Dr. Wood is Associate Professor, and Ms. Toronto is Assistant Director of the Clinical Learning Center, William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts.
The authors have disclosed no potential conflicts of interest, financial or otherwise.
A Dean’s Incentive Grant from the William F. Connell School of Nursing, Boston College, supported this research. The authors thank undergraduate research assistant Alexandra Mulloy for her assistance in the preparation of the manuscript.
Address correspondence to Robin Y. Wood, EdD, RN, Associate Professor, William F. Connell School of Nursing, Boston College, Chestnut Hill, MA 02467; e-mail: email@example.com.
It is widely believed that the use of a human patient simulator (HPS) to solve virtual patient problems in novel and realistic scenarios will enhance students’ critical thinking. However, research-based evidence to support that belief is lacking (Ravert, 2008) and the influence of HPS on critical thinking dispositions has remained unstudied. Critical thinking dispositions are attributes—the internal motivation or habits of mind used to confront problems and make relevant decisions using focused thinking. These are the characteristics that will promote and enhance critical thinking skills when sufficient knowledge has been acquired to formulate clinical decisions.
Use of HPS in high-fidelity simulation has become a popular method of promoting skills needed for clinical decision making in nursing schools. The American Association of Colleges of Nursing’s (AACN) Essentials of Baccalaureate Education for Professional Nursing Practice (2008) proposes that simulation in education provides an effective, safe environment for learning and applying the cognitive and performance skills needed for practice. According to the Essentials, simulated patient care experiences increase student self-confidence in the communication and psychomotor skills critical to providing nursing care, thereby fostering professional role development. Integral to the development of these basic skills is an attitude of openness to innovation and continual learning on the part of the learner (AACN, 2008). More research is needed to appraise the influence of HPS on critical thinking dispositions in novice nursing students.
Our purpose was to assess the influence of HPS practice on critical thinking dispositions in a sample of undergraduate nursing students. Outcome measures included overall and subscale scores on the California Critical Thinking Disposition Inventory (CCTDI) (Facione, Facione, & Sanchez, 1994). Data reported in the current study are from a 2-year longitudinal study assessing performance outcomes of students using HPS in several clinical courses. This report seeks to answer two specific research questions early in the study: Does a 2-hour practice session with HPS improve overall CCTDI scores? Does a 2-hour practice session with HPS improve scores on any of the CCTDI subscales?
The conceptual framework for this study is guided by affective critical thinking dispositions, one dimension of the two dimensions of critical thinking described in the landmark American Psychological Association Delphi Research Project (Facione, 1990). The principal outcome of the 2-year project was identification of characteristics of critical thinking, including core cognitive skills. Facione and Facione (2010) described critical thinking dispositions as the traits or habits of mind the ideal critical thinker would use to define, analyze, and resolve high stakes problems using reflective judgment. Empirical methods reduced multiple trait descriptions of the ideal critical thinker, proposed by a panel of 46 international academic experts, to seven dispositional characteristics: truthseeking, open-mindedness, analyticity, systematicity, critical thinking self-confidence, inquisitiveness, and judiciousness or maturity of judgment. The result is the CCTDI, an instrument widely used in nursing to measure critical thinking attributes, which are the attitudes and values that influence the learner’s capacity to effectively apply critical thinking skills (Facione et al., 1994). The 75-item scale takes 20 minutes to administer. An overall critical thinking disposition score is calculated, as well as sub-scale scores. The total score possible on the CCTDI is 420, with overall scores below 270 being very rare and above 350 being relatively rare in undergraduate populations. Good reliability of the CCTDI has been reported, with alphas for the seven scales ranging from 0.71 to 0.80 and an alpha of 0.91 for the overall instrument (Facione & Facione, 2010).
Critical Thinking Dispositions
Promoting critical thinking has been a goal in nursing education for many years (Del Bueno, 2005). However, no consensus has been reached on a definition of critical thinking, and measuring critical thinking in students yields conflicting and confounding results (Daly, 2001; Ravert, 2008; Riddell, 2007; Scheffer & Rubenfeld, 2006; Stone, Davidson, Evans, & Hansen, 2001; Walsh & Seldomridge, 2006). The AACN (2008) defines critical thinking as all or part of the process of questioning, analysis, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application, and creativity. Developmental issues preclude full engagement of these processes by the youngest learners. Novice nursing students have not achieved the metacognition or experience required to formulate decisions based on critical thinking. The real learning task at this stage is to build critical thinking attributes. These are stepping stones (or dispositions) that will lead to critical analysis and knowledge application at a later stage of professional development when knowledge is sufficient to guide action.
Human Patient Simulator
As a teaching method, high-fidelity simulation holds the potential for nurturing critical thinking dispositions. It is a promising method to inspire the intrinsic connections required for organized thinking. Basic learners who need increased reaction times to apply new learning to specific situations can benefit from repetitive practice of skills (e.g., vital signs, assessment skills) in a virtual environment (Seropian, 2003). Repetitive practice with HPS may increase deliberative focus on data collection when an unexpected event occurs. Early engagement of students in HPS scenarios may increase the learner’s flexible thinking while fostering a process of linking thoughts and prior-itizing actions in a way that improves patient outcomes. Using HPS can be a significant facilitator in building skill organization and accuracy in assessing physical signs as they change in real time. Practicing assessment skills followed by detailed debriefing of HPS scenarios holds the potential for building critical thinking dispositions among young and inexperienced students.
This was a quasi-experimental design with a self-selected convenience sample (N = 85) of novice nursing students learning health assessment skills in a campus laboratory. Following university approval for protection against research risks, students who volunteered were randomly assigned to the experimental group (n = 42) or the control group (n = 43) on the basis of their exposure to HPS practice prior to the course competency examination. Preintervention, all students completed a researcher-designed demographic and descriptive survey (age, gender, ethnicity, grade point average). The CCTDI was administered to all students as a pretest–posttest 2 weeks prior to and following the intervention.
Students in the experimental group practiced critical assessment competency skills for 2 hours on the HPS manikin and also practiced traditionally (i.e., out-of-class practice with peer partners). Human patient simulator practice was organized in peer groups of four to five students. During the first hour with the HPS, each student was oriented to manikin use then given an opportunity to practice the competency skills on the manikin. During the second hour with the HPS, students individually performed the entire critical assessment on the manikin and observed while peer group members performed the same skills. Simple primary care scenarios were designed so that each student in the peer small group was assigned a different HPS patient with varying ages and vital signs. Small group peers observed individual assessment performance via video feed. Thus, every student in the small group both performed the skills and watched as three to four other students performed the same skill on a different “patient.” Debriefing with group peers and a course instructor followed each assessment performance.
The control group (n = 43) used traditional practice alone to practice the same critical assessment skills. Following HPS practice combined with traditional practice (experimental group) and traditional practice alone (control group), the critical assessment competency examination was given to all students per the usual course protocols. The critical assessment examination was performed on a live peer partner while being observed and graded by a course instructor. Following the competency examination, students were posttested on the CCTDI. After CCTDI scores were obtained at that time point, control group students completed the 2-hour simulation experience given to students in the experimental group.
This sample was predominantly female (96%) and Caucasian (87%), with a mean age of 19.4 years. Their mean grade point average was 3.38. All students were taking a campus laboratory health assessment course in the second year of the nursing program prior to beginning clinical courses.
The mean CCTDI total pretest score was 304.5 for the experimental group and 303.2 for the control group. The mean CCTDI total posttest score was 311.3 for the experimental group and 304.2 for the control group. Mean CCTDI pretest subscale scores ranged from 36.4 to 48 for the experimental group and from 37.7 to 41.1 for the control group. Mean CCTDI posttest subscale scores ranged from 38 to 47.4 for the experimental group and from 38.2 to 47.1 for the control group. Using t-test analyses, there were no significant differences between groups on CCTDI total scores or on the seven CCTDI subscales.
To identify CCTDI gains from pretest to posttest, further analysis examined score differences for each individual across time. Using paired sample t tests, results revealed higher mean posttest total scores compared with pretest total scores in experimental group students (mean difference = 6.54, t = 2.26, df = 38, p < 0.05). Experimental group students performed significantly better on the posttest than they did on the pretest. Significant within-group differences for experimental group students occurred on the CCTDI subscales of truthseeking (mean difference = 2.02, t = 3.27, df = 39, p < 0.01) and judiciousness or maturity of judgment (mean difference = 2.58, t = 3.27, df = 39, p < 0.01). For control group students, there were no significant differences from pretest to posttest on total scores or on any of the CCTDI subscales.
Our findings to date suggest a trend in the direction of improved individual gains in critical thinking dispositions in a sample of novice students using HPS to learn health assessment skills. Even a brief HPS intervention produced significant improvements for individual students in total critical thinking dispositions and in the disposition subscales of truthseeking and judiciousness or maturity of judgment. The debriefing process following HPS scenarios may explain the differences. Debriefing has been described as the linchpin to successful high-fidelity simulation (Issenberg, McGaghie, Petrusa, Gordon, & Scalese, 2005). Awareness of one’s thinking may be a first step in improving critical thinking (Guhde, 2010), and debriefing is a process whereby students are guided to think cognitively and purposely about the HPS experience (Howard, Englert, Kameg, & Perozzi, 2011). Debriefing offers immediate instructor and peer feedback and analysis of performance in hindsight, all of which are not offered by hands-on simulation alone (Shinnick, Woo, Horwich, & Steadman, 2011).
The CCTDI truthseeking disposition scale attempts to measure qualities of being eager to seek the truth and courageous about asking questions (Facione et al., 1994; Kawashima & Petrini, 2004). The individual with a higher truthseeking disposition is not biased and would rather find the truth than win the argument. Truthseekers recognize the pitfalls of preconceived notions and assumptions and seek to challenge original beliefs. This necessarily requires that the individual is flexible in considering alternatives and the opinions of others. Truthseeking may be reinforced through the debriefing process, when accurate or inaccurate assessment findings are played back from direct video feed and validated or challenged by peer and faculty feedback. This leads the performing student to reanalyze the skill performance and reconsider the findings. Students practicing traditionally with peers do not have real-time feedback on the accuracy of findings.
The judiciousness or maturity of judgment scale attempts to measure the qualities of reflective judgment and cognitive maturity. The individual with a higher judicious disposition approaches problems and decisions with discernment, a sense of more than one reasonable solution. Judiciousness is good judgment requiring forethought. It relies on an understanding that decisions based on uncertain standards sometimes must be made (Facione et al., 1994; Kawashima & Petrini, 2004). The HPS experience of assessing a virtual patient compared with a healthy peer may give more purpose to inquiry, promoting fair-minded reasoning and prudent judgment. It is the reflective process of self-analysis and commitment to improvement inherent in HPS debriefing that may increase judicious or mature clinical judgment.
Despite individual gains in dispositions, the strength of the intervention (2 hours of practice with HPS) was probably not sufficient to significantly affect disposition score differences between the groups. Further research will explore how longer HPS practice sessions will affect critical thinking dispositions. For the entire sample, disposition scores fell within a mid range typical of novice students who are evolving in terms of cognitive development (Facione & Facione, 2010). Considerable individual growth in critical thinking dispositions and higher order thinking skills would be expected as students progress through the undergraduate curriculum.
Given that HPS practice is costly in terms of personnel time, space, and technology, the findings reported here merit further study. Additional data collected in this study included outcome measures of accuracy of assessment findings (e.g., blood pressure, pulses, respiratory rate, oxygen saturation, breath, and bowel sounds) in the competency examination and time required to complete the examination. Analysis of those data will provide further insight into the relevance of using HPS to teach these basic skills. If using HPS combined with traditional practice and traditional practice alone achieve similar competencies, perhaps HPS practice should be reserved for teaching more complex fundamental nursing skills.
Limitations of the study included the small sample size and the homogenous nature of the groups. Data were collected in a private 4-year college, and findings cannot be generalized to other nursing programs.
Recommendations for Future Research
This study reports the preliminary findings of a longer longitudinal study exploring the influence of HPS on critical thinking dispositions. Further exposure to HPS practice in clinical nursing courses over four more semesters may reveal differences in CCTDI performance for this cohort compared with prior students who had no HPS practice. Following this cohort through 2 more years of undergraduate nursing education will yield additional findings on these and other practice outcomes of HPS training.
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