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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.