Teaching standardized nursing language: Fostering critical thinking using a case study method

Full text

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Teaching Nursing Diagnoses,
Interventions and Outcomes (NNN):
Fostering critical thinking by
using a case study method
Maria Müller-Staub (PhD, MNS, EdN, RN)
Pflege PBS, Switzerland
Groningen, Oct. 2013
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Presentation
• Background
- Critical thinking and the Nursing Process
- Classifications = Knowledge Base of Nursing
- Problems: Educational needs
• Research aims
• Case Study Method (CSM)
• Sample and duration of CSM
• Example CSM-Session
• Evaluation and Findings
• Conclusions

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Background: Critical Thinking /
Clinical Reasoning
• Practice requires complex thinking processes
• Critical thinking: an intellectual, disciplined
process of !
"!ac%ve!conceptualisa%on!
"!applica%on!and!!
"!synthesis!of!informa%on!
• It is gained through observation, experience,
reflection and communication and leads
thinking and action (Paul, 1993; Müller-Staub, 2010; 2011; 2012)
M. Müller Staub, Groningen 2013
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Background
Cri%cal!thinking!influences!all!aspects!of!clinical!
decision!making:!
a. !diagnos%c!judgement!
b. !therapeu%c!reasoning!
c. !ethical!decision!making!!
(Gordon, 2009; 2013)
!
Human!reac%ons!on!health!problems!are!complex!
processes!!
!
Human!behaviour!is!interpreted!in!the!focus!of!health!
(Lunney, 1998; 2011; Müller-Staub, 2012)

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The nursing process (problem-solving)
Attention to the nursing diagnostic process
(Carlson-Catalano, 1998; Lunney 2007)
The nursing process includes
- stating nursing diagnoses
- choosing nursing goals/desired
outcomes
- choosing nursing interventions
- evaluating diagnoses, interventions
and outcomes
(American Nurses Association ANA, 2009)
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Classifications = Knowledge Base
• Nursing diagnoses (NANDA)
(impaired mobility, hopelessness)
• Nursing interventions (NIC)
(exercise therapy, hope instillation/self-
modification assistance)
• Nursing outcomes (NOC)
(enhanced ambulation, hope)

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Problems
• Clinical decision making/critical thinking
underestimated in school settings
• Research reveals nurses’ educational needs
- in clinical decision making/critical thinking
- in use/application of nursing classifications !
!!!!!
!
!
!
!
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(Delaney, Herr, Maas, & Specht, 2000; Ehrenberg
& Ehnfors, 2010; Thoroddsen, 2009;
Paans, 2011; Müller Staub, 2007; 2010)

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Research!aims and methods
1. Development of a Case Study Method (CSM) to
foster clinical decision making and critical thinking
in nurses
2. Application of CSM in continuous education
sessions
3. Evaluation of the effect of CSM by qualitative
questionnaires
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Case!Study!Method (CSM)
Aims
Fostering nurses’ clinical decision making and
critical thinking skills
Nurses can accurately assess patients’ needs,
choose accurate nursing diagnoses, interventions
and outcomes based on NNN

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Case study method (CSM)
• Interactive ‘reflecting rounds’
• Iterative hypothesis testing
• Using actual patients’ situations (cases)
Phases of CSM-Sessions
• Pre-phase
• Case selection phase
• Case delineation
• Case work
• Case evaluation
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Case!study!method (CSM)
Phases of CSM-Session
• Pre-phase
• Selection phase
• Case delineation
Example

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Case!study!method (CSM)
• Case work
• Case evaluation
- nursing diagnoses (NANDA-I, PES)
- choosing nursing interventions
- stating and evaluating nursing
outcomes
(Müller-Staub & Stucker-Studer, 2007; Müller-Staub, 2008, 2010a, 2010b,
2011; Doenges et. al., 2003, 2013)
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Case Evaluation (CSM)!
• Which nursing diagnoses (label and definition, problem
statement)?
• Related factors/etiologies of the patient?
• Which defining characteristics does the patient show?
• Choosing coherent, desired outcomes
• Planning/performing effective, etiology-specific interventions
• Evaluating/documenting patient outcomes
• Coherence: Interventions + outcomes
• Coherence: Diagnoses + outcomes

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Sample and application of CSM
Case study sessions were provided to
• 5 groups of nurses
(n = 13-15; N = 72 nurses)
• 10 Sessions were provided over a
duration of 1.5 years to all groups
• The duration of each session was 1/2 day
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Evaluation of CSM
• Qualitative questionnaires (N = 72)
• Containing nine semi-structured questions
• Analyses: Mayring’s qualitative analysis
approach
• Summarizing, rephrasing and categorizing
findings
• Findings: Core themes

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Findings
Nurses’ learning effects, thematically
categorized core themes:
➤ Patients’ problems were perceived more patient -
centred
➤ Accurate nursing diagnoses were stated
➤ More effective nursing interventions were chosen
and implemented
➤ Nurses improved communication skills and
relationships with patients
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Findings
Patients’ problems are perceived more patient -
centred
“I understand patient’s situations in a more patient-
centred way”
“I learned that standardized nursing diagnoses are
formulating the patients problems in his/her perspective”
„ My care plans show more specific patient problems,
described in the patients perspective“

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Nurses’ learning effects
Accurate nursing diagnoses were stated
“I learned to state accurate diagnoses, based on
corresponding signs/symtoms and related, etiological
factors”
“My care plans contain exactly stated nursing
diagnoses in PES”
“I state accurate, individual nursing diagnoses in care
plans, containing signs/symtoms and related factors”
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Nurses’ learning effects
More effective nursing interventions were chosen
“Hypothesis-testing rounds helped me to differentiate
between nursing diagnoses and to search specific
nursing interventions”
“I’m choosing more specific interventions”
“I learned to appreciate and implement effective nursing
interventions”
“My view about nursing and interventions has
broadened, I now choose more and different nursing
interventions, such as active listening, comfort-giving”

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Nurses’ learning effects
Nurses improved their professional relationships
and enhanced their communication skills and
caring behaviour
“I became aware that I got a better understanding of
patients’ situations - I’m stepping into their perspective,
and I’m more reflecting on my care given”
“I enhanced my communication skills and caring
behaviour”
“By using CSM, I became more sensitive to listen/
observe to patients’ cues, hints and what they say -
verbally and non-verbally”
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Conclusion
Studies confirmed: CSM fosters Critical thinking and Clinical
Decision Making
Using NNN helps to accurately state nursing diagnoses and to
choose effective interventions
(Paans, W., Sermeus, W., Nieweg, M.B., Krijnen, W.P., Schans, van der, C.P.; 2012)
Use CSM combined with standardized Nursing Classifications
(Doenges et.al, 2009;2013, Gordon, 2009/2013; Müller-Staub & Stucker-Studer, 2007; Müller-
Staub, 2008, 2010a, 2010b, 2011, 2012, 2013)
Thank you! www.pflege-pbs.ch
M. Müller Staub, Groningen 2013