All critical thinking habits of the mind and skills as conceptualized by Scheffer and Rubenfeld (2000) appeared among RN-to-BSN students during the simulation experience. Findings are reported according to the two main categories of Habits of the Mind, and Skills.
Habits of the Mind
Confidence. The confidence of RN-to-BSN students was affected to varying degrees, reflecting differences in practice experience, delivery method, and simulation focus. Confidence was influenced by the proximity of students’ current practice to the simulation scenario. Students whose practice shared similarities with the patient simulation expressed little change in confidence because the simulation “reinforced what I already know.” Students whose practice was unlike the simulated patient expressed either the need for more practice to promote confidence or the value of the simulation in building confidence, as noted by one ETV student:
I think it has [increased my confidence] because you can say “I’ve seen this and I’ve heard this and I know what this is now” rather than guessing or something like that. It’s a whole lot easier and you feel a whole lot more comfortable with dealing with this kind of situation.
Students associated increased confidence in assessment with their enhanced knowledge of the underlying physiology. One student articulated:
It has increased my confidence level. I feel I’m able to assess and know what signs and symptoms to look for in a patient in some type of heart failure.
The delivery method and focus of the simulation affected confidence. Students expressed the simulation focus on assessment as a limitation to confidence building because it “didn’t show anything regarding the care for a patient in this situation.” Internet students found that the lack of immediate feedback and instructor validation associated with the DVD format influenced their confidence in making assessments and interpreting data. An Internet student highlighted how the lack of immediate feedback affected her confidence:
The video showed assessment techniques. It would be nice for it to ask the questions and then give the results that you should have gotten. Right now, I know I did the best I could but I’m not positive that I saw [and] heard what I was intended to observe.
Contextual Perspective. Students spoke repeatedly about the value of the simulation in providing a contextual perspective. One student expressed:
I learned to look at the whole picture. You have to put all the pieces together to figure out what’s going on with the patient.
One ETV student even created the context in which she viewed and performed the assessment by imagining the patient situation taking place in the emergency department, her area of practice.
Creativity. The simulation prompted students to create their own ideas about performing the assessment and reflected their perceptions of the reality of the simulation. Students who found the simulation a poor reflection of their reality responded to the simulation by proposing alternative approaches, emphasizing different sequencing, pacing, and priority setting. This creativity is reflected in the following ETV student’s comment:
We would have done things a little bit differently than they showed here. It was very slow and we would have moved a lot faster and you have to prioritize and you have to deal with the main thing first.
Flexibility and Open-Mindedness. Varying levels of flexibility and open-mindedness were evident among RN-to-BSN student participants, reflecting differences in their experiences and backgrounds. Many RN-to-BSN students came to the simulation with well-established practices and ways of thinking and doing that served both to hinder and to facilitate flexibility and openness. For some students, the familiarity of the simulated patient with everyday practice made it challenging to see ways their existing assessment skills could be modified or expanded. Other students, despite this familiarity, spoke of new skills they had learned, as articulated by one Internet student:
It was a good review that I feel I can [use to] build my skill level…. For me, seeing how someone else does a particular skill allows me to find what I like about it, and build off of it.
Despite the preprogrammed simulation that fixed the assessment to some extent, these experienced practitioners responded with remarkable flexibility. This was observed as they responded to the immediacy of the patient’s emergent situation, recognizing the need to modify the simulated comprehensive assessment to a “focused” assessment.
Inquisitiveness and Perseverance. Questions inserted throughout the simulation were a built-in way to foster inquisitiveness. Inquisitiveness was influenced by differences in the simulation delivery method, with Internet students showing more evidence of this habit than did ETV students. The effort expended by one Internet student to know and understand the findings from the simulated assessment is expressed as, “I reviewed the DVD twice and did pick up on something different each time.”
Perseverance similarly showed differences between ETV and Internet students, with this habit appearing to a greater extent in Internet students versus ETV students. Perseverance was expressed by one Internet student who verbalized her determined pursuit in differentiating S2 and split S3 heart sounds:
It was hard going back and forth between the simulation DVD and the assessment DVD of heart and lung sounds.
Intuition. The intuition of the expert practitioner, which described many of the RN-to-BSN students, was evoked by the simulation. RN-to-BSN students described immediate “gut reactions” to the assessment findings, as captured by one ETV group in the following way:
While we were watching the assessment, we could sit there and say “this was going on, this was going on, this is going on.” We kind of already knew by what the patient was saying and what the instructor was saying what was going on already…. “Okay, this is going on so this, this, this needs to be done.”
At the same time it evoked intuition, simulation also created new mental models, the building blocks of intuition, by giving students pictures they perceived would help guide them in practice. This is reflected in the following student statement:
And when we see some of these things going on, we will already have seen something similar to it even though this was just a [manikin]. It did give us a picture of what might be happening or what to look for in a patient.
Intellectual Integrity. RN-to-BSN students demonstrated various degrees of intellectual integrity, from those who honestly pursued correct and validated conclusions, to those who quickly arrived at questionable conclusions because of premature closure. One ETV group described a high level of intellectual integrity:
At the very, very first, because her chest was so barreled,…at first we weren’t sure whether it was just a bad case of [chronic obstructive pulmonary disease] exacerbation or if it was actually heart failure, but as the assessment went on we began to identify it more as heart failure.
Reflection. The debriefing session that followed simulation engaged students in reflection. It gave students the opportunity to gain insights into their thinking and to promote deeper understanding and self-evaluation. Such insight was expressed by an Internet student who experienced a shift from seeing assessment as a task to an opportunity to listen and get to know the patient.
Analyzing. The in-depth nature of the assessment findings required students to make interpretations to gain an understanding of the patient’s problem. Gaps in analysis were evident, with RN-to-BSN students experiencing difficulty in looking at the assessment findings and categorizing the data to arrive at nursing diagnoses. For example, students could see by the end of the simulation that the patient had heart failure but did not identify altered cardiac output as the key priority nursing diagnosis. In addition, RN-to-BSN students experienced the tension between attending to the parts of the assessment and connecting it to the larger context of interventions. This was expressed by an ETV student:
She [the instructor] didn’t ask us so much what we would do as she was assessing each system and going on and finding things that were wrong and asking us what’s wrong and what’s different in this picture, not what we would do in this case.
Applying Standards. RN-to-BSN students applied standards throughout the simulation as they interpreted assessment findings, such as vital signs, breath sounds, heart sounds, edema, and color, and compared them with normative criteria. This critical thinking skill includes understanding changes in the role parameters of nursing and medical practice. Although RN-to-BSN students were being introduced to expanded, in-depth health assessment skills, they were cautious in articulating changes in their role perceptions, as alluded to by an ETV student:
We all can sit here and tell you that we know what S1 and S2 sounds like but when you throw another sound in there you know its not my job to say “hey he’s got this or he’s got that.” My job is to say “I hear another sound. I’m not really sure what it is.”… You bet your bottom dollar I’m going to find somebody that’s going to be able to help me.
Discriminating. RN-to-BSN students were discriminating as they distinguished crucial pieces of information from those of less importance. One Internet student described it as, “I learned what was important in an assessment and what could be done later.” Although students discriminated in terms of triaging priority assessments, discrimination was less evident when it came to categorizing patient data. Students were asked to formulate the top three nursing diagnoses; in the majority of cases, the priority nursing diagnosis was not identified. One group of students, who initially suspected that the patient was experiencing congestive heart failure because of edema (a diagnosis that was later confirmed), identified impaired airway and gas exchange, rather than altered cardiac output, as the priority diagnosis.
Information Seeking. Overall, RN-to-BSN students tended to see themselves more as doers than as information seekers and felt frustrated that the simulation focused on assessment and deemphasized interventions. The simulation done alone or as a group tended to influence information seeking. The individual effort required of the Internet students cultivated information seeking in a way not evident with ETV students, as articulated by an Internet student:
Listen to what the patient says and assess a little further for more information…also to use critical thinking a little more. So many times now we are task oriented and rush from one patient task to another without paying attention to what information we are getting.
Students’ perceptions of their role in the simulation influenced the depth of information seeking. Students who perceived their role as one of resolving the patient’s respiratory distress viewed the need for focused information gathering to resolve the immediacy of the situation. Conversely, students who viewed their role as understanding the patient’s situation from a contextual perspective wanted the depth of information seeking that “you read about in a textbook.”
Logical Reasoning. RN-to-BSN students’ logical reasoning was evident throughout the entire simulation and primarily elicited through questioning. These students were skilled in using evidence from their assessments to draw inferences about the nature of the patient’s underlying problem. One ETV student group captured their logical reasoning in the following statement:
We did assume that she had a very low cardiac output because of all the edema and swelling she had.
Predicting. RN-to-BSN students were skilled in predicting, evident in the ease with which they planned and implemented care concurrently with assessment. These students, many of whom were experienced in the care of patients with cardio-pulmonary issues, readily moved from assessing to planning and on to implementation of care. An ETV student described the skill of predicting:
Maybe when I was assessing the lung sounds and saw that she was in respiratory distress I would have gone ahead and done some interventions.
Transforming Knowledge. RN-to-BSN students spoke about how they anticipated applying the simulation content to real practice situations. The opportunity to observe someone else perform an assessment increased students’ readiness for applying this knowledge in the clinical setting. In many ways, the simulation served as a safe venue to experiment with how transforming knowledge would look in real life. An ETV student described this specific critical thinking skill:
You can actually put this practice kind of thing into real working place because you have seen it and you have kind [of] heard these things before. It’s all kind of putting it into the real-world use.