The Impact of Critical Thinking upon Clinical

Judgment during Simulation with Senior

Nursing Students Mary Cazzell, RN, PhD

Mindi Anderson, PhD, RN, CPNP-C, CNE, CHSE-A, ANEF

Acknowledgements

Funding for this study:

• 2012 NLN Foundation for Nursing Education Fund

Kathie Lasater, EdD, RN, ANEF

Carol Howe, RN, MSN, PhD(c)

Problem

Confusion among nurse educators regarding which high quality student outcomes to facilitate in didactic, clinical, and simulation settings: • Critical thinking

• Clinical reasoning

• Clinical judgment

Purpose

Examine the impact of components of critical thinking upon clinical judgment during a pediatric medication administration OSCE with senior-level nursing students

Background/Significance

Challenge: Radical transformation of nursing education (Benner, Sutphen, Leonard, & Day,

2010)

Numerous interchangeable and overlapping definitions

• Profetto-McGrath (2003): critical thinking: process of logical reasoning with prudent judgment

• Pesut & Herman (1999): clinical reasoning: process of critical thinking, reflection, and creativity used to make judgments

Theoretical Framework

1. Clinical Judgment Model (Tanner, 2006)

a) Noticing

b) Interpreting

c) Responding

d) Reflecting

e) Lasater Clinical Judgment Rubric (Lasater, 2007)

2. Neurodevelopment of critical thinking

(McAnarney, 2008; Steinberg, 2008)

• Guided choice of independent study variables

Methods

Sampling

• Convenience sample

• 160 Senior 1 pre-licensure baccalaureate

nursing students

• Fall 2012 and Spring 2013 semesters

• University ranks in nation’s top 10% for

racial diversity

Research Design

• Quantitative descriptive correlational study

Methods: Independent Variables

Study Measures:

1. Student Demographic Survey

2. Tower of Hanoi (Welsh & Huizinga, 2001)

3. Health Science Reasoning Test (Insight

Assessment, 2011)

Methods: Dependent Variable

Pediatric Medication Administration OSCE

• Videotaped performances scored

• Lasater Clinical Judgment Rubric

• 11-items based on Tanner (2006) model

• Perfect score = 44 points

• 4 dimensions of effectiveness

–Beginning

–Developing

–Accomplished

–Exemplary

Results: Demographic Data

85% female

Median age: 23 years (Range 20-62 yrs)

Ethnicity:

• 42% Caucasian

• 25% Asian

• 16% Hispanic

• 11% African American

GPAs: 2.5-3.0 (46%) & 3.0-3.5 (43%)

49%: previous healthcare experience

Results: TOH & HSRT

Tower of Hanoi:

• Average 7 moves over minimum/task

• Did better in earlier easier vs. later more complex tasks

•>70% required 1-15 moves in Tasks 11-15

Health Science Reasoning Test

• Average score: 25.31 (out of total 38)

• Induction highest scores (7.26)

• Inference lowest scores (2.90)

Results: Lasater Clinical Judgment Rubric

• Total scores: 30.74 (SD 2.41)

•Out of possible 44 points

• Noticing: 8.60 (SD 1.07)

•Out of possible 12 points

• Interpreting: 5.98 (SD 0.17)

•Out of possible 8 points

• Responding: 10.41 (SD 1.52)

•Out of possible 16 points

• Reflecting: 5.77 (SD 0.77)

• Out of possible 8 points

Results: Regression Analyses

4 critical thinking variables predicted clinical judgment

1. Gender: females scored higher than males

2. Ethnicity: African Americans had significantly lower scores on LCJR

3. HSRT deduction score: higher score predicted higher LCJR score

4. HSRT analysis score: higher score predicted lower LCJR score

Implications for Nurse Educators

Critical thinking and clinical judgment:

• Need separate concise definitions

• Small overlap between components

Develop innovative teaching strategies to address predictors of clinical judgment

Attention to gender and ethnicity

References

Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco: Jossey-Bass.

Insight Assessment. (2011). Research: Health sciences and critical thinking. Retrieved from http://www.insightassessment.com/CT-Resources/Research-Health-Sciences-and-Critical-Thinking.

Lasater, K. (2007). Clinical judgment development: Using simulation to create a rubric. Journal of Nursing Education, 46,496-503.

McAnarney, E. R. (2008). Adolescent brain development: Forging new links. Journal of Adolescent Health, 42, 321-323.

Pesut, D. J. & Herman, J. (1999). Clinical reasoning: The art and science of critical and creative thinking. Albany, NY: Delmar Publishers.

References

Profetto-McGrath, J. (2003). The relationship of critical thinking skills and critical thinking dispositions of baccalaureate nursing students. Journal of Advanced Nursing, 43(6), 569-577.

Steinberg, L. (2008). A social neuroscience perspective on adolescent risk-taking. Developmental Review, 28, 78-106.

Tanner, C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment. Journal of Nursing Education, 45, 204-211.

Welsh, M. C. & Huizinga, M. (2001). The development and preliminary validation of the Tower of Hanoi-Revised. Assessment, 8(2), 167-176.