On Impostorship, Cultural Suicide, and Other Dangers: How Nurses Learn Critical Thinking

A qualitative study of reflective practice in the workplace. Speech-language pathologists have their say

PURPOSE

Engaging in reflective practice (RP) and demonstrating reflective abilities is an essential graduate skill for speech-language pathologists (SLPs), yet limited studies have examined the perspectives of practicing SLPs and how and why they engage in RP. This qualitative study aimed to examine SLPs' experiences and perspectives of RP in diverse workplaces.

METHOD

Individual semi-structured interviews were conducted with 30 SLPs working in health, education, or private practice sectors. Interviews were analysed using thematic analysis.

RESULT

Three themes were developed from the data, describing what SLPs use RP for, what SLPs perceive as important in order to engage in RP in the workplace, as well as the barriers they have identified, and how SLPs have observed a change in engaging in RP as they have progressed in their careers.

CONCLUSION

SLPs described that RP is valued in the workplace for supporting client focused care, problem-solving, and lifelong learning. SLPs wanted time to be protected for RP at all stages of their career and valued the relationships with others as contributing positively to RP. Perceptions of and engagement in RP changed in relation to SLPs' clinical experience. Implications for clinical practice are discussed.

Politics or paranoia: Reading between the lines when undertaking social research studies

Although reports of political issues in social research were popular in the 1960s and 1970s, more recent accounts of nursing research largely neglect this area. This paper highlights such political issues, offering guidance to help equip researchers to deal with these.

Published reports of research studies necessarily present a linear account of how, and how well, the research question was answered. It is rare for research to follow so straightforward a path, because interwoven is a little discussed, but not uncommon, political arena. Standard texts offer plenty of guidance on research ethics, but there is little advice to help researchers walking a thin line between diverse political elements. This paper draws on the literature and provides examples from the authors' research to illustrate some of the key political scenarios researchers may face. The advantages and disadvantages of insider/outsider status are discussed in order to present a 'matrix of involvement' to illustrate key issues. It is suggested that as the pressure to undertake funded research rises there is likely to be an exponential increase in the complex political environments in which research takes place. This paper offers some pointers towards reading between the political lines and navigating research successfully towards a conclusion.

Recognising the challenges of collaborative, multi-site research

Background: Collaborative multi-site research is gaining recognition. In particular, across stakeholders in the health and social care professions, there has been an increase in the documentation of such approaches, with the majority acknowledging the strengths and few identifying the pitfalls. Four universities in the south west of England collaborated on the design, analysis and implementation of a project scoping the staff development needs of nursing and midwifery academics to meet the National Health Service Modernisation Agenda in the United Kingdom.

Aim: This paper highlights the challenges and the lessons learned from each stage of the process of this large multi-site collaborative study. Consideration has been given to addressing the site-specific differences as well as the politics of the processes and power relations across the research team.

Discussion: From an analytical reflection across the team, there were a number of lessons learned from the process of collaboration. Initially, the main challenge was the selection of the team and lead researcher and these were its greatest success. Nevertheless, managing each individual's competing roles within the organisation remained problematic. Particular challenges included gaining consensus on the research design, the chosen sample and data collection to reflect the site-specific differences and were overcome through discussion and effective leadership. Towards the end of the study, adequately representing each institution in the findings, as well as dissemination have remained the greatest challenges.

Conclusions: While collaboration has been lauded as a way forward, this analysis of the process highlights some of the difficulties of working as a multi-site virtual team who are widely spread geographically and who have no previous connection. At different stages of the process there has been acknowledgement of the political dimensions affecting such an approach and a need to avoid the pitfalls of collaborative working in order to harness the potential of all team members, if success is to be achieved.

Attitudes of paediatric intensive care nurses to development of a nurse practitioner role for critical care transport

AIM

This paper is a report of a descriptive study of the attitudes and opinions of nurses before and after the introduction of independent Retrieval Nurse Practitioners into a critical care transport service for children.

BACKGROUND

Little is known about nurses' attitudes to advanced practice roles, particularly when these function as part of a team in a high-risk, remote setting (distant to the base hospital). Increasing knowledge in this area may give insight into ways of improving team working and enhancing quality of patient care.

METHOD

A qualitative questionnaire was sent to nurses pre- (June 2006) and post- (July 2007) retrieval nurse practitioner introduction. Questionnaires were analysed using an adapted phenomenological method.

FINDINGS

The response rates were 62% (2006) and 48% (2007). The main themes that emerged included fear, communication, trust, team working, role conflict, role division and role boundaries. In the first survey, most nurses anticipated difficulties during retrieval with retrieval nurse practitioners and felt anxious about the prospect of being part of a team with an independent retrieval nurse practitioner. However, by the second survey (after retrieval nurse practitioner introduction), the majority reported confidence in the retrieval nurse practitioners' knowledge and skills.

CONCLUSION

This advanced practice development has been a challenge for the nurses and the retrieval nurse practitioners, but initial anxieties and fears of a host of anticipated problems have been largely dispelled as enhanced communication and team working were reported.

Constrained physical therapist practice: an ethical case analysis of recommending discharge placement from the acute care setting

BACKGROUND AND PURPOSE

Constrained practice is routinely encountered by physical therapists and may limit the physical therapist's primary moral responsibility-which is to help the patient to become well again. Ethical practice under such conditions requires a certain moral character of the practitioner. The purposes of this article are: (1) to provide an ethical analysis of a typical patient case of constrained clinical practice, (2) to discuss the moral implications of constrained clinical practice, and (3) to identify key moral principles and virtues fostering ethical physical therapist practice.

CASE

The case represents a common scenario of discharge planning in acute care health facilities in the northeastern United States.

METHODS

An applied ethics approach was used for case analysis.

RESULTS

The decision following analysis of the dilemma was to provide the needed care to the patient as required by compassion, professional ethical standards, and organizational mission.

DISCUSSION AND CONCLUSION

Constrained clinical practice creates a moral dilemma for physical therapists. Being responsive to the patient's needs moves the physical therapist's practice toward the professional ideal of helping vulnerable patients become well again. Meeting the patient's needs is a professional requirement of the physical therapist as moral agent. Acting otherwise requires an alternative position be ethically justified based on systematic analysis of a particular case. Skepticism of status quo practices is required to modify conventional individual, organizational, and societal practices toward meeting the patient's best interest.

Masters at work: a narrative inquiry into the experiences of mental health nurses qualifying with an undergraduate Masters degree

The University of Nottingham provides a unique course in the UK that enables undergraduate students to obtain a Masters degree and registration with the Nursing and Midwifery Council (NMC). The curriculum equips graduates with the skills to practice nursing with an analytical attitude and adopt both professional and humanistic values. This research aims to explore significant experiences of graduates, from the undergraduate Masters course, relating to their education and nursing practice in mental health care. A narrative approach to data collection was employed using unstructured individual interviews. Participants worked through a process of contemplation. Their commitment to working with people in a relational manner and studying at graduate level were of high importance. The process continued with assimilation to a philosophy which was intrinsic to the course, including developing therapeutic relationships, self awareness and critical thinking. Participants encountered conflict relating to a perceived dissonance between this philosophy and nursing practice. As a consequence, participants questioned mental health nursing and their abilities as nurses. Resolution occurred when participants were able to work within the constraints of the system whilst effectively realising their philosophy. The findings demonstrate the importance of supportive networks to maintain values and criticality.

Mistaken, misshapen and mythical images of nurse education: Creating a shared identity for clinical nurse educator practice

The hospital-based clinical nurse educator is pivotal to the integration of formal learning and clinical practice. Clinical nurse educators are generally considered to be expert nurses within a particular clinical environment; however, many of those who are expert clinicians suffer some loss of identity when assuming clinical teaching roles. It is necessary to facilitate the expression of identity in order to foster collective agency and to empower individuals and groups. In a health care system that is awash with change, the importance of this may often be overlooked. This paper reports on the process and outcomes of a series of workshops with clinical nurse educators in a New South Wales area health service that sought to create a shared identity and role for clinical nurse educators within the health service. Challenges in role demarcation and delineation of the roles and functions of clinical nurse educators clinical nurse specialists, clinical nurse consultants, practice development facilitators and nurse educators have been reported. Each of these has overlapping and complementary roles to support learning, however, the primary focus and area of responsibility varies among each of these groups.

Evaluation of a reflective learning intervention to improve critical thinking in novice nurses

AIM

This paper reports a study to determine if a reflective contextual learning intervention would improve novice nurses' critical thinking skills during the first 6 months of their practice.

BACKGROUND

Nursing research evaluating the development of critical thinking in novice nursing practice is limited. The continual struggle by nurse educators to improve critical thinking demonstrates the need for innovative educational interventions that assist in the development of critical thinking as novice nurses enter into practice.

METHOD

This small case study was conducted in the United States of America in 2004 with six student/preceptor dyads. The contextual learning intervention was the case through which the novice nurses' critical thinking were analysed using Stake's phases of data analysis. Specific questions (i.e. novice nurses' use of reflection, context, dialogue, time) guided the analysis. Repeating patterns were coded and isolated and later collapsed/enhanced as the analysis moved forward.

FINDINGS

Three main themes describe the novice nurses' development of critical thinking: (1) influence of anxiety and power on critical thinking; putting pieces together; (2) questioning as critical thinking: sequential thinking to contextual thinking; and (3) emergence of the intentional critical thinker.

CONCLUSION

Used as a reflective practicum, contextual learning can be a model of clinical learning in nursing education that develops the contextual, reflective nature of critical thinking.

A Qualitative Tool for Critical Thinking Skill Development

Quantitative measures were not meeting the needs of faculty for evaluating critical thinking among Baccalaureate of Science Nursing students. The authors discuss the critical thinking self-reflection tool that was developed for teaching critical thinking and qualitatively evaluating changes over time with established interrater reliability and content validity. The tool is consistent with the concepts of critical thinking in the curriculum and was implemented systematically in all clinical nursing courses.

Living theory: enhancing the psychological support of patients

This article explores how nurses, involved in a research project incorporating teaching psychological theories and counselling skills to enhance the psychological support of patients with wounds, had, one year on, changed their professional practice. This inquiry was framed by living theory, a concept previously only used in education, which is based on the integration of known knowledge, newly taught knowledge and increased self-awareness. The major principle of living theory is that one's values are questioned, modified, clarified and sometimes changed completely in striving to improve one's professional practice. This research showed nurses creating their own living theories, aspiring to really care for the whole person by developing strong, meaningful relationships with patients. The steps that participants took from first using the enhanced way of working with patients with wounds, to using it to support all patients psychologically, are demonstrated.

The use of reflection in a palliative care programme: a quantitative study of the development of reflective skills over an academic year

The use of reflection in a palliative care programme: a quantitative study of the development of reflective skills over an academic year Reflection has gained a reputation for encouraging the integration between theory and practice within professional education. However, this reputation is based on an evidence base that mostly consists of theoretical debate. The aim of this study was to test our experience that the ability to reflect is developmental and that some reflective skills are harder to achieve than others. The research was undertaken by assessing the degree to which registered nurses achieved reflective criteria within assignments submitted for a variety of palliative care undergraduate modules. A total of 160 assignments were analysed using a marking grid constructed from a literature review and the results were compared between students and across academic terms. The results suggest that students are able to describe their practice but find it harder to analyse knowledge, the context of care and to action plan. Nevertheless, reflective abilities developed over time with significant developments made between each term. However, the development of skills indicative of critical reflection was less evident and confined to the ability to raise implications for future learning. The lack of multivariate analysis limits the study. However, the findings build on previous research and prompt questions for future work, particularly with respect to the process of reflection and how this can be supported in order to encourage the development of critical reflective skills.

A Case Study Approach: Developing Critical Thinking Skills in Novice Pediatric Nurses

BACKGROUND

The development of critical thinking skills in pediatric nurses is imperative to ensure quality nursing care is delivered. Many new graduates have had limited exposure to pediatric nursing.

METHOD

The case study method is an approach to develop competencies with real or hypothetical situations.

RESULTS

Case studies provide an interactive teaching-learning strategy that can be applied to novice pediatric nurses in a variety of settings.

CONCLUSION

By using case studies, nurse educators responsible for the professional development of new graduates, help expand learners' critical thinking as they assume increased responsibility for pediatric nursing care.

Mediating conflict and control: practice challenges for nurses working in palliative care

A work-based professional development program was offered to a group of registered nurses working in palliative care. The goal of the program was to improve skills in psychosocial care (Yates et al., 1996). Participants were encouraged to reflect critically on their practice experience within a group setting. The focus of the group discussion and reflection were shared practice incidents. Each participant was given the opportunity to identify and describe an incident from their professional practice that presented a challenging issue within palliative nursing. This paper explores the themes of conflict and control, evident within the collection of fifteen practice incidents and discusses the nurses' role as mediator. The concepts of patient advocacy and professional autonomy are challenged through the nurses' experience of providing care within a hierarchical and bureaucratic health service. The outcome of reflection for the organization is most effective when shared experience and collective action (rather than individual practice) are the focus.

Inquiry-based learning and critical thinking in an advanced practice psychiatric nursing program

The advanced practice psychiatric nurse must be prepared to meet the changing demands being placed on the nursing profession. Some changes are the product of health care reforms, especially managed care. Others are more fundamental, because continuing scientific advances drive rapid changes in the knowledge base required of mental health nurses. Curricular reforms initiated earlier this decade were intended to equip nurses with the problem-solving and critical-thinking skills required to deal with novel and complex situations in a rapidly changing healthcare system. This article describes how the Inquiry-Based Learning tutorial method attends to the mental processes of graduate students and fosters critical-thinking skills.

Inquiry-based learning as a teaching strategy for critical thinking

Changes in the healthcare system have prompted educators to rethink and revise nursing curricula. The National League for Nursing has outlined recommendations for the successful implementation of socially relevant curricula that reflect the diversity and plurality of local communities. Such revisions should better prepare graduates to function in a reformed healthcare system. Educational goals have shifted from curricula content to curricula outcomes. Beyond the mastery of content (which may quickly become outdated), the development of specific skills (critical thinking) and innovative responses to problems are now required of advanced practice nurses. Inquiry-based learning (IBL) offers an opportunity for graduate students to develop the necessary skills for effective practice. This article presents a model of IBL in graduate mental health education and an investigation of critical thinking skills as a possible outcome of the IBL method.

Critical Thinking in Nursing: Classroom Tactics That Work

Critical thinking ability is one of the required outcomes of nursing education and content coverage is a focus of the past (National League for Nursing, 1996). As educators, we must attend to how we define critical thinking, what educational methods support its development, and how we can assure that students have achieved some acceptable level of critical thinking skill (Tanner, 1993). This article describes the emergent development of one critical thinking format in a Community Health Nursing course. Rather than approaching critical thinking from a theoretical perspective or focusing on one type of assignment or experience as a tool to foster critical thinking development in nursing courses, this article shares with the reader a complete package. Problems, pitfalls, new insights, and changes are shared as they developed through the teaching of a semester-long Community Health Nursing course. The authors hope their experiences give faculty ideas about how to infuse critical thinking into nursing curricula.

It is time to move from the nursing process to critical thinking

As we reflect on the concept of critical thinking in perioperative nursing practice, we should ask ourselves whether we think critically. If not, we must learn the principles of critical thinking and apply them in our clinical practice settings. Our perioperative nurse managers and directors must demonstrate critical thinking in leading other nurses in the delivery of quality, cost-effective, service-oriented patient care. They also must identify peers who use critical thinking skills to support and sustain them in their quest.

Thinking About Thinking

BACKGROUND

The nursing leadership at a 900-bed tertiary-care facility in the southeast believed an opportunity existed to improve the critical thinking abilities of the professional nursing staff.

METHOD

A team, consisting of a diversified group of nurse educators and managers, had the opportunity to gain understanding of the critical thinking process of the nursing staff as well as to develop a plan designed to improve critical thinking skills.

RESULTS

Outputs of the team included development of a critical thinking model and process as well as an action plan that specifically outlined how it would implement the model within the organization using a preceptor-based educational process.

CONCLUSION

Nursing leadership within this facility believes that nurturing critical thinking in the staff will have a positive impact on care delivery outcomes. Creating shared visions through the assumptions that the staff and organization hold is important to improving care provided. Assisting staff with using a critical thinking process in order to construct, tear down, and then reconstruct clinical incidents as encouraged by this model is one key to problem-solving.

Education for the nursing of children and their families: standards and guidelines for prelicensure and early professional education

To strengthen the preparation of nurses for care of children and families, standards and guidelines for prelicensure and early professional education were developed by a working group with broad-based input. Assumptions, theory, practice, and research underlying the standards and guidelines concerned the nature of health care, knowledge, teaching, learning, and evaluation. The 11 standards are presented and guidelines are illustrated. How they are implemented will depend on local resources and philosophies. Continued dialogue among nurse educators is needed to refine and develop the standards and guidelines.

Community Program Planning: A Clinical Outcome

Healthcare reform has affected all aspects of the healthcare system including nursing education. According to Nursing's Agenda for Health Care Reform, a major focus of future care will be in the community. Critical thinking skills are needed to practice effectively in this domain. Critical thinking has been identified by the NLN as an outcome criteria for baccalaureate education. The following community health project was designed to develop this outcome skill of critical thinking.

Walking Around the Elephant: A Critical-Thinking Strategy for Decision Making

The parable of the blind men and the elephant provides a metaphor for emphasizing important characteristics of critical thinking and strategies for decision making. The article describes critical thinking as a process and cognitive skill that functions in identifying and defining problems and opportunities for improvement; generating, examining and evaluating options; reaching conclusions and decisions, and creating and using criteria to evaluate decisions. Critical thinking improves the quality of professional and personal decisions. Critical thinking also contributes to the effectiveness of group decision making by creating synergy and collaboration. The article presents evidence of the crucial nature of critical thinking in nursing practice, management, and executive roles, and in the practice of continuing education and staff development. The article identifies and develops the major defining characteristics of critical thinking. Illustrating the characteristics in practical examples, the article suggests ways to foster critical thinking for ourselves, with our learners, with managers, and with our colleagues.