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Clinical Scenarios for Critical Thinking.

Introduction

Critical thinking is an important cognitive skill for students to develop in a health professions program. Through critical thinking students consider multiple perspectives to patient care, critique different approaches possible in a clinical situation, weigh options and make sound decisions, and raise questions about issues to further clarify them (Oermann, 1997, 1998; Oermann & Gaberson, 1998).

Critical thinking is essential for clinical practice. Patient assessment, diagnosis, intervention, and evaluation require critical thinking. In assessment, critical thinking enables students to differentiate relevant from irrelevant data, identify important cues in the data, identify when additional data are needed for decision making, and identify patient problems. Other important skills requiring critical thinking are: generating competing diagnoses, evaluating each diagnosis to determine what is wrong with the patient, comparing different interventions that might be possible, deciding on measures to use in a particular situation, and evaluating the effectiveness of interventions (Oermann, 1998).

Critical thinking skills are not developed through lectures and readings and require instead teaching strategies that present real-life problems and patient care situations for student critique. The purpose of this article is to describe how to develop and use clinical scenarios as a method for teaching critical thinking.

Developing Clinical Scenarios for Critical Thinking

Clinical scenarios provide simulated cases for student analysis and decision making. The scenario has two parts: a case situation for analysis by the student and questions to answer about the case or from its analysis. The actual situation described in the case should be short; it should contain enough information for analysis without guiding the student's thinking in a particular direction.

The case should present a patient situation not described previously in class or through other instructional methods. Without the introduction of new material in the case, students may have memorized how to problem solve and arrive at decisions for the situation from prior discussion or their readings rather than thinking through the possibilities themselves (Gaberson & Oermann, 1999).

The questions developed for the scenario are the key to using this method for promoting critical thinking. The questions are not intended to review essential facts but instead are to provoke critical thinking, allow students to consider different solutions to problems, and encourage students to examine their own value systems (Fuszard, 1995, p. 82). Questions should be open-ended, asking for alternate possibilities and perspectives. With most scenarios the questions should ask students to provide a rationale for their answers. It is important that students describe the thought process used to arrive at an answer rather than the answer alone.

The questions should be geared to the objectives to be met. For instance, if the intent of the scenario is to promote development of decision making ability, then the questions should ask about different possible decisions and consequences of each. If the goal is problem solving, then questions should ask about alternate possible problems in the case, how to rule them in or out, different solutions that might be appropriate, and their potential effectiveness.

The scenario should assist students in applying concepts and theories learned in class and through readings to a particular patient situation. Neill, Lachat, and Taylor-Panek (1997) described their use of case studies throughout a nursing course as a means of helping students apply course content to clinical practice. Each case consisted of a description of a patient at different points in time followed by questions on critical thinking. Scenarios may be integrated in classroom presentations and discussions, completed by students outside of class, and/or discussed in clinical conferences.

In health professions programs, case studies have been used over the years as a means of helping students apply theory to practice. Critical thinking scenarios differ from these traditional case studies because they are short, and thus do not provide extensive background information about the patient, and they are geared to promoting specific critical thinking skills, such as problem solving, decision making, and ability to consider multiple clinical perspectives. The teacher first determines the critical thinking skill to be developed, then designs a scenario to promote this thinking.

Types of Clinical Scenarios

The clinical scenario may be developed around actual or hypothetical patients. Depending on how the scenario is written, this method is effective for (1) applying concepts and theories to clinical practice, (2) learning how to analyze a clinical situation, (3) identifying problems and solutions, (4) comparing alternate decisions possible and developing decision making ability, and (5) considering multiple perspectives in a clinical situation. See Table 1 for an application example of each of these types of scenarios.

Table 1: Types of Clinical Scenarios for Critical Thinking

Applying Concepts and Theories to Practice

The nurse visits a patient who was sent home from the hospital two days after the normal delivery of her third child. The baby is jaundiced and appears dehydrated. When the nurse tells the mother that she is calling the doctor, the mother begins to cry and yells, "I can't handle this right now."

1. What are possible reasons for the baby's jaundice? Describe the physiology of this occurrence in the newborn.

2. What should the nurse do now? Why?

3. Select one theory that can help explain the mother's reaction. Analyze the mother's response in terms of this theory.

Analyzing a Clinical Situation

Mrs. K is in her 32nd week of pregnancy. Her ankles and hands are swollen, and her blood pressure is 160/90.

1. Discuss the relationship between Mrs. K's swelling of the ankles and hands and her blood pressure.

2. What additional data should be collected at this time? Why is this information important?

Identifying Problems and Solutions

Mr. Z, 26 years old, was admitted with extensive bums on his face and ears. When walking toward the room, you see him crying while looking in the mirror. When you walk into the room to console him, he stops and says, "I'm fine now."

1. What are two possible responses you could make to Mr. Z? Provide a rationale for each of these.

2. What problems need to be solved in this scenario?

3. What approaches would you plan for Mr. Z's continuing care? Why would these be effective?

Developing Decision Making Skills

You overhear your friend telling a new nurse on the unit not to worry about wearing sterile gloves when changing the patient's dressings because "he has an infection any way."

1. What are your options?

2. What are the consequences of each of these options?

3. What would you do? Why?

Considering Multiple Perspectives

Ms. P is 18 years old and dying from bone cancer. She has severe pain that is not relieved with medications. She asks you if she can refuse her next dose of chemotherapy because it is "not working any way. I am only taking the chemotherapy because my mother wants me to."

1. How would you respond to Ms. P? Why is this an appropriate response?

2. What questions would you ask her?

3. What assumptions did you make about Ms. P?

4. What are issues to be resolved in this situation?

5. What are Ms. P's options?

Applying Concepts and Theories to Clinical Practice

Clinical scenarios help students learn how to apply concepts and theories presented in class or through other teaching methods to patient situations. Students may be asked to identify different problems given the data, identify additional data to be collected, analyze the case using specific concepts and theories presented in class, give alternate views of the scenario, and decide on approaches to use in the situation. In responding to these questions, it is important for students to provide a theoretical rationale that supports their answers.

Analyzing a Clinical Situation

Clinical scenarios can also be used to provide experience for students in analyzing data, differentiating relevant from irrelevant data, determining missing information for problem solving, and identifying additional data needed before any decisions are made. Ulrich and Glendon (1999) emphasized the importance of students having experience in analyzing complicated and often incomplete data sets to better prepare them for the realities of clinical practice.

Identifying Problems and Solutions

If the goal is to promote problem solving, the scenario should describe a clinical situation with possible alternate problems given the information in the case, or the approaches for problem resolution should be unclear. Questions with this type of scenario might ask students to:

?? Identify all possible problems in the scenario and provide a rationale for each

?? Describe problems that might be possible if more data were available and discuss what additional information they would collect

?? Propose different interventions and approaches to solving the problems, discuss why they would be effective, and describe advantages and disadvantages of each

?? Decide on the best approaches for solving problems in the scenario and provide a rationale, derived from theory and research, for their use.

Developing Decision Making Skill

Clinical scenarios also may be used for developing decision making ability. For this purpose, the scenario may present the case up to the point of a decision, then ask students to critique the situation and decide what to do. Another strategy is to describe the clinical situation and the decision of the health professional, then have students provide a rationale as to whether this is the best decision for the situation. Because the focus of these scenarios is decision making, the questions with the case should routinely ask for possible alternative decisions and the consequences of each, the decision of the student, and why that decision is the best considering the alternatives.

Considering Multiple Perspectives

Few clinical situations are clear cut, and students need to develop the ability to "think beyond" the obvious in the practice setting. Experience in considering alternate views, comparing different possibilities, and "thinking beyond" the obvious may be provided through clinical scenarios. For cases of this nature students should be asked to:

?? Raise questions about the case that influence its analysis

?? Describe multiple problems and issues in the case and discuss alternate ways of approaching them

?? Record the assumptions they made when analyzing the case

?? Identify and compare two or more points of view about the case and provide a supporting rationale for each

?? Take a position about an issue in the case and develop a rationale to support it.

Critical Thinking for Interdisciplinary Education

Providing health care for a given population is an interdisciplinary activity. Rarely can one type of health professional meet the needs of patients along the continuum of care. More interdisciplinary models of care delivery have evolved as a means of providing coordinated and cost-effective care in different phases of the patient's recovery.

Future health professionals need to learn about the roles and responsibilities of other providers and appreciate the knowledge and skills of interdisciplinary team members. This learning includes an understanding of the interventions of multiple disciplines and how to coordinate them to provide the most effective care to patients. This outcome is important so students appreciate the interdisciplinary nature of patient care rather than viewing care from only their discipline. Yet, few health science students are educated to participate in interdisciplinary care (Mitchell et al, 2000).

Critical thinking scenarios are one strategy to assist students in health profession programs to better understand the nature of interdisciplinary care. Scenarios can be designed to examine how different health providers think through patient care situations, weigh options for care, and make decisions. See Table 2.

Table 2: Example of Scenario for Interdisciplinary Education

Mr. P was involved in an accident at the factory where he worked resulting in a closed head injury, when he arrived at the emergency department, the admitting nurse recorded in the medical record that the patient was "restless and incoherent." His vital signs were: BP 130/80 HR 92bpm Respirations 20/minute

After admission Mr. P became increasingly incoherent and drowsy. The physician ordered a computed tomography (CT) scan that showed a left-sided epidural hematoma.

1. Describe the pathophysiology of an epidural hematoma, what are anticipated responses of the patient to an epidural hematoma that is left-sided?

2. what is the classic clinical picture of epidural hematoma? Are Mr. P's responses consistent with this diagnosis? Why or why not? What additional data should be collected?

3. The physician is concerned about an uncal hernation. Describe this condition from a medical perspective. What observations should the nurse make?

4. Discuss surgical and medical options for the patient. Compare these in terms of effectiveness.

5. Mr. P is sent for another CT scan. What actions by the technician could result in increased intracranial pressure? What actions by other providers might increase intracranial pressure? Why?

6. What pharmacologic agents decrease cerebral edema for a patient with an epidural hematoma? How do these work?

7. As a group, plan care for Mr. P. How would you include occupational health?

These scenarios would be a valuable strategy for use in interdisciplinary seminars in which students from varied health professions discuss patient care. Mitchell, et al. (2000) described problem-based seminars for students in health sciences. Analysis of critical thinking scenarios in these seminars would allow students to appreciate how health professionals analyze patient situations, understand the unique contributions of the provider to patient care, and learn how to work together as a team to solve patient problems.

Summary

In clinical practice, students are continually faced with patient problems as well as other problems to be solved. As students progress through a health professions program, they need experience in learning how to solve these problems. Critical thinking ability is essential when faced with problems that are not clear-cut and when multiple decisions are possible. Clinical scenarios are short cases with open-ended questions that encourage development of critical thinking skills, bridging the gap between theory and practice.

References

Fuszard, B. (1995). Case method. In B. Fuszard, Innovative teaching strategies in nursing (2nd ed.), pp. 81-92. Gaithersburg, MD: Aspen.

Gaberson, K., & Oermann, M.H. (1999). Clinical teaching strategies in nursing education. New York: Springer.

Mitchell, P.M., Crittenden, R., Howard, E., Lawson, B.Z., Root, R., & Schaad, D.C. (2000). Interdisciplinary clinical education: Evaluating outcomes of an evolving model. Outcomes Management for Nursing Practice, 4(1), 3-6.

Neill, K.M., Lachat, M.F., & Taylor-Panek, S. (1997). Enhancing critical thinking with case studies and nursing process. Nurse Educator, 22(2), 30-32.

Oermann, M.H. (1997). Evaluating critical thinking in clinical practice. Nurse Educator, 22(5), 25-28.

Oermann, M.H. (1998). How to assess critical thinking in clinical practice. Dimensions of Critical Care Nursing, 17, 322-327.

Oermann, M.H., & Gaberson, K. (1998). Evaluation and testing in nursing education. New York: Springer.

Ulrich, D.L., & Glendon, K.J. (1999). Interactive group learning. New York: Springer.

Marilyn H. Oermann, Ph. D., RN, FAAN, teaches in the College of Nursing, Wayne State University, Detroit, Michigan.
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Author:Oermann, Marilyn H.
Publication:Academic Exchange Quarterly
Date:Sep 22, 2000
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