions facilitate the expression of rich, meaningful, and substantive descriptions of the targeted phenomena (Moustakas, 1994). Qualitative 100
phenomenological research questions are open ended and inviting of reflection. Questions designed for the proposed study began with exploring how the phenomena (the three strategies) made the individual feel about the impact on individualized critical thinking learning. According to Creswell et al. (2007) and Groenewald (2004), questions beginning with words such as why, what, or how are appropriate to facilitate a deeper dialog. The modified interview structure technique included open-ended questions, clarifying questions, probing questions, and reflective questions. Analysis Once this study was completed, each confidential individual interview was individually transcribed. Interview transcription was completed immediately after the interviews, and the transcriptions were filed away as appropriate to maintain confidentiality. Participants joined in this study voluntarily. Data collection, sorting of data, and extrapolation of generated themes were performed using conceptual theme extrapolation applications through NVIVO 10 (2015). NVIVO 10 is a computerized application that sorts themes obtained through interview process, reflective journaling, and organized anecdotal notes. Common themes and perceptions derived from the interview process became apparent during the sorting process, thus aiding in the recognition of the saturated data. The digitalized audio taped data were transcribed and analyzed closely. File conversion from digital audio taping device to computer was achieved by the computer application known as Express Scribe (2015). Files were uploaded and then the transcribed data was uploaded into the NVIVO 10 system. Because the researcher is the instrument, any one of these can be employed to obtain information
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and credibility becomes the key component to the proposed study’s rigor and trustworthiness (Lincoln & Guba, 1985). All notes taken were handled professionally and confidentially. All information was taken from the site of the interview to the researcher’s primary residence where it was immediately stored in a locked, secured lock box. Only the researcher has access to the key. No one else will be able to obtain, handle, or touch the privileged information derived from interviews. The information was uploaded within 24 hours of each day’s completed interviews. The information will remain confidential and the sole responsibility of the researcher. All data and documentation related to the study will be stored for three years. These data will be locked in a lock box at the researcher’s office and will be destroyed after three years. Confidentiality Confidentiality and maintaining anonymity of participants in research are especially important. Confidentiality was established between the researcher and the participants at the time the meeting. Individual privacy was maintained using pseudonyms during the recording process. Making appropriate assurances about confidentiality is easier when the researcher’s intentions are clear and specific (Kaiser, 2009). For this study, the dominant approach, which is a common approach to protecting respondents’ identity in sociological paradigms, was used (Kaiser, 2009). Using the dominant approach, if collected data cannot guarantee anonymity, researchers must collect, analyze, and report the results without compromising the participants’ identities (Kaiser, 2009). The researcher’s purpose, how the researcher will use the study’s results, confidentiality, destruction of materials, and what the researcher hoped to learn from the 102
study were explained to all participants. This elemental part of procedural ethics prevents any ambiguity and misunderstanding between the researcher and the participants (Kaiser, 2009). The act of protecting interviewees was performed using pseudonyms as a means to maintain participant’s confidentiality because the participants' names cannot be divulged. The researcher protected participants’ privacy during all phases of the study. Preventing Bias Bias is an error that occurs when researchers knowingly or unknowing introduce preconceived notions or judgments into a study (Pannucci &Wilkins, 2010). Bias was prevented for this study by not interviewing students this instructor has taught in past semesters. For this purpose, the researcher has not participated in any clinical rotations and has not had intimate knowledge of or extensive exposure to student populations. No sampling biases were evident in the study. Participants were student nurses at senior level who had limited exposure to the person performing the proposed study. Participants were apprised of the need for complete honesty in their responses. The researcher was looking for stories, revelations, anecdotal responses, feelings, and perceptions. The researcher did not possess or emanate any biases for this study because of randomization of sampling, and participants were not pressured or coerced into participating. Al Yateem (2012) emphasized the potential for participants to try to please the interviewer during the process by giving the interviewer what they think the interviewer desires to learn. This form of bias was avoided through semi-structured interview questions and the lack of familiarity between the interviewer and the participants (see Appendix A: Interview Guide Questions).
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Conclusion Chapter 3 contains an outline and explanation of the procedural implementations for this study using phenomenological design to examine the lived experiences of seniorlevel student nurses who have been taught using the three specified strategies: journaling, case study, and simulation. Chapter 3 contained information about the study design, the sample, and geographical location, methodology for data collection, confidentiality, and rigor of this qualitative study. Chapter 4 includes results from this proposed study and analysis of those results. Chapter 5 will reveal results and conclusions that will be derived from the study.
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Chapter 4 Findings The purpose of this study was to determine how students in an associate's degree nursing program perceived the effectiveness of three strategies - case study, journaling, and simulation - in influencing their critical thinking abilities. The three specific strategies included journaling, case study (seminar), and simulation. This chapter includes a presentation of the findings of this qualitative phenomenological study exploring senior-level nursing students’ perceptions of the three strategies as related to individualized critical thinking learning. Data Collection Process Solicitation for senior-level student nurse participation occurred as soon as the researcher received permission from the University of Phoenix IRB and Montgomery County Community College. The researcher notified the college nursing faculty, the nursing program director, and the Dean of Health Sciences of the general premise of the study and the researcher’s purpose for the study. The researcher posted a generic solicitation letter of study intent on the college’s nursing Blackboard site (Appendix B) upon receiving approval from the college nursing administration, near the end of the 2015 summer session (Appendix C). The solicitation letter remained on the college nursing department’s Blackboard site into the fall semester. Desire to participate was completely voluntary. Communication occurred through email and personal cell phone conversation. The volunteer participants and the primary researcher agreed on dates and times for interviews (Appendix D). Mondays were reserved for the interviews, although the researcher afforded additional dates and times to the senior students based on their 105
availability and convenience. All interviews were conducted individually in a private office space. Nursing faculty granted clearance to use office space without difficulty. The researcher and participants met at an agreed upon date and time. The researcher met each participant in the private office, explained the informed consent form, witnessed them signing it voluntarily, and retrieved the form from them. Data collection was performed using a hand-held digital audio recorder. The researcher anticipated the interviews would take approximately one to one and a half hour to complete; however, for this study, each interview took approximately 25 to 45 minutes. Ultimately, the primary researcher was able to secure 12 interviews. Saturation of data became evident at approximately the ninth interview. Despite recognition of possible data saturation, the primary researcher continued to collect interview data to increase the sample size because the length of the interviews did not meet the originally intended time allotments. Once each separate interview was completed, each audio file was immediately uploaded to the researcher’s private computer through a software system called Express Scribe (2015). Through the Express Scribe (2015) computer application, the transcribed files were converted to appropriate file formats, and uploaded to the data collection application. Transcription proved a tedious process and required more time than anticipated. Each transcription consumed approximately one to two hours. The researcher read the transcriptions multiple times to search for repetitive themes and ideas. The researcher cross-referenced each taped interview to ensure the material’s accuracy. Once the researcher was satisfied the transcriptions were accurate, the information was uploaded to
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the researcher’s computer. The researcher then uploaded the transcribed information into a data analysis system specifically designed for qualitative forms of study: NVIVO 10. Upon completion of uploaded transcriptions, the researcher used the data analysis software NVIVO 10 to organize, identify, and isolate common themes derived from interviews and student nurse perceptions. Each transcribed interview was carefully read and themes generated were categorized using labeled nodes. Identification of themes and ideas occurred after each transcription was read multiple times. Theme code organization within the NVIVO 10 program proved simplistic yet complex. By using the perceptive guide questions, the researcher was able to glean themes from the transcribed information. Each transcription was read four or five times in order to develop a deeper understanding of each student nurse’s perception responses. The transcribed information drove the code identification. The nodes were grouped based on category: case study (seminar), journaling, and simulation. From those points, themes obtained from the transcribed information provided the direction for development of related child nodes and unanticipated themes. By using Nvivo10 software, the researcher uncovered six main codes (See Table 2 below): a. Case study b. Critical thinking c. Journaling d. Preferred strategy and why e. Simulation f. Non-preferred strategy and why 107
Once codes were added, the transcripts were individually reviewed. The researcher added sub-codes when themes showed patterns. During the review process, the researcher dragged specifically identified themes into the assigned designated code using a drag and drop method. Using a drag and drop method of adding transcribed information made the manual categorical process easier to manage. During the review, three distinct themes surfaced in saturation: instructor impact, personal impact, and time impact. Other themes arose during analysis that did not meet categorical definitions: the researcher placed these outliers in the miscellaneous category. Table 2 NVIVO codes and sub-codes Code identification Case study
Sub codes Challenges Positives
Journaling
Challenges Positives
Simulation
Challenges Positives
Critical thinking
Case study Journaling Simulation Personal definition
Personal impact
Case study Journaling Simulation Non-specific personal impact
Time impact
Case study Journaling Simulation 108
Table continued Instructor impact
No sub-code
Miscellaneous
No sub-code
Descriptive Findings and Themes To describe senior level nursing students’ perceptions of the three strategies relating to individualized critical thinking learning, 12 senior-level students voluntarily participated in one-on-one interviews. The research questions guided this study included: RQ1: What are the lived experiences of nursing students at an associate degree nursing program in Southeast Pennsylvania? RQ2: How do nursing students perceive the three teaching strategies (simulation, seminar (case study), and journaling), as each influences individualized critical thinking learning? Research Question 1: What are the lived experiences of nursing students at an associate degree nursing program in Southeast Pennsylvania? Audio-taped perceptions of senior students’ experiences throughout the program provided anecdotes about the participants’ lived experiences in the nursing program. During the audiotaped interviews, participants’ opinions provided a clearer picture of the impact the three strategies had on learning. From the very beginning of nursing school to the end, students’ perceptions placed value on the three strategies as each facilitated or did not facilitate critical thinking acquisition. Research Question 2: How do nursing students perceive the three teaching strategies (simulation, seminar (case study), and journaling), as each influences “individualized critical thinking learning”? Descriptive categories were derived from 109
the perception guide questions. The first group of open-ended questions included the following:
Please share your feelings about what case study (seminar) means to you.
Please share your feelings about what journaling means to you.
Please share your feelings about what simulation means to you.
Please share with me your perceptions and your feelings about which strategy you may or may not prefer and why.
Please share your feelings about what case study (seminar) means to you. A variety of answers emerged from this question. Many students referred to case study as seminar more often than not. Participants defined case study as “a real life example of a patient case”, “comprehensive client case”, “the whole big picture”, “I got more value out of, like, the critical thinking part of the case studies”, or “real patient example”. One student explained, I like seminar because it helps me think through what pieces of information that I should focus on and what information is just kind of extraneous information that while I might not want to disregard it, it's not critical to me diagnosing, giving a nursing diagnosis for what I need to do. For this particular student, the case study provided a larger view and helped to pave the nursing care pathway. Furthermore, the same student expanded on the view. It really does help me understand the whole pathophysiology of what's going on and then understanding how we need to give the kind of treatment based on what the medical diagnosis is and what we should be doing in terms of a nursing diagnosis to support that. 110
Another student stated, “in the lower levels, case study and seminar helped me learn critical thinking techniques.” Reiterating Benner’s (1991) novice-to-expert theory as one that is progressive, one student recognized personal growth in critical thinking as follows “I think as the semesters have progressed, I have become proficient in critical thinking, and that's how I think on a daily basis now.” Benner et al. (2010) maintained that critical thinking is not easy to teach; in fact, teaching critical thinking is very difficult to do. Additionally, Benner et al. (2010) reiterated that critical thinking is very difficult to validate; however, during the interviews, the themes were clear about the positive correlation between case study and critical thinking. The experiences of student nurses for this study helped to answer RQ2 about the critical thinking teaching strategies the student nurses perceived were most effective and why they perceived them that way. One student in particular correlated the strategy directly to personal critical thinking by noting, “I found more value in having to really take the true case study from a critical thinking aspect. So I think the case studies and the seminar work definitely help to develop critical thinking skills.” Please share your feelings about what journaling means to you. Journaling is a frequently used strategy in many professions to facilitate self-reflection. Husserl (1931) defined journaling as reflective thought about a phenomenon or situation. The majority of students interviewed believed that journaling strategies are intended for self-reflection, but at the same time, the strategies were scripted, thus minimizing the ability to selfreflect. During the interview process, interviewees expressed the general theme about the purpose of journaling is to reflect on the practices that occurred on any given clinical day. Understanding the value journaling practices have on student nurse learning can provide 111
a direction for future use. Through students sharing experiences about their perceived values of journaling, nursing academia may begin to see the journaling practice in a different paradigm. One student’s experience with journaling as a strategy stated journaling is a way to “vent about your day if something interesting happened, if you made a mistake maybe and you're kind of upset about it. You just get to kind of talk and about how your day went. I think it's like therapeutic. I like journaling.” Another student commented, “I would say the journaling probably would give me the most challenges because I mean you're evaluating yourself.” This student described the journaling as “challenging” but “great.” Others perceived journaling as a “waste of time” or “busy work.” One student expressed experiences of journaling as “doing things that just fill time rather than a productive towards my learning.” Very few students perceived journaling as intimately connected to critical thinking learning. While students the previous paragraph acknowledged the connection between critical thinking and journaling as beneficial, most students viewed the strategy as a way to vent frustrations. The term “therapeutic” was used a few times to describe the personal value journaling had on stress reduction. One student wrote about journaling as a way to purge feelings but never went back to re-read journals as a way to judge personal growth toward critical thinking acquisition. A few students expressed the lack of purposeful retrospective review of their previous journals. During the interview process, student nurses’ perceptions negated the belief that periodic review of logs and journals may help facilitate critical thinking learning. Students who do not see value in the exercise will not experience this growth in personal critical thinking.
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A few students expressed an inconsistency in instructor feedback during the journaling process that devalued the strategy. Feedback is necessary for growth. Students explained what was expected during the journaling assignment. Students commented: Instructors would just give a checkmark, so there wasn't much feedback on it
It didn't seem to matter if you were putting in a lot of effort and really trying to think critically about what had happened during your clinical experience
Once I realized that the people were reading it, and really going through it, and trying to help me develop as a nursing student, I started putting in additional information and time, and really started reflecting on how my clinical performance
It really makes you think about your day and kind of like examine things that you didn't think about during the day you have time to kind of sit down and like go over your day. And it like brings out stuff that you may not have thought of before.
Others described journaling as a “great way to reflect on what you did; good or bad,” “therapeutic,” and some would rather “have that dialog learning rather than sitting by myself at home on a computer writing it.” Most students expressed a positive perception of journaling, but also expressed inconsistency in instructor expectations. Some instructors followed the template for journaling while others wanted reflection, lab 113
work, and pathophysiology. “Journaling helped me tie together pathophysiology and it’s what the instructor demanded, so I had to deliver. That really helped me to learn.” Clearly, journaling is valuable; however, inconsistencies limit the value because not every student benefits from the strategy on the same level. Despite some negative or undesirable comments, journaling was described as necessary for reflection and “recollection” of the shifts events. This description coincides with industry definitions (Dwyer. 2012). Please share your feelings about what simulation means to you. In order to describe the perceptive value of simulation, the researcher asked students to describe experiences throughout their nursing program progression. Perceptions of simulation varied greatly. Some students enjoyed the experiences of using simulation while others expressed disappointment in the strategy. One student stated, “the simulation was not really what I expected. It was, I mean it was okay. It was all right. But do I think it like is gonna help me like in a real life situation? Probably not.” Another student stated, “simulation has guided my confidence and made me feel I can do things like care for patients. Performing and doing things, not on real patients so we don’t make errors and potentially hurt people.” A third student said It is an opportunity for me to have very real life situations controlled by my instructors that guide different scenarios. It is very realistic that you have a patient code and it's not something I've lived through in real life but having done it in simulation with the guidance of my instructors has given me the confidence that in the case of it happening I have seen a similar situation. I think being able to
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physically hands on do something rather than learning it in lecture are very different things. The interviews indicated most students saw tremendous value in the strategy but also expressed doubts about the value of simulation towards personal critical thinking learning. Reservations expressed included the inconsistent use of simulation throughout the degree program. Some students even stated they “never had” an actual simulation. In fact, a few students expressed that “They kind of hype it up to be this big deal,” but it did not meet personal expectations. A common theme coming from interviews is that simulation is “nerve wracking” and anxiety producing. Comments made about having to “perform” in front of peers and instructors put the students on the “spot,” thus producing extreme anxiety and fear. Roy (2014) found students described the use of sim as “anxiety producing” and “awkward.” This complaint about feeling anxious during simulation is common across the literature. These feelings may certainly effect participation and learning absorption. There are many reasons for these fears, including past experiences, both negative and positive. This finding is not a significant one; however, understanding the impact that experiences have on personal learning could affect the perceived personal value in relation to critical thinking learning. A few students expressed the lack of realism in scenarios resulted in little learning, if any. Roy (2014) studied student nurse perceptions of simulation in a similar form of research study and received similar comments. Roy’s (2014) study alluded to students perceiving the lack of realism of simulation. Findings from interviews from the current study also revealed students believed simulated activities were not real enough, were too scripted, and the ability to use the simulators varied among instructors. Students 115
offered several reasons for this perception. The perceived inconsistency with faculty competency levels and comfort levels of implementing simulated activities was of real concern among students. Some students felt the faculty members were either very prepared or comfortable, or not at all. Students explained that if simulation is going to be used consistently, then all instructors should be prepared the same way and possess the same skill level. A few students felt the instructors did not seem to know what to do, so they talked the students “through the simulation” and that lessened the overall value the students perceived of the experience. Other instructors were overly confident and competent in the strategic use of simulation. As a result, the disparity caused confusion between clinical groups because some instructors were competent and others were not. This situation led to inconsistent experiences across the different groups. Some students were not correlating the activity with a simulation because the students perceived faculty as telling them what to do, rather than allowing the students to act out activities. Despite concerns over the use of simulation, authorities in nursing foresee it will only become more widely used in nursing programs in the U.S., thereby necessitating training faculty to be more competent and confident in its use (NLN, 2011). However, understanding challenges that face industry leaders such as faculty shortages, diminished availability of real life clinical sites, faculty preparedness, and faculty skill level have raised questions pertinent to the expanded use of simulation (NCSBN, 2014; Suling, 2008). Some students thought that simulation was valuable. Students expressed enjoyment of the experience by showing others what they know as well as demonstrating their skill level and critical thinking skills. A few students wanted the chance to practice 116
more and be offered more preparation for simulated activities: “we didn't get to practice,” “I really wish we had the chance to go over it first,” “wish we could prepared beforehand,” and “wished we had more time in the lab to practice.” Students equated the lack of preparation and familiarity with the simulated activities to personal anxiety levels. “I felt stressed because I was not prepared,” “did not know what to expect,” “I panic,” and “I get anxious.” When I mention the term “critical thinking,” please share what that means to you. Understanding student nurse perceptions of the term “critical thinking” is extremely important for this study. Specific for emphasis is the basic definition of critical thinking as student nurses define the term. The interviewed students defined the term critical thinking in a variety of ways. Reflections revealed commonalities in students’ themed definitions of critical thinking. One student expressed critical thinking as “a way of thinking that encompasses all things that are involved, not just one particular route or answer or thought. It’s kind of cause and effect but not just one effect.” Other students expressed critical thinking as “comprehensive,” “a way of thinking and dissecting the problem,” and “walking through the steps until you can figure out what the actual true problem is.” Other participants defined critical thinking as “applying everything to come up with a solution,” “to apply knowledge,” the “whole big picture,” “drawing a connection, or making a connection.” Collectively, students expressed the concept of critical thinking as problem solving and solution seeking. These statements validate that students understand the essence of critical thinking. This question helped the researcher understand the participants perceive critical thinking as a comprehensive process, not a task. Understanding the student nurses’ definition secured the knowledge of what the 117
term “critical thinking” means for individualized learning. In turn, this definition helped the researcher understand student nurse perceptive beliefs about the different strategies in relation to critical thinking. In other words, obtaining the participants’ definition clarified the researcher’s understanding of their beliefs about the conceptual boundaries of critical thinking. Students defined the term “critical thinking” in many ways. Examples included “whole big picture,” “comprehensive,” “everything about a patient,” “drawing that connection” to deeper explanations such as the following: Critical thinking means that there's not – just – there's not one answer. It means pulling on – drawing on all kinds of different information and putting it together like a puzzle, making it fit together. I think critical thinking really means take what's in your textbook, but don't stop there.
Critical thinking means translating what you learned in class into a practical setting. Later on when we got into the second and third semesters, we were learning about different conditions in class, and we actually saw those conditions in the different units that we were in. And we could start applying some of the concepts we were learning, and knowing about different labs that we needed to look for. One student elaborated on the understanding of the term from the beginning of the nursing school journey until current, as a shift in understanding by noting, “previously, if you asked me what critical thinking would be I would've thought it was like multitasking or how can I get this done first.” 118
This evidence helped explain the accumulation of knowledge from a starting point to an end point and proves growth progression and learning transition. Based on responses, students have a basic understanding of what applied critical thinking means and how to apply critical thinking skills. Please share with me your perceptions and your feelings about which strategy you may or may not prefer and why. Participants expressed strong feelings about all three strategies. Out of the 12 students interviewed, nine participants expressed simulation is a more valuable strategy than journaling or case studies. Another student placed the strategies in order of personal importance “sim was the best, seminar was the second best, but I think the first half of seminar is better than the second half. And then journaling.” Despite the challenges associated with simulation, the strategy is very effective if done correctly per the interviewed students. Comments and terms such as “hands on experiences,” “mimicking real life,” “real life situation,” and “allowed me to gather my thoughts like, OK, this is what I need to do” support this assertion. One student stated that simulation was “critical for me,” “hands on,” and “makes me think quickly and on my feet.” Despite the anxiety, fear and apprehension associated with simulation, the majority of interviewed students celebrated simulation as the most preferred strategy. Students who liked the premise of simulation expressed their desire to have it incorporated as a more consistent part of the curriculum. Some students emphasized the irregular use of simulation throughout their degree program. Essentially, students believe simulation would have a more positive effect on their learning if it was offered consistently and they had the opportunity to prepare for the activity. One student 119
expressed that preparing for the simulation in advance would facilitate personal critical thinking learning. In addition to the increased availability of simulation, as mentioned previously, students also mentioned the inconsistent level of preparedness of instructors. Students shared that all instructors should share the same comfort level and level of skill in executing simulation effectively. One student commented about the effect of instructors: The recent simulations we had were through our seminar instructor, which was different than earlier, when we would do it through a lab process. And so our seminar instructor had us do a full sim lab, but some of the other people had different seminar instructors, and so they chose what they covered during that time. Secondly, case study proved a very strong strategy and journaling as third. Case study was celebrated by most students as extremely valuable; however, overwhelming in preparation. A few students expressed that the information required to prepare for seminar (case studies) had little effect on personal learning. They were armed with facts but did not know what all of the facts meant in relation to the case study. Facts are beneficial when you understand what these facts mean. Students shared that the case study strategies were very intense and full of facts but contained no tangible explanations. In essence, either a student put the facts together and understood them or they did not and had many questions. Students usually described case study as very valuable, but “time consuming,” “I need to do a lot of research,” and “dependent on the instructor involved”. Students expressed the importance of case study as tangible and “extremely valuable,”
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but with inconsistencies similar to those of simulation. A large majority of interviewed students repeated this theme. Time Impact Because of the interviews, the researcher recognized the impact to students, which led to the added category of time impact in NVIVO. Students expressed that the time element for case study preparation was necessary but very labor intensive. Students made several comments about time in relation to case study preparation: “I think the challenge for seminar is just the efficiency. Like you’re learning things, but the amount of time that you're spending learning them is ridiculous.” In regards to time, one student stated the following about journaling and time: “I don’t like journaling.” Another student expressed discontent with journaling as “I hate using the word waste of time, but I’d rather have the “opportunity to have a dialog” with an instructor than sitting at home typing, so dialog is much more beneficial than a one-way answering of questions.” Preparation and time consumption was a common emerging theme from the interviews: “The time that it (seminars) takes was the most frustrating thing for me” and “They (seminars) weren't my favorite thing to do because they were very time-consuming.” Two participants commented: The seminars could be a little shorter because 25 to 30 questions sometimes is a lot. But I don't think there's any questions that are, like off the wall. They become a little more busy work in my mind, giving me 35, 40 questions to answer that are not necessarily all critical thinking based. An English-as-second-language student commented on time issues:
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English is my second language, so I think slower. I think I do slower, so it's very, very time consuming, and I have to read for different kinds of book and sometimes the Internet. Student perceptions about the effectiveness of journaling also led to the same conclusion about time constraints. The students shared feelings about the laborious work done to prepare for journal submissions as “meaningless” because instructors provided little to no feedback. Students explained that instructors left checkmarks or wrote very little, communicating a message that the journal was not valuable. Because participants perceived their instructors did not value journaling, the students did not value it either. Most of the students who mentioned inconsistencies in meaningful instructor feedback felt that feedback is imperative to a student’s progress. Text frequency for the following words was generated through NVIVO coding. A query for the most frequently used words for time impact relating to case study revealed the following: Table 3 Word Frequency Word Like Just Think Time Really Feel Seminar Thinking Action Questions
Length 4 4 5 4 6 4 7 8 4 8
Count 530 430 367 307 224 214 210 175 169 149
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Weight 3.24 2.63 2.24 1.88 1.37 1.31 1.28 1.07 1.03 .89
Instructor Impact Another factor affecting the preference of strategies included instructor involvement. Seeing this emerging theme led to another NVIVO category of Instructor impact. Students not only explicitly expressed personal desired strategies but also expressed their belief about whether instructors used the strategy correctly or incorrectly. One student expressed the following about seminar: “I don't think that the teachers are not on the same page with seminar.” This theme was consistent across all of the strategies. In simulations, the students felt that the instructors had different levels of competence, comfort, and skill. “I just think that everyone really needs to be on the same page.” Participants shared the same disappointment when they described how instructors used journaling. Specifically mentioned were key pieces pertinent to the journal requirements. Students defined journals as a strategy used to reflect about a particular clinical day’s events. Journaling includes honest personal reflection that is meant to promote personal and professional growth. Two students expressed the belief that some instructors punish students for truthful reflections about events that occurred during the clinical day. The same students described the journal remarks as negative and subsequent clinical warning as “punitive.” A clinical warning is a written document used to serve as remediation for students’ inadequate progress toward a goal. If journals are meant to express reflection, either good or bad, then reflection can be used effectively as an auspicious strategy to solidify learning. Three of the 12 students interviewed felt that if they expressed in their journal that they made a mistake, the instructor would use the opportunity to punish them. This feedback influenced students’ feelings about reflecting honestly. Students expressed 123
discontent with the journaling process because five of the12 participants felt the journals did not promote true personal reflection. A few students explained that requirements are too succinct and scripted based on the three roles of the nurse; provider of care, manager of care, and member of the profession (MCCC, 2013). Instructors had “different expectations” and some “didn’t even follow the requirements.” One student explained frustration as “the difference in the expectations from level-to-level and instructor-to-instructor has been very frustrating for me.” When referring to journals, students believed they were “fulfilling the journal requirements similarly every day” but also felt instructors had different expectations that occasionally or often made journaling difficult. Students shared other sentiments about instructors’ varied expectations for journaling, such as instructors wanting a “reaction of the day type of thing that I go through and just kind of spit out anything that happened” and requiring a more elaborate “reflection of what my day was like.” Moreover, four students described the journaling experience as “a sheet you fill out that you kind of follow the prompts, a redundant exercise about the roles of the nurse and how we fulfill those roles but at the same time, I feel like there are more important things that need to be addressed.” Participants consistently avowed that explaining the scripted questions about the three roles of the nurse was redundant and unproductive. However, despite what students perceived as scripted, the journals contained an area for the students to reflect on the day’s events, including what went well and perhaps what did not go well (MCCC, 2013). Nonetheless, students’ perception that noting daily events honestly could mean repercussions for them meant journaling was not a very celebrated
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strategy for learning how to think critically. Students made several comments on the nonreflection of journaling: The journals I can recall having to do, there were specific things that had to be mentioned, and I almost felt like I was writing to just achieve or to put what they were looking for as opposed to a true, absolute personal journal where you're putting your feelings and things like that
I'm trying to think about these journals. And I know care planning is important, but putting them in a journal – I guess it makes sense because you have to critically think when you're writing your care plans and what you're gonna do for your patient. But I think when people hear "journal," they think of feelings and reactions, not a clinical journal ‘cause that's hard to do. It's hard to separate, like, what you did , how you felt about it, was it appropriate, was it not, so that can get kinda frustrating. Personal Impact Some of the interviewed students discussed critical thinking learning on a personal level. “I feel I have grown into this competent nurse.” The nursing school learning experience has afforded personal “confidence” that “carries me through.” One student applied her learning as a family assessment tool. The same student surmised, “nurses who are family members frequently get consulted for help.” The personal learning progression was so valuable to this student that she celebrated her application of its use to her own world. Some students expressed the belief that nursing school changed their way of problem solving and viewing the world. Two responses demonstrated just 125
how profoundly the strategies influenced students on a personal growth level as a proficient and confident nurse who “can go out and practice” and “do a very good job.” Other students expressed, “the component of the confidence and in conjunction with the skills I've developed from that critical thinking has pushed me through a very tough program” as well as I know I do this in my personal life with family members. I apply it, and I'm right in my thinking, so that just validates for me that I'm critically thinking effectively for me to understand it, not for anybody else to explain it to anybody.
I was at Panera Bread, and I diagnosed somebody with Parkinson's. In my mind, I was sitting there, and I was like, he's got the tremor. I can't even go through a normal day without critically thinking. That's just a nursing student thing. Word frequency between instructor impact and personal impact was performed using NVIVO 10 software. Percentages revealed the following words as frequently used to describe a cross comparison. The word personal was used most frequently (7.69%), followed by extensive (3.85%), discrepancy (3.85%), critically (3.85 %), and challenges (3.85%). When examining word frequency in the instructor category alone, the following words were used by students frequently to describe the impact the instructors had on personal learning. These included like (2.42 %), think (1.92 %), thinking (1.33 %), know (1.26%), and critical (1.17 %). This result infers that across the interviews, students had similar experiences about instructor’s impact and personal impact.
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Cost Considerations Cost and equipment repair were mentioned several times as student concerns. Some students felt the equipment was old and outdated, thereby resulting in a less than appealing experience. One student expressed discontent by stating, “the mannequins seem outdated and in need of repair”, while another acknowledge the potential costs by stating, “I can see how it's expensive to maintain (the mannequins) because it's hard to have staff to oversee it over time and the various equipment necessary to use.” Other students often did not express this concern; however, one student expressed a concern about cost and efficiency: Sim mannequins that we have here, are very slow to respond, which made it difficult to really feel like it was a real situation. Even the last sim test that we did, the mannequins and the sim models weren't really the ones responding. It was actually just coming from an instructor, and I think had we had started using simulation in the earlier semesters, I think that could have really been beneficial from a learning standpoint. Summary Chapter 4 covered much of the descriptive responses as directly quoted by the participants. Responses were honest and delivered in a sincere manner. The information derived from the interviews provided the researcher with solid takeaways. The importance of students’ feelings and perceptions about their experiences is validated through the very open and unanticipated responses.
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Chapter 5 Discussion The purpose of this study was to determine how students in an associate's degree nursing program perceived the effectiveness of three strategies - case study, journaling, and simulation - in influencing their critical thinking abilities. Many professionals in the nursing field and nursing education explain critical thinking is an arduous process (Benner et al., 2010; Facione et al., 2007; Tanner, 1997). Each individual learns differently, thus making the delivery and validation of critical thinking education difficult (Benner et al., 2010). Developing a deeper understanding of what students believe helps achieve personalized critical thinking will help academia make sound judgments about what to change and what not to change in strategy and tactical delivery. Research Question One: What are the lived experiences of nursing students at an associate degree nursing program in Southeast Pennsylvania? The researcher in this study explored the perceptive experiences of student nurses in using the three aforementioned strategies during an associate’s degree nursing program. Exposure to these strategies happens throughout students’ progress through the nursing program, which explains the lived experience during the academic progress from beginning to end. Senior students can articulate the progression and the assimilation of learning and skill acquisition along the novice-to-expert continuum. (Benner, 1991) as the novice student to expert student regarding personal intake of critical thinking pathways. The researcher sought to understand how the students learned to think critically during their educational journey. Experts in the field have explained validation and provisional pathways in the application of critical thinking as difficult to execute and 128
difficult to validate (Benner, 1991; Benner et al., 2010; Tanner, 1997). Critical thinking is applicable in every aspect of life and every profession, including nursing (Bodin, 2012; Facione, 2007). The improvement of critical thinking skill acquisition in nursing is urgent as the nation approaches industry vacancies as echoed throughout the literature. This urgency is extremely important for future healthcare practice and nursing care delivery (AACN, 2014; IOM, 2011; NLN, 2003, 2011; PSNA, 2010). Predicted workforce challenges call for a consistent, effective and measurable way to effectuate critical thinking skill acquisition in nurses entering the profession, satisfying the nurse workforce deficit that is predicted by 2020 (AACN, 2014; IOM, 2011; NLN, 2003, 2011; PSNA, 2010). Nursing education must work smarter to fill a necessary void. Research Question 2: How do nursing students’ perceive the three teaching strategies (simulation, seminar (case study), and journaling), as each influences “individualized critical thinking learning”? This research question represented the core of this study. Understanding how each of the three chosen strategies affected “individualized” student nurse personal “critical thinking learning” was the desired outcome. For the researcher to understand that point, she first had to understand how the participants define and understand critical thinking The participants’ definitions fit well with global definitions. Key terms such as “the whole big picture,” “comprehensive,” “entire,” and “everything” pointed to student nurses’ understanding of the critical thinking phenomenon. The information gathered through the interview process provided the researcher with tangible understanding of the students’ definition of critical thinking. Students do understand that critical thinking is more than simple deployment of treatment regimens, 129
corrective measures, and interventions. Solid critical thinking correlates with better results and better patient outcomes (AACN, 2014). Students had varied experiences with each strategy. Students expressed that none of the three strategies was perfect for learning critical thinking. Although students had preferences, there were also reservations expressed about each strategy and how students felt things could be better. Developing connections to patients, disease processes, treatments and outcomes are not innate to individuals. These skills and abilities are taught, fostered, and facilitated throughout the nursing school curriculum. These abilities are also validated periodically during the nursing school process, which is why the researcher focused on them in this study. Critical thinking is pivotal to the nursing profession and can mean the difference between performing the correct action in response to a patient’s presentation versus an incorrect action. Variations in delivery, validation, and execution can affect students differently. Education should be delivered consistently from semester to semester, from year to year, and from instructor to instructor. Variations fragment the teaching and learning processes, which is another reason that education should be succinct, prescriptive, and predictable. Instructor Impact Students told stories about the instructors’ impact on their personal learning and how the instructors’ involvement or lack of involvement directly influenced their learning. Because students view instructors as expert practitioners who help students learn how to be nurses, the feedback received from instructors provided important information. Across all three strategies, students revealed details that affected personal learning and perceptive experiences considerably. Students felt that although the 130
instructors were knowledgeable, instructors delivered content differently and inconsistently. Students from various rotations often made comparisons about the different experiences that occurred across the rotations and often had conversations about those comparative differences. Three out of the 12 participants felt that certain instructors demonstrated strengths in specific areas and weaknesses in other areas, and that this disconnect was very apparent, thus offering students different learning experiences. Information obtained in this research study revealed many students desired to receive the same experiences as others; the students recognized that alignment across the rotations is important for consistent delivery of the education. Case Study Students expressed that case studies were extremely helpful in the critical thinking process; however, instructors would not only facilitate seminars differently, but students would oversee sessions differently. As a part of seminar, students serve as facilitators. A few students expressed a discontent with this role because the facilitating students could not satisfy the answers to questions skillfully and confidently. Students expressed that instructors should be available to interject input, feedback, direction, and information to help students connect different concepts. Students expressed that some instructors did not always contribute to the discussion, perhaps because the instructors also did not know the answers to the case study questions. Students expressed during the interview process that the information obtained for seminars was overwhelming and preparation was immense; however, having a consistent process from week to week would help link concepts together. Instructor inconsistencies caused confusion that affected personal learning. Case study is revered as a great way to analyze real life situations, so this coincides with much 131
of the recent literature about the value of case study as a reliable and effective strategy. No literature was discovered about student nurse discontent with the overwhelming amount of content. Case studies developed from real life situations provide students with situations analogous to real life (Woods, 2012). These studies are dissected and analyzed and can provide students with valuable lessons on pathophysiology, clinical situations, patient assessment, and intervention. Despite the valued perception of case study to critical thinking learning, a few students felt they could not effectively draw conclusions from the large mass of information presented in seminars. Students had difficulty fully connecting concepts, resulting in a less effective critical thinking experience. Students expressed that time expectations for the preparation for seminar was overwhelmingly consistent as “time consuming.” Students felt that too many questions to prepare made the activity less meaningful because essentially, students were just regurgitating material to look prepared, but did not necessarily understand everything that was logged on the case study/seminar template. This activity was related to having all the facts but lacking the ability to make sense out of all of the facts. The idea behind the seminar strategy intrigued the participants because these case studies were based on real situations that interested them. When students made connections and acquired clearer understanding of the material, they felt that seminar (case study) was extremely effective. Instructor alignment again was mentioned to ensure student nurse experiences as similar for consistency. Journaling Instructor expectations for journaling also proved challenging for many students. Journaling was not the participants’ favored strategy for several reasons. Students noted 132
the inconsistent expectations of the journaling process from semester to semester. Although the objectives in the syllabus explained the expectations, students found instructors had different personal expectations and those superseded the ones noted in the course syllabus. Reflectiveness was also varied or restrained depending on the instructor’s preferences. Blake (2005) and Kuiper and Pesut (2004) avowed deep reflection is similar to a story that stimulates thought. Furthermore, deep reflection improves cognition and motivates healthy, self-evaluation that is important in personal growth. A few students described the journaling process as “punitive” and subsequently, students would not reveal true inner feelings or incidents they thought were profound enough to affect their personal learning. A few students expressed reservations about being transparent because instructors would punish the honesty and dismiss it as being “unsafe.” This fear inhibited honest expressive reflection and subsequently minimized the strategy’s effectiveness. A few students expressed the belief that true journaling allows for reflection on positive or negative experiences such as near misses, administering medication incorrectly, or treating injured patients. By reflecting on these experiences, students work through the sensations associated with feeling vulnerable and human. Students expressed knowledge of what a journal should entail but few actually thought the journal was reflection-based. The “roles of the nurse” were ‘redundant” and few students found that repeatedly explaining the roles in a restricted way helped them to think critically. In fact, a few students felt suppressed by not being able to openly reflect and learn from experiences. Being “expressly scripted” inhibited personal critical thinking because all that was written were repetitive ideals about serving the roles of the nurse. 133
Simulation Variations can be explained by the lack of sufficient full-time faculty, frequent use of adjunct and part-time faculty, and faculty who are unfamiliar with simulation equipment and procedures. Students also made comments about inconsistencies in clinical rotations. One group rotation would have a simulated activity, but another did not share that same or similar experience. Students could not understand the disparity in delivery of simulations but also recognized the importance and extreme value in the experiences when they were done correctly. Instructors’ familiarity with the simulator and the equipment did not always appear consistent. Some comments revealed the instructors sometimes treated simulation like a class lesson, reviewing and informing rather than allowing students to act out different scenarios. Because of the significant preparation needed far simulations, students stated they required more clarity from their instructors about simulations goals and requirements. Students did not appreciate having to react perfectly when their instructors did not prepare them well enough. Students believed a more consistent in-class experience would enhance their learning. Students saw the definite value in simulation but felt the activities were designed to cause stress and anxiety in students because they had to function realistically in a spontaneous manner. Preparation would make the activity less stressful, and perhaps students would learn more because they were less stressed. Further, post-scenario debriefing did not always occur and a few students expressed this lack of consistency also led to fragmented learning. Debriefing is used in simulated activities to remediate and reiterate correct and incorrect actions in similar real life situations. Tanner (2006) explained that reflection-inaction is the nurse’s ability to understand and connect patient responses to interventions. 134
Students were “lost” at times, and that disconnect from understanding actions and interventions prevented learning from simulated experiences. Students also expressed that instructors who were familiar with the simulation equipment provided a much better experience than those instructors who were not, and that all instructors should know how to use the equipment and how to follow scripted simulations. Nursing programs should design and implement required teacher-training programs so that faculty members’ preparation is consistent, thereby leading to a more consistent student learning experience. Despite the negative responses about simulation use by students, the use of simulation as intended remains a steadfast and valid strategy used to teach critical thinking in nursing academia. Current literature supports this assertion (Bambini et al., 2009; Jefferies, 2012; Lapkin et al., 2010; Lasater, 2007a, 2011; NLN, 2011). The Impact of Time Students spend many hours studying and preparing for lessons and tests. Time is a variable but essential component in organization of required expectations. By empowering students with assignments that not only optimize their time and maximize knowledge, students may place an increased value on assignments. The end result is a higher satisfaction in the perceived effectiveness of education. If students are not placing value on assignments they view as “wasteful” or ineffective, then perhaps nursing educators need to review strategies and improve how they deliver knowledge. Time was a major complaint from students, especially regarding preparation for case study and journaling. Simply asking for assignments that students are saying is “busy work” seems counter-productive. Students have to see the purpose or value in a strategy in order to benefit from it. 135
The time spent on journaling was explained as “just satisfying the instructor.” The roles of the nurse are specifically defined and are meant to compartmentalize key points about a student’s particular clinical day. Provider of care, manager of care, and member of the profession are the roles of the nurse exemplified at Montgomery County Community College (MCCC, 2015). Each role of the nurse is defined and presents the student with the opportunity to present a very personal view of a student nurse’s day, thus allowing for reflective journaling. Open reflection is designed to allow for transparency. Punishment for transparency may be counterproductive, so mandating specific objectives for genuine reflection about the roles of the nurse might help students learn those valuable lessons. Charles (2010) and Kennison (2012) shared this sentiment that students cannot create honest, reflective journals if they fear their honesty will head to punishment. When performed correctly, journaling exercises help students identify personal gaps in knowledge as well as their own weaknesses and strengths (Charles, 2010; Kennison, 2012). Reflection as per the literature should be a reflective process and not intended to be a punitive one. Allowing for deep thought into a clinical day, incident or patient care issue may help students learn to connect the dots. This might improve student participation in valid journaling because students are allowed to reflect honestly on performance. This belief is echoed throughout the literature on journaling that if used as intended, is effective as a strategic pedagogy for personal growth and development. Bridging the Gap Between Theory and Practice Nursing is based on theory. For this study, the researcher used Benner’s (1991) novice to expert theory to explain how nurses learn to think critically, integrate the 136
knowledge they obtain, and apply that knowledge to the patients at the bedside. Nurses learn through the instructors’ example, by doing, and by understanding. In nursing schools, the integration of theory is important for the growth and development of all nurses. Nursing educators attempt to prepare student nurses to begin the integration of deeper thought about patient conditions that translates to care at the bedside. Critical thinking is a cornerstone in the nursing profession for the analysis of patient presentations, implementation of procedures, and monitoring of conditions that translate to patient outcomes. Using pedagogies as nursing education intended will help foster the critical thinking acquisition; however, these strategies should be expertly deployed for the purposes intended. All three strategies investigated in this research study are deep in nursing theory. All are proven strategies as noted within the literature, but the substantiation of these strategies comes from execution and continued appropriate use. Developing succinct objectives for any educational initiative should be the goal of education. Nursing educators must determine which strategies work best, either alone or in conjunction other strategies, to solidify future nurses’ critical thinking skills. Educational and theoretical development of nurses who can think critically is a high priority. Experts agree that quality care is dependent upon nurses’ integrated ability to problem solve, implement sound judgments, and integrate strong thinking skills for the purpose of improving patient outcomes (AACN, 2010; Benner et al., 2008, 2010; IOM, 2010,2011; NLN, 2011; Tanner, 2010). Decision making. Nursing school administrators routinely evaluate curricula. Performing in-depth evaluations of current pedagogies as well as how these pedagogies are developed, employed, and evaluated will help improve how they impact nursing 137
education. Decisions about modifying, changing, or altering current strategies should be performed through appropriate channels such as shared governance committees. Dialog about student concerns and preferences relating to individualized learning should be entertained sensitively and comprehensively. The premise of this research study was to examine student nurse perceptions about how the three strategies affect personal critical thinking learning. Wolf (2012) maintained that programs across the country consider students’ input for program evaluation and improvement. This study has revealed some valuable input that program directors and faculty should consider as healthcare moves forward. Case study. Streamline and possibly combine strategies to complement one another. Have one major case study a semester with smaller ones leading up to the final graded case study/simulation. One student related an experience where the knowledge learned in a case study led directly to a structured simulation. Offering students activities that prepare for learning activities might bring more meaning to pedagogical strategies. Further, providing direction as to what to expect might decrease student anxiety and improve engagement. Having students prepare for case study seminars in segments might also improve the value derived from the copious information necessary to prepare for the activity. Prepare students in blocks or segments weeks before a major case study/simulated activity. This preparation would allow students to research, validate, and learn at a more reasonable pace. Journaling. Journaling should be scripted to incorporate level objectives such as the roles of the nurse; however, the instructors should allow students to create open journals that encourage reflection. Encouraging open reflective exercises should be 138
carefully considered to help mold students’ professional responses. Students should not be punished or reprimanded for honest reflection. Lack of reflection should be cause for point loss. Journaling criteria should reflect the objectives for honest reflections that also allow for achievement of curricular goals. Future dialog might be helpful in discussing alphanumeric grading procedures for journaling. Instructors should encourage students to discuss patient safety near misses and takeaways. Simulation. Simulations should be consistently planned and delivered. Simulation learning objectives should be posted on the learning level Blackboard site so students can prepare for them in a comprehensive manner. If case studies are linked directly to simulation activities, students should be allowed a provisionary period to prepare. Weekly case study objectives should be incremental, leading up to the final simulation of the semester. This form of activity satisfies curricular goals, but also allows students time to prepare for the final graded activity. Instructors should all receive formal education on simulation, directives, equipment use, deployment, and debriefing procedures. Equipment should be in optimal working order and materials used to mimic real conditions should reflect real life assimilation. Moulage is a French term for realism in simulations; creating lifelike medical maladies and conditions so students can apply knowledge in a realistic controlled environment (Merica, 2012). Conclusions and Recommendations The researcher developed several general and specific recommendations from this study’s results. First, nursing schools should solicit student feedback more consistently and make sure students know their input is valued. Program evaluation should 139
incorporate open-ended responses that may be useful for comprehensive program evaluation. Student responses can serve as valuable anecdotal prescriptive recommendations for program improvement. Nurse leaders should consider investigate ongoing research in this area of nursing education to improve and prepare for the future of musing education. As a result of this study, the researcher recommends that more studies be considered to define what strategies will help facilitate an improved, meaningful education system for nursing’s future.
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Appendix A: Student Perception Interview Guide Interview Guide Questions Main questions: RQ1: What are the lived experiences of nursing students at an associate degree nursing program in Southeast Pennsylvania? RQ2: How do nursing students’ perceive the three teaching strategies (simulation, seminar (case study), and journaling) as each influences individualized critical thinking learning? Probe Questions
The following questions are about the three strategies related to your critical thinking: Case Study (seminar), Journaling, and Simulation
Please share your feelings about what Case Study (seminar) means to you?
Please share your feelings about what Journaling means to you?
Please share your feelings about what Simulation means to you?
When I mention the term “critical thinking”, please share what that means to you
Based on your own perception, please share with me, your perceptions and your feelings about which strategy you may, or may not prefer, and why?
• In your own words, share with me your feelings about critical thinking and what impact “Case Study” (Seminar) strategies have on your personal critical thinking learning • In your own words, share with me your feelings about critical thinking and what impact “journaling” strategies have on your personal critical thinking learning 166
• In your own words, share with me your feelings about critical thinking and what impact “simulation” strategies have on your personal critical thinking learning • Please share with me your perceptions of any challenges you encountered with any of the three teaching strategies: Case Study (seminar), Journaling ,and simulation • Speaking freely, is there anything else you would like to mention about the three teaching strategies?
Student Perception Interview Guide adapted from Breckenridge’s Perception Interview Guide (Breckenridge, 1994, 2006, 2010)
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Appendix B: An Invitation for Senior Student Nurses
Dear MCCC NUR 212 Senior Student Nurses, August, 2015 I am a registered nurse working toward achieving a doctoral degree in education. I would like to invite you to help me in my research study on educational teaching strategies that you, as student nurses have experienced during your nursing education here at Montgomery County Community College. I am extremely excited at the prospect of learning from each of you as I begin this process. By doing this study, I hope to develop a better understanding about these strategies and the relationship these strategies have to your personal learning. Each interview will be conducted on campus, and will be a private one to one interview that will take approximately 30-60 minutes. Each interview will be audiotaped. Your participation in this study is completely voluntary as well as confidential, but your participation will be of significant value to nursing education and the education of future nurses. You may withdraw your participation at any time without repercussions should you change your mind in participating in the study. I have received approval for this study through the Institutional Review Board (IRB) at Montgomery County Community College and my educational institution: the University of Phoenix. I value your input tremendously, and am hopeful this study will help nursing faculty learn how teaching strategies impact student learning. I am planning to begin conducting interviews in the near future, and continue into the fall 2015 semester. Interviews will be conducting on campus at a mutually agreed upon time to meet your schedule. You can RSVP your interest in participating in the study via email at email. Please email me directly to discuss setting up an interview. I appreciate your willingness to participate in this valuable study, and look forward to hearing from you. Respectfully,
Caree Updyke Caree Updyke RN, MSN/Ed Doctoral Student
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Appendix C: Request to Perform Study Email to Mr. ABC May, 2015 Good morning Mr. ABC, my name is Caree Updyke and I am a part time nursing faculty member here at MCCC, currently working in the nursing laboratory. I am also a doctoral student at the University of Phoenix in the EdD/CI program. I am emailing you and Dr. Linda Roy of my pending intention to apply for IRB at MCCC for my doctoral research study. My proposal is currently being assessed for IRB approval at the University of Phoenix. My study is qualitative, and examines the experiences of senior student nurses, and their perceptions of three teaching strategies used to enhance and foster critical thinking. These strategies are: journaling, case study (seminar) and simulation. I’ll be using interview technique in a naturalistic setting to collect my data. It is my hope that this study will reveal not only reveal which strategy student believes helps student nurses learn to critical think, but also point me in the direction for potential further research study. At this point, I am merely a doctoral student learning the process of research. I believe I can begin the process to attain IRB at MCCC, but I wanted to notify the both of you of my intent before I begin that process. I am currently waiting for preliminary committee and IRB approval at the University of Phoenix. Any advice you could afford me would be greatly appreciated. Thank you for your attention and understanding in this initiative, and in helping me achieve my degree. Thanks very much. Caree Updyke
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Appendix D: Consent to Participate
Informed Consent: Participants 18 years of age and older This form may be used as a general guide to fulfill the requirements of informed consent. Items in bold typeface or underlined must be written to describe specific elements of the research study. [Please remove this paragraph when finalizing this form for use.] Dear Student Participant name My name is Caree Updyke and I am a student at the University of Phoenix working on an EdD degree. I am doing a research study entitled Critical Thinking teaching and Learning Strategies as Perceived by Student Nurses in an Associate Degree Nursing Program. The purpose of the research study is to understand more about teaching strategies as perceived by student nurses. Your participation will involve an interview one on one. You can decide to be a part of this study or not. Once you start you can withdrawal from the study at any time without-penalty. The results of this research study may be published but your identity will remain confidential and your name will not be made known to any outside party. You can decide to be a part of this study or not. Once you start, you can withdraw from the study at any time without any penalty or loss of benefits. The results of the research study may be published but your identity will remain confidential and your name will not be made known to any outside party. In this research, there are no foreseeable risks to you except “None” Although there may be no direct benefit to you, a possible benefit from your being part of this study is to determine if change is needed I no change, alter or improve nursing education/academia from the student nurses’ perspective. If you have any questions about the research study, please call me at email or mobile phone. For questions about your rights as a study participant, or any concerns or complaints, please contact the University of Phoenix Institutional Review Board via email at IRB. As a participant in this study, you should understand the following: 1. You may decide not to be part of this study or you may want to withdraw from the study at any time. If you want to withdraw, you can do so without any problems. Your identity will be kept confidential. If no personal identifiers are being collected by the researcher, then you would indicate that the participant’s identity will be kept anonymous. 2. Caree Updyke, the researcher, has fully explained the nature of the research study and has answered all of your questions and concerns. 3. If interviews are done, they may be recorded. If they are recorded, you must give permission for the researcher, Caree Updyke, to record the interviews. You understand that the information from the recorded interviews may be transcribed. The researcher will develop a way to code the data to assure that your identify is protected. 4. Data will be kept secure. The data will be kept for three years, and then destroyed.
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5. The results of this study may be published. “By signing this form, you agree that you understand the nature of the study, the possible risks to you as a participant, and how your identity will be kept confidential or anonymous When you sign this form, this means that you are 18 years old or older and that you give your permission to volunteer as a participant in the study that is described here.” (
) I accept the above terms.
Signature of the _____________
research
(
) I do not accept the above terms. (CHECK ONE)
participant
____________________________________
Date
Signature of the researcher _____________________________________ Date _____________
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