The Essentials of Critical Care Orientation (ECCO) Program's Impact on New Graduate Nurses' Critical Thinking Development Sigma Theta Tau International s 21 st International Nursing Research Congress Mahmoud A. Kaddoura BSN, MSN, CAGS, PhD. 1
Health Care has become more complex over the past 3 decades as a result of expansion in technology and demand for quality care. If nurses are to deal effectively with such changes, Critical Thinking is required today more than ever to provide safe care to patients. How is Critical Thinking (CT) developed in new graduate nurses in ICU? And how do Didactic and Online critical care training programs differ in developing novice nurses CT? 2
Critical Thinking Definition CT Definitions vary in breadth or inclusiveness. Some equate CT with the cognitive processes and strategies involved in Decision Making, Problem solving, or Inquiry. CT was also defined in the literature as a process that includes the following skills: Analytical Thinking; Logical Clinical Reasoning; Clinical Judgment; Reflective Thinking; Self- Directed, and Independent Thinking 3
CT Operational Definition: Critical thinking is a higher-order thinking skill which mainly consists of evaluating arguments. It is the purposeful, self-regulatory judgment that results in interpretation, analysis, evaluation, and inference. This process gives reasoned consideration to evidence, context, conceptualizations, methods, and criteria (APA, 1990; Facione, 2006, p.21) 4
Critical vs. Passive Thinkers (Luckowski, 2003) Critical Thinkers Are active & reflective; they raise vital questions & problems, formulate them clearly, gather & assess relevant information & evidence, use abstract ideas, & think openly. Are inquisitive & focused in inquiry, willing to consider & communicate with others, ask questions & analyze, & are willing to challenge their thoughts & investigate evidence. 5
Passive Non-Critical Thinkers Rely on emotions rather than on reasons, ignore known evidence, suffer a limited, selfcentered view; are concerned more with being right rather than finding the best explanation, are not ready to challenge their beliefs. They answer questions with yes or no without details, accept answers without asking for additional data and resources & avoid further inquiry or reflection of the options. 6
Critical Care Training Programs Two Components: 1. Theoretical NGCCP (Didactic) ECCO (Online) 2. Experiential (Clinical) Preceptorship 7
Didactic Critical Care Program Online Critical Care Program Experiential Component Preceptorship Clinical Experiences of Grads with Preceptors Clinical Experiences of Grads with Preceptors Organization of program content Modules of body Systems Modules of body Systems Duration of the Program six months six months 8
Didactic Program Online Program Theoretical Component NGCCP ECCO Presence of Teacher Teacher Available Teacher Not Available Group Discussion Yes No Simulation Yes No 9
Purposes of the Study 1) Explore the perceptions of new graduate nurses related to their CT development in their critical care Orientation programs 2) Investigate the differences between Didactic & Online Education programs in relation to the CT development of each approach 10
Research Questions 1. How do new graduate nurses characterize the role of the didactic education program in influencing their CT? 2. How do new graduates characterize the role of the online education program in influencing their CT? 3. How might the differences in the two programs explain the differences in the new grads perceptions of CT development? 11
Literature Review Abundant literature on CT: No common understanding of what CT means. 6 CT Skills Interpretation Analysis Inference Explanation Evaluation Self-Regulation (Facione, 2006) 6 CT Dispositions Open Mindedness Inquisitiveness Truth Seeking Analytical Thinking Systematic Thinking Self-Confidence 12
CT Studies Walsh & Hardy (1999): Interactive educational programs improved CT dispositions in nursing students (pretest-posttest). Brunt (2005): No relationship between CT and clinical competence in both nursing students and practicing nurses. Rogal & Young (2008): CT scores of nurses enrolled in a post-graduate critical care course improved over time (pre-posttest). 13
Didactic Teaching Face to face lecturing is the most common teaching method used in educational instruction (Handelsman, et al., 2004). Didactic teaching often lacks learner/teacher dialogue. It is explicitly focused on memorization, and is deficient in illustrations, implications, and application. Lecturing often emphasizes rote learning rather than CT; topics are discussed sequentially rather than critically. 14
Online vs. Didactic Teaching Research There s no significant difference in learning between the online and didactic methods of teaching (Johnson, et al., 2000). Online education is as effective as didactic teaching (Bernard, 2004). As time goes by, there s more positive trend of students achievement in online teaching than in didactic teaching settings. 15
Methodology Design: Exploratory qualitative descriptive. Sample: N = 16; 8 Didactic & 8 Online subjects Data Collection: IRB Approval/Informed Consent Tools: Surveys & Semi-structured interviews. Data Analysis: Content analysis, interviews were taped, transcribed & analyzed using software.. 16
Ethical Considerations Data may help understand how online & didactic education programs enhance CT; guide education of future grads & contribute to research on CT. No foreseeable physical/emotional risk to subjects. Confidentiality was maintained (all surveys coded). IRB guide: (voluntary participation, audiotapes destruction, anonymity). 17
Findings Demographic data of participants: All were females, with BSN Degrees, All spoke English as their first language Ages were 21 to 35 years old 15 are White Americans and 1 is Hispanic, 18
Development of Themes Four distinct themes emerged. Each theme had further sub-themes. First Theme: New Grads Description of CT Sub-themes Multi- Perspective Thinking Analytical Activities Nursing Process (Assessment-Evaluation) 19
Second Theme: Methods of Gaining Knowledge and the Impact of each on CT Development Third Theme: Application s of Knowledge and its Role in the Development of New Grads CT. Fourth Theme: The Teaching/Learning Environment and its Impact on New Grads CT Development. 20
Participants Perceptions What Did Grads Say about the Didactic Program? The program helped develop my CT skills through questioning, scenarios, discussions in class, tests & questions that were asked in a way to develop CT skills such as analysis, application, reflection, reasoning, and evaluation. (Nurse 1) The simulation & case studies helped develop my CT to a great extent, they engaged me in analytical decision making. (Nurse 5) 21
What Did New Grads Say About the Online ECCO Program? Nurse 11: the theory part of the program helped her in developing CT, tutorials were informative. I'm glad that I have access to the ECCO for a year to go back and look at it (Nurse 13) Nurse 17 liked the option of learning online at home & wherever there s Internet. The length of the ECCO program we re required to attend was intense, at times boring (Nurse 12) 22
What Did New Grads Say About their Overall CT Development in the Online & Didactic Programs? After 6 months orientation, am more intuitive to monitor my patient & my clinical skills, looking at the whole picture, am thinking big now. (Nurse 1) I know now I can handle difficult situations, analyze, evaluate and manage critical patients conditions, I think that is CT because I am now more able to solve clinical problems and use logical reasoning appropriately. (Nurse 12) Well, I ve got some CT now. I didn t have any before. (Nurse 14) 23
DISCUSSION New Graduate Nurses Definitions of CT The study showed that new graduate nurses perceptions of their own descriptions of CT were in line with those in the literature (Analysis, synthesis, problem solving, decision making, intuition, inquisitiveness, reflection, looking at the holistic picture of patients, thinking outside the box, etc. 24
Grads Perceptions of the Didactic Program Grads reported: Teaching by didactic lecturing developed their CT. Their interaction with their peers & teacher greatly developed their CT. Grads reported: case studies built up their CT. Discussion of cases & activities acquainted them with skills & attitudes associated with CT & provided them with practice to improve care Strategies & skills in CT are keys to independent judgment & learning, which can be transferred to inquiry within & outside class to think critically and act more effectively. 25
Grads Perceptions of the Online Program Grads reported advantages to using ECCO: content was informative; they made huge gains in learning with ECCO. They cherished the ability to view the Online content as many times as desired for a year; they referred back to ECCO whenever they had a case for the first time in ICU. They liked using Online Program at their own pace with the ability to review difficult sections whenever needed. 26
Teaching Learning Environment There is a strong relationship between an open, supportive, & structured classroom climate, where opinions on issues may be explored & expressed in a non-threatened manner, & development of CT & attitudes. Effective teachers challenge learners to examine alternative positions on topics or issues, require justification for beliefs about what is true or best for the patient. 27
Implications for Nursing Education Findings point to the Didactic grads perceptions related to the value & importance of simulation & case study teaching as they impact learning. Results point to perceptions of the Online grads related to the importance of the presence of a nurse educator to facilitate the teaching learning process that in turn enhances grads CT. Lessons/lectures that stimulate questions & criticism in pursuit of knowledge, appropriate to the cognitive & personal development of students, should be encouraged to promote CT. 28
Implications for Nursing Practice The findings point to grads perceptions related to knowledge they gained through their Didactic & Online programs, teaching methods as case studies & simulation experience & the value of transferring knowledge to the clinical settings. This transfer of knowledge is crucial to apply the knowledge & bridge the gap between theory & practice, which would enhance grads CT. Nurse educators play a key role in helping grads to apply the knowledge & develop CT. They should be acknowledged for what they do. 29
Implications for Nursing Management and Administration Nurse managers & administrators should be involved in allotting budget for assigning at least one nurse educator to support grads learning needs, purchasing and encouraging the application of simulation and needed technology. Nurse managers should ensure that the educators they hire challenge nurses to apply interrelated knowledge & skills to decisions about what to do. In the process of evaluating knowledge claims & value judgments involved in problem solving and decision making, novice nurses will be able to develop propensity for & capability in CT. 30
Recommendations Conduct research to explore more critical care orientation programs; include a larger sample, males/females from various ethnicity. Compare upon program completion, and 6 months & 1 yr after, the effects of participation in these or other training programs: (1) measure the ability of participants pre- & post-orientation to think critically; 2) performance evaluations; (3) retention in the facility or organization that provided the training; (4) job satisfaction; & (5) seeking additional credentialing or education. 31
Conclusions This study found: all new grads (in the Didactic and Online Programs) perceived their own CT increased throughout the training programs despite the # in the 2 approaches. New Grads (Didactic Program): The Teacher played a key role in developing CT. Teaching-learning environment was relaxing, motivating, and engaging to NG. Case studies & simulations offered opportunity to apply knowledge & promote CT. 32
Conclusions (Cont ) New grads (Online Program) reported: Content was very informative & helped them gain fundamental knowledge they needed in ICU. They appreciated that the Online ECCO was accessible from hospital & home. They valued the fact that they have access to the Online program for one year. Lack of a teacher & Discussion Forum stressed them out & limited their CT development. 33
Take Home Messages The word didactic, was possibly used for lectures in which the active teacher presents information to passive students. Yet, that is not how Didactic is being used in contemporary education. Now, didactic teaching may engage learners minds & make them active learners. It s not the content that promotes learners CT, it s how we prepare the material & learners & how we present the content. 34
Take Home Messages (Cont d) All learners, regardless of the program they are educated with or the presumed limitations in CT ability, have some degree of potential to think critically. This potential can be developed to the fullest by embedding CT in the core curriculum, school subjects required of all learners. The teacher & learners can be engaged in mutual dialogues & thoughts; both can actively think about the ideas placed before them. As a result, both move toward a better level of CT. Active teaching strategies (ATS) not only produce actively engaged learners; but critical thinkers who are problem solvers, decision makers and lifelong learners. The critically thinking teacher is who uses ATS properly/effectively. 35
Take Home Messages (Cont d) Didactic teaching is a useful means to introduce strategies and skills, but reliance on this method is insufficient. Learners must be stimulated to think critically on their own to resolve dilemmas, take stands on issues, judge propositions about theoretical knowledge or clinical situations (application) 36
THANK YOU Mahmoud A. Kaddoura, PhD. 37