ABSTRACT Faced with increasingly complex clinical situations, nurses must respond with accurate clinical judgment. But del Bueno (2005) reports that only 35 percent of new graduate nurses exhibit entry-level expectations of the necessary critical-thinking skills. Croskerry (2003) argues that clinicians' education should be directed at developing cognitive strategies that reduce errors in clinical decision-making. A challenge for nurse educators is finding activities to help students analyze their thinking as they address clinical problems. The author describes an assignment, given to third-year baccalaureate students, that used both online learning and high-fidelity patient simulation. Through discussions with instructors and peers, as well as personal reflection, students gained insight into both their sound and faulty critical thinking and clinical decisions.
Key Words Case Study--Clinical Decision-Making--Clinical Judgment High-Fidelity Simulation--Debriefing
As patients' conditions and their treatments become more complex, nurses are expected to make clinical judgments that match that complexity. But del Bueno (2005) has reported that only 35 percent of new graduate registered nurses (those in their first year on the job) possess the critical thinking abilities expected of entry-level nurses; examples include "inability to differentiate when and why diuretics are used" and "indiscriminate monitoring of all vital signs without relevance or priority" (p. 280).
New nurses often have difficulty sorting out available clinical information and acting upon it, and they may miss important information needed to act in ways that prevent near misses or adverse events (Elbright, Urden, Patterson, & Chalko, 2004). Croskerry (2003) argues that students should be educated on cognitive strategies to reduce errors in making clinical decisions. In an integrative review of the literature, Olejniczak, Schmidt, and Brown (2010) found that, although the evidence is limited, it does suggest that for new graduate nurses, "scenario-driven, problem-based learning using simulation" helps them learn "to manage at-risk patients in a safe, confident, and competent manner" (p. 56). THIS ARTICLE DISCUSSES AN ASSIGNMENT, BASED ON CRITICAL THINKING THEORY, THAT COMBINES ONLINE LEARNING AND HIGH-FIDELITY PATIENT SIMULATION TO HELP STUDENTS ANALYZE THEIR THINKING AS THEY ADDRESS CLINICAL PROBLEMS.
Related Theory and Research Elder and Paul (2010) define critical thinking as the ability to improve one's thinking through ongoing self-assessment. They say that students develop critical thinking skills in six stages: in Stage I, the Unreflective Thinker lacks knowledge and approaches problems with a random thought process; in Stage 6, the Accomplished Thinker continually analyzes his or her own thought processes and develops "new insights into problems at deeper levels of thought." Elder and Paul theorize that college students fall into the early stages of critical thinking and recommend that educators help students examine examples of both their sound and unsound thinking.
Bain (2004) suggests that educators create a "critical learning environment" where students confront authentic problems and examine their mental models (thinking). He states that the best teachers challenge their students intellectually by creating an "expectation failure" wherein a student's way of thinking leads to faulty expectations. For example, a nursing student might assume that he or she does not need to check the type of intravenous (IV) solution running because another RN had hung it. Later, if the instructor points out that the incorrect solution had been hung, the student discovers the error of his or her initial assumption and learns about the importance of IV assessment. Tanner (2006) writes that a nurse will often improve his or her clinical-reasoning skills after an error in clinical judgment, at which time the nurse analyzes the problem. …