Clinical Reasoning Judgment-share · 2017 –Over 2,000 new nurses Strategic Practice Analysis 2017...

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Clinical ReasoningClinical Reasoning Applicable to Undergraduate and Graduate Programs

Tim Bristol, PhD, RN, CNE, ANEF, FAADN

[email protected]

866.861.2896

Next Generation Learning

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• Discuss the use of clinical reasoning in undergraduate and graduate education.

• Develop learning activities that promote clinical reasoning.

• Assess curricular structure and policy for emphasis in clinical reasoning.

Goals for this Discussion

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• Note card….

• Write, Pair, Share

Definition of Critical Thinking

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“All of part of the process of questioning, analysis, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application, and creativity…underlies independent and interdependent decision making.” AACN, 2008

Definition of Critical Thinking

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“The process used to assimilate information, analyze data, and make decisions regarding patient care.” as cited in AACN, 2008

Definition of Clinical Reasoning

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Skill in recognizing cues about a clinical situation, generating and weighing hypotheses, taking action and evaluating outcomes for the purpose of arriving at a satisfactory clinical outcome. Clinical judgment is the observed outcome of two unobserved underlying mental processes, critical thinking and decision making. (NCSBN)

Definition of Clinical Judgment

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1. CJ is more influenced by “what did the nurse bring to the situation” than “objective data”

2. CJ is based on knowing the patient and their desires/needs, requires engagement

3. CJ is impacted by context and the culture of the unit

Tanner on Clinical Judgment

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4. Nurses use a variety of reasoning patterns

5. Reflection on practice is vital


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Noticing

Interpreting

Responding

Reflecting (Habits)


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Definition of Clinical Judgment

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Based on NCSBN research…next up in importance…

Professional communication

Active listening

Next in line after CJ

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CJ is linked to more than 46% of nursing tasks for the new nurse

Problem solving / Critical Thinking is linked to more than 30% of nursing tasks for the new nurse

Why Clinical Judgment

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https://www.ncsbn.org/11435.htm

Practice Analysis

2017 – Over 2,000 new nurses

Strategic Practice Analysis

2017 – Over 1,200 new

nurses, faculty, and

supervisors

Why Clinical Judgment

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Basic Steps

1. Recognize Cues

2. Analyze Cues

3. Prioritize hypotheses

4. Generate Solutions

5. Take Actions

6. Evaluate Outcomes

CJ NCSBN‐Style

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*NCSBN wants test questions to focus more and more on Clinical Judgment

THEREFORE

*LEARNING needs to focus more and more on Clinical Judgment

So what?

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The NCSBN data is the most current up to date database we have on what practice entails (especially for the new nurse) therefore, we will use their CJ model for guidance.

So what?

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Why use NCSBN data? Building without plans leads to…

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Looking at the Practice Analysis

What class is most important?

• Med Admin Rights

• Universal Precautions

• Client ID – Confidentiality

• Collaboration

Discharge Planning begins on ………

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Using the Test Plan to make learning real

Ctrl + F

G‐tube

Discharge Planning begins on ………

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NCSBN.org

Level of Difficulty“Good ole” Bloom!

• Knowledge• Comprehension

• Application• Analysis• Synthesis/EvaluationLevel of difficulty is determined by the question construction – not the level of difficulty of the content of the question.

Want to increase difficulty not adding obscure information.

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Level of Difficulty“NEW” Bloom!

• Remember

• Understand

• Apply

• Analyze

• Evaluate

• Create

Want to test how they think “instead of what they know…”

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If Bloom’s is good for testing, is it good for lesson plans?

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Time to Create…

Reverse Case Study

1. Student review one of the client needs.

2. Students find a Youtube video that highlights a concept from lecture.

3. Students write a test item based on the client need and the concept.

Quick Instructional Design

Keeps me accountable to higher

order thinking learning activities

Let’s take a look at how you could use it the next time you teach…

How could a graduate student use it in developing a project?

HOTLAF

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Class ClinicalPrep for…

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Since Class time is Clinical time

• Prep is clinical focused?

• Prep is guided?

• Prep helps cover knowledge and comprehension so that class is Application and Analysis

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Since Class time is Clinical time• Highlighting in the text!

• 3 Greens and 3 Yellows

• Ticket to class is a clinical tool.• CT Map is a ticket to class.• When they arrive to class they get a 2+2 on the map.

• Video as prep for class• Tour guide for Learning how to Learn

• Prepare to be carded!• Top 3 client needs (need to focus based on HESI report)• Create cards now

• Preclass quiz.• Try it now in Evolve – Week 2 – Preclass Prep – Ch. 33

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Client needsNCLEX helps us aim for

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Client NeedsSafe and Effective Care Environment

• Management of Care…17‐23%

• Safety and Infection Control…9‐15%

Health Promotion and Maintenance…6‐12%

Psychosocial Integrity…6‐12%

Physiological Integrity

• Basic Care and Comfort…6‐12%

• Pharmacological (Parenteral) Therapies…12‐18%

• Reduction of Risk Potential…9‐15%

• Physiological Adaptation…11‐17%

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Management of CareCoordinated Care

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Management of Care

• Determine priority of care for a group of clients.

• Determine priority of care for a client.

• Delegation and Collaboration

• Confidentiality

• Performance improvement, ethics, informatics

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Delegation

• Client needs focused, assessment of competency and outcomes

• 5 Rights ‐ right task, right circumstances, right person, right direction or communication, right supervision or feedback

• Minnesota – Use of Protocols

• Texas – Delegation Resource Packet

• Utah – Delegation of Nursing Tasks

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Management of Care

• Based on a sample question from the Detailed Test Plan at NCSBN.org

• Confidentiality & Collaboration• Student groups of 3‐5 come up with a nurses response who is caring for a client receiving a liver transplant

• Two statements that are correct about client confidentiality and two statements that are not

• Can focus on one client or give student groups different scenarios

• CULTURE FOCUS – The Hispanic client’s significant other says “I have a right to know…”

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Management of Care

• Time to get carded…

• How is the concept related to the patient status post liver transplant?

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Management of Care

• Lab / simulation activity or discussion in class / online.• In the lab, student receives report then reviews the chart for medications, recent assessment data, and labs.

• Next the student enters the patient’s room for a quick hello to introduce herself and collect a set of vitals.

• Upon entering the room, the patient has an IV running with a fluid that is different than noted in report/e‐MAR and has a nitro paste patch on (also not mentioned in report or on the e‐MAR).

• What is the expected response of the student nurse?

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Management of Care

• Lab / simulation activity or discussion in class / online.

• The nurse is entering the room and a ‘physician’ comes into the room with him.

• The client is on reverse isolation because of severe neutropenia.

• The physician entering the room does not put on the required protective wear and keeps her stethoscope and labcoat.

• What is the expected response from the nurse?

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NurseThink® Note CardPriority DelegationFor your client today, what are 3 things you can delegate and why? What are 3 things you can not delegate and why? Present to a peer for feedback.

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Management of Care

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• Penguin Video

Management of Care

• Faculty Focus

• Review the Management of Care section of the Detailed Test Plan.

• Come up with an activity you can do the next time you have nursing students (lecture, lab, clinical) to address some part of this client need.

• How does your activity promote clinical judgment / reasoning?

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Safety andInfection Control

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Safety and Infection Control• Ergonomics, assistive devices when providing care

• Emergency response

• Error prevention

• Standard precautions, transmission‐based precautions, surgical asepsis

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3 Priority Safety Concerns for this patient at Home…

SAFETY Pause

• Identify a safety buddy.

• Individually – Your ticket to class is 3 safety concerns for the client at the end of the chapter.

• Together – Upon arriving in class, compare your top 3 for each client, how similar / different were your top 3’s?

• Be prepared to share your similarities/differences when called upon.

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NurseThink® Note CardSafety in the HospitalYou have been alerted to the following situation for your client. Find a blank sheet of paper and create a sign that would direct care providers and visitors on actions to be taken. Present your sign in post conference.

• Critically low WBC

• Positive TB skin test

• History of MRSA in the nares

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Health Promotionand Maintenance

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Health Promotion and Maintenance

• Aging / maternal‐child

• Developmental Stages and Transitions

• Health belief / change – lifestyle

• Physical assessment

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Compare/Contrast Collaboration•Developmental Stages – Post Op Pain

• Every other person at your table• 7 Year Old

OR

• 70 Year Old• 3 Blue Assessments

• 3 Pink Interventions• Swap with someone

who did the other age

Generations Collide

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• Ipad cutting board VIDEO

NurseThink® Note CardHealth Promotion

What are 3 priority health promotion and maintenance recommendations you should make for your client today? Discuss how you can make this education happen and the results of the education when complete. What are tools / strategies you can use (eg.an app on the client’s phone)?

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Clinical Imagination

• Clinical imagination facilitates clinical reasoning (Educating Nurses – Benner, Sutphen, Leonard, & Day, 2010)

• Use your imagination. • What would a teen say is a good way to promote healthy living?

• Tools?

• Strategies?

Clinical Imagination

• 877877• Hookup

• Clinic + zipcode

• 30364• Tests

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Quizzing that Counts• During class

• Faculty opens the adaptive quizzing and chooses Client Needs / Health Promotion.

• With each question the students vote and the instructor answers in the software.

• With each question the students look at their Concept cards to discuss one concept related to the question.

• UNINTENDED SIDE EFFECT• When we use the study tools in class (books, quizzing, etc.) the students are more likely to use them effectively when studying.

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Birthday Time

September 12

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Psychosocial Integrity

Psychosocial Integrity

• Abuse/neglect

• Chemical and other dependencies

• Cultural diversity

• Family dynamics

• Respect beliefs/values

• Alzheimer’s, dementia

• Therapeutic communication

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Psychosocial Integrity• Based on a sample question from the Detailed Testplan at NCSBN.org

• Picture Perceptions• Show students in class a picture of clinical situation (simulated, off the internet, etc.)

• Each small group writes a small scenario that could include a potential for abuse and passes their scenario to another group

• Receiving group then writes two comments the nurse could make to assess or intervene

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Therapeutic Texting

• 10 People / 10 Colors

• Presence, lean forward, no barriers/distraction

• Instant access, safe, lack of social inhibition

• One piece of paper per person.

• “I am done.”

• Pass to the right.

• Nurse Responds (160 characters)

Thoughts

• Review the PSYCHOSOCIAL INTEGRITY client need in the NCLEX Test Plan and come up with an idea for developing clinical judgment/reasoning for your students in their next class.

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NurseThink® Note CardPsychosocial IntegrityBefore post conference, create a test item that includes…

• Your client (don’t violate HIPAA)•A significant psychosocial need•A need to address psychosocial BEFORE physiological

•Make all options REALISTIC• Present in post conference

Basic Care and Comfort

Basic Care and Comfort

• From Transfers to Elimination

• Skills r/t Transfers, Elimination, etc.

• Alternative therapy, sleep/rest, pain

• Nutrition and Hygiene

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NurseThink® Note CardCulture Creation

Identify 3 connections between your client’s cultural background and some of their desires related to basic care and comfort. Only discuss this with a fellow student and your instructor. Because this may be a sensitive discussion/topic, ask your instructor before approaching the client.

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Clinical Judgment Sightings

• Where have you seen…• Peer learning

• Individualized learning

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Pharmacological Therapies

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Pharmacological and Parenteral

• Safety, Safety, Safety• It is not what they know, it is how they learn

• Top 5

• 5 Rights? 6 Rights? (Show your Voting Card)

• Clinical Calculations

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Top 5

• Given a concept…• For that concept, as a group come up with the Top 5 meds a NEW nurse should know

• Is this a list that could be a curricular thread?

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Culture and Medication• Grandpa does not take his pain medication because he feels it makes him look weak.

• My daughter is Ethiopian and she can’t use codeine because Ethiopians tend to be genetically wired to rapidly convert codeine into morphine.

• She won’t let us check her blood pressure because a friend had it checked and then died.

“Explore why client is refusing/not following treatment plan (e.g., non-adherence)” – NCLEX-RN Detailed Test Plan 2016 p. 25

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Thoughts

• Review the Pharm and Parenteral client need in the NCLEX Test Plan and come up with an idea for developing clinical judgment/reasoning for your students in their next CLASS / LAB / CLINICAL.

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NurseThink® Note CardElimination Options

Pick a medication that may be eliminated from the client’s regimen. What would be 3 possible benefits of this medication being eliminated?

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Reduction of Risk Potential

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Reduction of Risk Potential

• Lab, Diagnostics, Vitals•CHANGES•Predict Complications

•Argue for a Change in Therapy

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Focused Assessment

• For Mr. J.H. • 3x3 in the EHR

• 3 Priority Systems

• 3 Priority Activities in each System

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10 Minutes of Psychomotor Qhour

• Find someone in the class you have not yet talked with today.

• Meet Mr. JH

• Time for focused assessment r/t perfusion.

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Polling Question (Voting cards)

What is the TOP of the revised Bloom’s taxonomy for cognitive learning?

1. Self actualization

2. Self esteem

3. Synthesis

4. Create

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Time to Create Multiple Response

The nurse has taught a client who is scheduled for a colonoscopy. Which statement by the client would require follow up?

1. “I will not be able to eat or drink anything for 24 hours before the procedure.”

2. “I may experience abdominal cramping after the procedure.”

3. “I will be sedated during the procedure.”

4. “I will be placed in the knee‐chest position for the procedure.”

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Sample … Detailed Test Plan

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Create Change

• For Mr. J.H. • Create a change in labs (or add labs) that would indicate a resolution in his condition

• Create a change in labs (or add labs) that would indicate his condition is worsening.

• Compare with someone else.

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NurseThink® Note CardCreate is Crucial• You are evaluating your client’s labs. Create 3 lab values that would indicate your client’s condition is worsening. List priority nursing actions to address the changes you created. Be prepared to give rationale for each change that you created as well as subsequent nursing action.

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Birthday Time

August 13

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Physiological Adaptation

Physiological Adaptation

• Hypo/hyperglycemia, cardiac, tracheostomy, ventilator

• Signs/symptoms of acute and chronic disease

• Wound care

• Disease specific patient education

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Polling Question

How many care plans should students do each semester?

1. <5

2. 5‐10

3. Weekly

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One‐Minute Careplan – Create It

• Creative Teaching Strategies for the Nurse Educator (2016). Herrman, J.

• In your groups create an outline for this form/activity

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One‐Minute Care Plan – Use It

• Complete the One‐Minute Care Plan on Mr. J.H.

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Quizzing in Class

• Know what you DON’t KNOW• Learning How to Learn

• Adaptive Quizzing

• Choose Client Needs

• Choose Physiological

• Vote with cards

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NurseThink® Note CardCreate is Crucial• Your client is being educated about preparation for a [insert procedure / diagnostic here] the following day. Create 3 statements by the client that would indicate a need for further education.

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Curricular successAim for

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How to avoid this?

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Consistent Strategies

• Time!

•Working together to

reach goals!!!

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• Study based on strengths and weaknesses

• Focused reading

• Studying at the bedside

• Frequent checks to see if you understand

• What will guide my lectures?

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Guided eStudy


• Focused reading



• Will guide my lectures

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Guided eStudy


• Focused reading




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Guided eStudy


• Focused reading




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Guided eStudy


• Focused reading




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• Getting Carded• HESI Report from last semester

• NCLEX in Clinical (and Class)

• CT Map

• Preclass QUIZ

• Lecture from Item Analysis

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Next Steps in Clinical Judgment• Keep the focus

• What is more important in class, covering content or CJ?

• Keep students in the loop• You need to TRAIN daily for CJ

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PROMOTE Clinical Judgment

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And Now!

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Thank you!

Resources• Next Generation NCLEX® (NGN) Resources -

https://www.ncsbn.org/11435.htm

• Strategic Practice Analysis -https://www.ncsbn.org/11995.htm

• Dickison, P., Luo, X., Kim, D., Wood, A., Muntean, W. Bergstrom, B. (2016). Assessing higher-order cognitive constructs by using an information-processing framework. Journal of Applied Testing Technology, 17(1), 1-19.

• Kavanagh, J.M., & Szweda, C. (2017). A crisis in competency: The strategic and ethical imperative to assessing new graduate nurses’ clinical reasoning. Nursing Education Perspectives, 38(2), 57-62.

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Resources

• Sutherland, K., Schwartz, J., & Dickison, P. (2012). Best practices for writing test items. Journal of Nursing Regulation, 3(2), 35-39.

• Tanner, C. (2006). Thinking like a nurse: A research- based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204-211.

• Wendt, A. & Harmes, J. C. (2009). Evaluating innovative items for the NCLEX, Part I: Usability and pilot testing. Nurse Educator, 34(2), 56-59.

• Wendt, A. & Harmes, J. C. (2009). Evaluating innovative items for the NCLEX, Part 2: Item characteristics and cognitive processing. Nurse Educator, 34(3), 109-113.

• Wendt, A. & Kenny, L. E. (2009). Alternate item types: Continuing the quest for authentic testing. Journal of Nursing Education, 48(3), 150-156.

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Clinical Reasoning Judgment-share · 2017 –Over 2,000 new nurses Strategic Practice Analysis 2017...

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