Clinical Reasoning Cycle

Book Club: Levett-Jones, T. (Ed.). (2013). Clinical reasoning: Learning to think like a nurse. Pearson Australia.

Clinical Reasoning Cycle

Define reasoning as “the process by which nurses (and other clinicians) collect cues, process the information, come to an understanding of a patient problem or situation, plan and implement interventions, evaluate outcomes, and reflect on and learn from the process”.

“Clinical reasoning is often confused with the terms ‘clinical judgement’, ‘problem solving’, decision making’ and ‘critical thinking’. While in some ways these terms are similar to critical reasoning, clinical reasoning is a cyclical process that often leads to a series or spiral of linked clinical encounters” (pg.4 Levett-Jones, 2013).

Stages of the Clinical Reasoning Cycle

  1. Consider the patient
  2. Collect cues/information
  3. Process information
  4. Identify problems/issues
  5. Establish goals
  6. Take action
  7. Evaluate outcomes
  8. Reflect on process and new learning

Why is this book important?

For nurse training and education delivery, the stages of clinical reasoning can be incorporated into training sessions to discuss the clinical judgments and decision making during a care intervention and applying the ‘nursing process’.  Simulated nursing environments are an ideal educational approach to challenge clinical decision making and clinical reasoning skills. Nurses are the constant presence on the ward level, providing the monitoring and making judgments form the clinical reasoning encounters every shift over a patients hospital journey. Responding to complex and time critical events requires sophisticated abilities which expand further than pure theoretical knowledge, such as assessing and responding to clinical deterioration.

In the current economic drive for cost cutting measures across healthcare (nurses make up the majority of the healthcare workforce, so are often seen as a costly element), the drive to replace with lower skilled, trainees and eventually robots are factors for the nursing profession to consider. Nurses need to be able to understand and explain the role they play and have a voice to raise the profile of what it entails to be a nurse and the efficacy of such skills to maintain levels of care and safety.

Summary

Thinking on the go and decision making are skills to develop over time and with experience but need to be incorporated into nurse training. Nurses with effective clinical reasoning skills have a positive impact on patient outcomes (School of Nursing and Midwifery Faculty of Health, 2009). It’s important to remember, during all this consideration of the patient and reflective process that you (the nurse) are human and as such wont get everything correct all the time.

References

Levett-Jones, T. (Ed.). (2013). Clinical reasoning: Learning to think like a nurse. Pearson Australia.

Alfaro-LeFevre, R. (2015). Critical Thinking, Clinical Reasoning, and Clinical Judgment E-Book: A Practical Approach. Elsevier Health Sciences.

Interprofessional Ambulatory Care Unit. Clinical Reasoning User Manual. Edith Cowan University.

School of Nursing and Midwifery Faculty of Health (2009) Clinical Reasoning Instructor Resources. University of Newcastle.

Peyton’s 4 Step Approach for Skills Teaching

We have all either delivered or been on the end of a “see one, do one” or “do one, teach one” approach to learning, often delivered in simulation with the aim for skill development. But maybe we should add another two-steps into the approach and follow Peyton’s four-step method. To aid the processing of information (learning) and then apply this new knowledge in context (situational awareness) the four-stage technique can be utilised.

Peyton’s Four-Step Approach: 

1. “The teacher demonstrates the skill at his normal pace without any comments (Demonstration)

2. The teacher repeats the procedure, this time describing all necessary sub-steps (Deconstruction)

3. The student has to explain each sub-step while the teacher follows the student’s instructions (Comprehension)

4. The student performs the complete skill himself on his own (Performance)” (Nikendei et al, 2014).

There are clearly defined instructional steps to guide educator and student. Provides small group or a 1:1 teacher:student ratio for successful instructional training in skills learning sims.

Keywords: Simulation; skills labs; 4-step; experiential learning; technical skills.

References

Bullock, I., Davis, M., Lockey, A., & Mackway-Jones, K. (Eds.). (2015). Pocket Guide to Teaching for Clinical Instructors. John Wiley & Sons.

International Clinician Educators (ICE) Blog. (2017). Effective teaching of technical skills requires more than see one do one. KeyLime podcast No. 142. ICE blog.

Münster, T., Stosch, C., Hindrichs, N., Franklin, J., & Matthes, J. (2016). Peyton’s 4-Steps-Approach in comparison: Medium-term effects on learning external chest compression–a pilot studyGMS journal for medical education33(4).

Nikendei, C., Huber, J., Stiepak, J., Huhn, D., Lauter, J., Herzog, W., … & Krautter, M. (2014). Modification of Peyton’s four-step approach for small group teaching–a descriptive study. BMC medical education14(1), 68.

Walker, M., & Peyton, J. W. R. (1998). Teaching in theatre. Teaching and learning in medical practice. Rickmansworth, UK: Manticore Europe Limited, 171-180.

Wang, T. S., Schwartz, J. L., Karimipour, D. J., Orringer, J. S., Hamilton, T., & Johnson, T. M. (2004). An Education Theory–Based Method to Teach a Procedural Skill. Archives of dermatology140(11), 1357-1361.

 

 

The Stress Curve (Yerkes and Dodson Law)

Background History

“Yerkes-Dodson law from 1908 to the present. In its original form, the law was intended to describe the relation between stimulus strength and habit-formation for tasks varying in discrimination difficultness. But later generations of investigations and textbook authors have rendered it variously as the effects of punishment, reward, motivation, drive, arousal, anxiety, tension or stress upon learning, performance, problem-solving, coping or memory; while the task variable has been commonly referred to as difficulty, complexity or novelty, when it is not omitted altogether” (Teigen, 1994).

Stress Curve By Yerkes and Dodson 1908

OriginalYerkesDodson

Pressure & Performance

There are four main influencers related to pressure and performance:

  1. Skill Level.
  2. Personality.
  3. Trait Anxiety.
  4. Task Complexity.

The perception of stress from the individual can trigger the innate fight or flight response.

For The Educator

  • Remember stress can be both a negative and positive experience. This stress theory can link to ’emotional intelligence’ of the individual, well-being and potential for burnout.
  • Simulation sessions can be set up to challenge the learner along the stress curve. The educator must be aware of how they can positively or negatively influence the learners experience.
  • The environment can also impact on stress and perceived threats (culture, unsafe workplace such as violence).
  • For the educator. the question when to challenge the learner and when to step back is very difficult and will require regular review and feedback from the learner and the wider nursing team. Its good to provide a challenge, with the required supports but dropping the learner into an unsupported situation may backfire and effect confidence. Also learners (nurses) are people and have personal lives and so sometimes private life issues means the level of stress the person is experiencing renders learning negligible. This is the time to step off the learning curve, give an extension and put supports in place and to regroup at an appropriate time. Provide a personal approach to learning, not one fitted around traditional university semester timetables.

Keywords: Resilience, mindfulness, stress curve; burnout; Yerkes and Dodson Law.

References

Gibbons, C., Dempster, M., & Moutray, M. (2008). Stress and eustress in nursing students. Journal of Advanced Nursing, 61(3), 282-290.

Intensive (2017) Training for Stress.

Selye, H. (1956). The stress of life.

Teigen, K. H. (1994). Yerkes-Dodson: A law for all seasons. Theory & Psychology, 4(4), 525-547.

Watson, R., Gardiner, E., Hogston, R., Gibson, H., Stimpson, A., Wrate, R., & Deary, I. (2009). A longitudinal study of stress and psychological distress in nurses and nursing students. Journal of Clinical Nursing, 18(2), 270-278.

Wikipedia (2017) Yerkes-Dodson Law.

Tag Team Simulation: Journal Club

Journal Club Article: Levett-Jones, T., Andersen, P., Reid-Searl, K., Guinea, S., McAllister, M., Lapkin, S., … & Niddrie, M. (2015). Tag team simulation: An innovative approach for promoting active engagement of participants and observers during group simulations. Nurse education in practice, 15(5), 345-352. [abstract]

Rationale for the Study

The authors state that “when simulations are conducted in large groups, maintaining the interest of observers so that they do not disengage from the learning experience can be challenging. We implemented Tag Team Simulation with the aim of ensuring that both participants and observers had active and integral roles in the simulation.”

Background 

“However, in nursing programs, where there may be hundreds of students, resource limitations often lead to simulations being conducted as group activities. Evidence suggests that when this happens, learners who take on an observer role instead of being an actual participant in the simulation, can lose interest and disengage from the learning experience” (Kettlewell, 2012; Harder et al., 2013).

The importance of active participation in education and simulation is highlighted. However, in simulation an observing role from watching through one way glass, auditorium or via video conference is part of increasing engagement and providing an alternative view or ‘lens’ from the non-active members. Learning can occur from this observation aspect, but the authors highlight the issue of a passive role, less immersion and boredom ensuing.

One of the most innovative parts of this article is that the idea was taken from performative theatre. It’s really interesting to take ideas from other professional fields and try them in the nursing environment and take some risks and consider new approaches to education delivery.

Tag Team Simulation (TTS)

“TSS is designed for groups of approximately 20 learners, with each participant and observer having a specific, active and integral role in the simulation.

  1. The narrator/director (the educator).
  2. The protagonist  (leading character- trained simulator actor, student or educator).
  3. The actors (the students).
  4. The audience (active observers).
  5. The set ( an authentic learning environment with high level of fidelity).
  6. The play (simulation scenario)

One of the unique features of TTS is that there are no formal scripts. The TTS play is comprised of a prologue, two acts, an intermission, a debrief and an epilogue.”

Results

The Satisfaction with Simulation Experience Scale (SSES) was used to measure student’s perceptions.

444 second year nursing students submitted the surveys from a population of 536 giving a response rate of 83%.

“The results of an independent sample t test revealed that those who participated in the simulation experience (the actors) reported slightly higher satisfaction with the simulation experience than observers (audience). However, the difference was not statistically significant on the SSES or any of the three subscales.”

Take Home Messages from the Article:

  • Simulation observers can lose interest and disengage from the learning experience.
  • Tag Team Simulation ensures that both participants and observers have equally active and integral roles in simulation.
  • A Tag Team pain simulation implemented with second year nursing students revealed no significant difference in satisfaction scores.

Summary

The holy grail for the perfect education approach continues, but this is a reasoned approach to the very real challenge of large group sessions and how to improve the educational approach. One question that I would like to know in regards to nurse training, relates to the increasing deregulation on the number of nursing enrollments in higher education and universities and the impact on the quality of education (I presume this is becoming a global phenomena with the predicted global nursing shortage?). Many simulation courses provide a 1:6 or 2:6 instructor to participant ratio for a quality learning experience. Is this article just responding to changing times and the stretch on nurse education resources?

Keywords: Tag Team Simulation; TTS; Simulation;active participation

Reference

Levett-Jones, T., Andersen, P., Reid-Searl, K., Guinea, S., McAllister, M., Lapkin, S., … & Niddrie, M. (2015). Tag team simulation: An innovative approach for promoting active engagement of participants and observers during group simulations. Nurse education in practice, 15(5), 345-352. [abstract]

Minecraft & Gamification

Now I am not a gaming person but for skills of the future I have decided for my own personal development, that my aims for the coming 12- 24 months are to engage in gaming environments (Minecraft to start) and also learn some basic coding skills. Hopefully you find these resources useful when starting out, if you know of any others please post them in the comment section at the bottom of this post. When I somehow find some spare time to commence coding I will create a post with links to any of the resources I have used (I aim to learn using open access resources so it will all be free).

For those in school education, there is also a Minecraft Education edition that promotes an online world with collaboration and problem-solving in an immersive environment.

Keywords; gaming, immersive, problem-solving, collaboration, Minecraft.

Resources

DigMinecraft (2017) Getting started in Minecraft.

Minecraft (2017) Minecraft Official Site.

Minecraft Education Edition (2017) What is Minecraft Education.

Wikipedia (2017) Minecraft.

Team Emergency Assessment Measure (TEAM)

Purpose

Development of a tool to measure teamwork performance in medical emergencies (TEAM measurement tool).

Background

The focus in healthcare on the importance of patient safety and developing safer healthcare systems. Reducing preventable errors in healthcare requires a culture of change. Errors are multi-factorial, but can be attributed to technical and non-technical skills as well as organisational issues. “The determinants of effective team performance include technical and nontechnical skills such as leadership and teamwork” (Cooper et al., 2010).

Key Performance Factors

  • Leadership skills
  • Team performance
  • Technical Skills
  • Task management
  • Non technical skills
  • Communication
  • Situational awareness
  • Environmental awareness

Findings

Study findings from the primary study found “TEAM was found to be a valid and reliable instrument and should be a useful addition to clinicians’ tool set for the measurement of teamwork during medical emergencies. Further evaluation of the instrument is warranted to fully determine its psychometric properties”.

Keywords: teamwork; situational awareness; training; debriefing; human factors.

References

Cooper, S. J., & Cant, R. P. (2014). Measuring non-technical skills of medical emergency teams: an update on the validity and reliability of the Team Emergency Assessment Measure. Resuscitation, 85(1), 31-33.

Cooper, S., Cant, R., Porter, J., Sellick, K., Somers, G., Kinsman, L., & Nestel, D. (2010). Rating medical emergency teamwork performance: development of the Team Emergency Assessment Measure (TEAM). Resuscitation, 81(4), 446-452.

Monash University (2017) TEAM.

Monash University (2017) TEAM measurement tool.

Workplace Training: Informal Learning?

Workplaces as Centres of Inquiry

Workplace learning and experiences are often seen as informal and subsequently ‘informal learning’ occurs. Billet (2002) states that an educational workplace pedagogy exists, and that learning does not just occur in schools and higher education. Workplace education delivers structured goal-directed activities and work practice relevancy so this ‘informal’ tag is actually incorrect. Learning is deemed as being “interdependent between the individual and the social practice” (Billet, 2002). This structuring of learning experiences is shaped and directed towards sustaining the continuity of current practice.

“Workplace practices and affordances, are dynamic, as their tasks, goals, interactions, participants and relations are likely to be constantly changing” (Billet, 2002, pg. 64).

Learning through work, and the participation and engagement in the social practice is an essential aspect. Just think of the importance of role modelling to set the culture of your workplace environment. Vocational learning is often considered of lower quality than education provided by educational institutions, but with current lifelong learning policies, the role of workplace learning is essential. Workplace participation and sustaining practice are required for positive learning experiences and outcomes. Workplace training can vary between ad-hoc to over structured teaching, which have contributed to some of the negative terms for workplace learning. If we think of the learners motivation to learning, there will likely be a difference in the learners level of engagement of learning in those opportunities chosen by the individual to that of enforced learning (such as mandatory training). Just think to the last time you went to an education event of your choice and compare to one you were ‘encouraged’ to attend, likely you experienced very different motivators. The workplace will have more mandatory training requirements so enthusiasm is likely to be low for such training, as the educator you will need to find a way to make the training meaningful for the participants.

Pathways of learning activities as part of a constructivist approach for skill development are approaches in contemporary work settings. Mentoring and apprenticeships are important learning pathways to navigate workplace practices and learn from experienced practitioners, again part of the social learning experience. Continuity of social practices and the opportunities of unintended learning is a product of these mentorship experiences in the work setting.

Relevancy in Nursing 

Nurse training is forever looking for the right balance between providing higher education and workplace experience for nurse training. Finding the perfect mix of theoretical with the hands on learning experience in the actual clinical setting is the overall aim. The mentor model is an essential part of nurse training in providing learning in the workplace setting. Workplace education is commonly more hands on and has a practical focus, combining theoretical and clinical. With simulation increasingly part of formal educational approaches to nurse training, a more hands on experiential learning approach is being embraced over the traditional ‘sage on the stage’ lecture approach. The multi-disciplinary teamwork and bonding that can occur in workplace training is vital as part of building a positive team culture.

Educator Program Aims

  • Professional growth and change (transformative practice).
  • Personal Change- Reorientation of values of attitudes.
  • Self-esteem linked to workplace confidence.
  • Teamwork and community of practice.

References

Billett, S. (2002). Critiquing workplace learning discourses: participation and continuity at work. Studies in the Education of Adults, 34(1), 56-67.

Harteis, C. & Billett, S. (2008). The workplace as learning environment: Introduction