Crucial Choices™ Live: Use of Branching Logic Ethics Cases to Teach and Evaluate Critical Thinking Skills in Undergraduate Nursing Students David Perlman, Ph.D. Senior Lecturer, Penn School of Nursing Associate, Penn Center for Bioethics President & Founder, E4 – Eclipse Ethics Education Enterprises, LLC A Proposal to the Dean’s Investing in the Future Program, Fund for Educational Initiatives, 2010-2011

 

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Abstract This project aims to integrate a method of critical thinking for ethics scenarios in NURS 330, the undergraduate ethics course. For two years, the Educational Initiatives Fund has provided generous support for NURS 330. In 2008-2009, TurningPoint clickers and student-produced and -recorded trigger videos helped to realistically simulate ethics cases. In 2009-2010, funding allowed integration of several Web 2.0 technologies, including TurningPoint’s web-based ResponseWare audience response system as well as podcasts, wikis in Blackboard, and branching logic ethics scenarios that serve as refresher education for students during and after the course. This proposal expands on these previous innovations by introducing a live version of branching logic cases to specifically develop nursing student critical thinking skills. Specific Aim This project aims to develop, pilot test, and evaluate a live, branching logic critical thinking methodology that can be easily integrated into decision-making processes for undergraduate nurses to solve ethical issues. Significance and Innovation Critical thinking skills are a hallmark of quality, professional nursing education and practice.1-12, 16-23. One common view defines critical thinking in terms of “…cognitive skills or strategies that increase the probability of a desirable outcome. It is used to describe thinking that is purposeful, reasoned and goal directed—the kind of thinking involved in solving problems, formulating inferences, calculating likelihoods, and making decisions, when the thinker is using skills that are thoughtful and effective for the particular context and type of thinking task.”15,p.6. Among critical thinking scholars, there is widespread disagreement regarding which cognitive skills are employed in problem solving, argument assessment, calculation of likelihoods, and other tasks.13 This project will focus on one kind of cognitive skill—critical assessment of arguments. This skill is fundamental for human reasoning, and arguments are the vehicle by which we convince others about the claims—scientific, economic, political, commonsensical—we make about the world. Argument structure is simple: we make claims about the world and provide reasons for those claims. Critical assessment of arguments consists of two distinct activities: deciding whether the reasons express truths and deciding whether the reasons are good reasons to believe the claim—that they support the claim, provide evidence for the claim, or show that the claim has a high likelihood of being true. Like much of the current nursing research, critical thinking expert Buechner argues that successful argument assessment requires active use of creative, imaginative abilities and makes simultaneous demands on (and improves) short-term memory, sensitivity to word meanings, analytical thinking skills, logical skills, and scientific reasoning skills.13 When applied to ethical decision-making, Buechner’s method first asks the thinker to transform an ethical dilemma into an argument, then present creative scenarios that would make the premises of the argument true but conclusion false. These so-called “loopholes” then provide innovative solutions to the ethical dilemma and a rational way to escape its horns. It is hypothesized that implementation of Buechner’s method in NURS 330 will enhance students’ prowess in ethical argumentation and the type of creative, critical reasoning that is a hallmark of the scientific method and professional nursing practice. Development and evaluation of a reproducible teaching methodology for critical thinking skill development dovetails with many of the competencies in both the recent revisions to the Penn Nursing undergraduate curriculum and the Commission on Collegiate Nursing Education (CCNE) Standards for Accreditation of Baccalaureate and Graduate Degree Nursing Programs and Essentials for Baccalaureate Education for Professional Nursing Practice.4,5 With regard to the Standards, this project meshes with the overall philosophy of educational innovation endorsed by the CCNE.5, p. 5 The Essentials, upon which a nursing education program should build its curriculum for accreditation, clearly articulate the need for future nursing professionals to have critical thinking skills to produce wise clinical judgments. The Essentials defines critical thinking much like Buechner does: “All or part of the process of questioning, analysis, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application, and creativity.… Critical thinking underlies independent and interdependent decision making.”4, p.36 The Essentials stresses the importance of critical thinking skills4, pp. 3,8,9,11,13,35 and its link to both ethics and professionalism4, p.13 and clinical judgment.4, p.36 What it lacks is precisely how – what pedagogical methods – can be used to inculcate the knowledge, skills, and abilities in critical thinking. This project fills this gap by testing such a method and showing that critical thinking skills can be taught and evaluated in a reproducible way among undergraduate nursing students.

2   The Essentials link critical thinking to future professional nursing practice. Penn Nursing has recognized this link and built acquisition of critical thinking skills in its recent revision to its undergraduate curriculum. A draft of the revised curriculum road map parses professional nursing education into four domains – engagement, inquiry, judgment, and voice – and each year of the 4-year BSN has its own theme to facilitate acquiring and synthesizing knowledge, skills, and abilities in these domains. Inquiry and judgment require independent critical thinking skills, and the proposed courses will have activities and objectives to ensure that by the end of their undergraduate education, each Penn nurse can use what the curriculum road map terms “sound and situated clinical judgment.” Like many clinical situations, ethical situations feature a similar type of uncertainty and momentousness or weight of decisions and consequences. As the revised curriculum and the CCNE Accreditation Standards suggest, nursing students need methods for learning, simulating, and practicing both types of decision skills – ethics and clinical critical thinking skills.5, p.38. This project will introduce specific teaching methods so that students can gain these essential skills and abilities and use this knowledge to wisely evaluate and resolve ethical difficulties that will certainly arise in their areas of future practice. In this way, this project will help to reinforce not only the CCNE Essentials and Accreditation Standards but also the four core domains of professional nursing practice to be included in the revised Penn Nursing Science undergraduate curriculum.

 

Methods One didactic, voice-over slide video podcast will be produced by critical thinking expert Jeff Buechner (Rutgers University, Department of Philosophy) on the “loophole” method and another one by Kenneth Richman (Massachusetts College of Pharmacy and Health Sciences), who has been using the “loophole” method in his instruction of health professions students. These podcasts will provide current and future students with theory and tools for the “loophole” critical thinking methodology and prepare them to use it to assess the quality of arguments to resolve ethics problems. Buechner’s “loophole” method will be integrated within already existing teaching methods in NURS 330, including those developed with previous support from the Educational Initiatives Fund. Students will continue to use the clinical pragmatism framework that has been used since Dr. Perlman began teaching NURS 330 at Penn.14 This framework utilizes methods similar to clinical decision-making that clinicians engage in to assess, diagnose, treat, and evaluate interventions given to patients. Students will continue to conduct research, prepare scripts, and enact video-recorded vignettes that will be shown in class to provide the context and viewpoints of a particular ethics case. After the videos are shown, students will be broken into small groups of 5 and determine what factual and values-based information the case has and what more information is needed to make a moral diagnosis to resolve the case. Discussion will ensue to clarify facts and values, then each student will compose his or her own moral diagnosis. Students will then use their small groups to discuss their various moral diagnoses. Each group will decide on a diagnosis and it will be written on an 8½x11” dry erase sticky sheet and displayed in front of the class. The instructor will then share his moral diagnosis with the class and each student will use TurningPoint clickers to rate (on a 4-point Likert scale) how close his or her own and the group’s moral diagnosis is to the instructor’s. It is hypothesized that as the semester progresses, students will achieve greater proficiency with moral diagnosis. After diagnosing the ethical problem, students will then re-group and brainstorm about options and interventions that can be used to solve the ethical problems in the case. Each option will take the form of an argument with a premise and conclusion and be recorded on a numbered 8½x11” dry erase sheet (option 1, option 2, option 3, etc.) and displayed at the front of class. Each student will then vote on which option will best resolve the ethical problems using TurningPoint clickers (the pre-test). Class discussion will then focus on various consequences of each option should it be implemented from the standpoint of the characters in the case. Here, the students will use Buechner’s “loophole” method to analyze the strength of arguments for or against each option. Each consequence will be labeled as a subset of the option from which it stems to illustrate the connection between option and consequence and to facilitate voting with TurningPoint clickers and discussion. Thus, if option 1 had four consequences, they would be labeled 1.1, 1.2, 1.3, and 1.4, respectively. Students will then re-group and discuss which option(s) and set of consequences represent(s) the most ethical outcome (or least worst ethical outcome) and their justifications for that assessment. Students will strive to use logic and critical thinking skills to assess the quality of arguments for each option and reach consensus

3   in their groups about which option(s) should be implemented. Students will then re-vote on which option should be implemented (post-test).

 

Data Analysis and Evaluation This project will collect quantitative and qualitative data. The quantitative data will consist of: (1) how close (on a 4-point Likert scale, with 1=almost exact, 2=somewhat close, 3=not very close, 4=not even close) each student and each group’s moral diagnosis is to the instructor’s; (2) pre- and post-test data from the options to be implemented to resolve the ethical difficulty; and (3) evaluation data of the teaching methods. Quantitative moral diagnosis data will be analyzed to determine whether students perceive their individual and group skills in moral diagnosis improve over the course of the semester. It is hypothesized that students’ and group’s Likert scores will trend more and more towards 1.0 as the semester progresses. Comparison of means with standard error calculations for each students’ pre- and post-test scores as well as aggregate calculations will help determine whether students’ first, uninformed and uncritically examined choices changed as a result of engaging in logical and critical thinking with their peers. At the end of each class session, students will also use their TurningPoint clickers to evaluate the effectiveness and engagement of the learning methods on a 4-point Likert scale (1=very effective or engaging, 2=somewhat so; 3=not very much so; and 4=ineffective or unengaging): (1) use of the videos; (2) use of the TurningPoint clickers; and (3) use of the branching logic critical thinking method. This data will be analyzed by computing aggregate means with standard error calculations. A cumulative score of less than 2.0 in each category will indicate that the learning activities have been effective, engaging, and produced greater proficiency in critical thinking skills. In addition, students will also evaluate their research for and production of videos. Students answer the following questions: (1) what was it like to write for or act (depending on your specific role) your part in the ethics case; (2) how did you conduct the research for your role and what would you want to tell future students to help them prepare for this particular role; and (3) what lesson(s), if any, will you take away for your future professional nursing practice? This qualitative data will be analyzed by content analysis and descriptive statistics. Since students are taking NURS 330 for a grade and it will be possible to link the quantitative and qualitative data, a high degree of social desirability bias will likely be present. To counter this bias, data will be compared to anonymously submitted course evaluations asking the same questions. Budget Item License for Crucial Choices™ Live Crucial Choices™ Live materials Wacom USB tablet for classroom use Podcasts from two ethics and critical thinking experts for didactic use Travel expenses for two experts to travel to and from Philadelphia (round trip, one hotel night, and meals) Travel to conferences to present findings Instructor time to adapt scenarios for live presentation TOTAL SUPPORT REQUESTED

Budget Justification This copyrighted ethics and critical thinking methodology requires license from E4 – Eclipse Ethics Education Enterprises, LLC (see disclosure below). Students working in small groups will require specific dry erase materials made by E4 – Eclipse Ethics Education Enterprises, LLC (see disclosure below). To display the branching logic scenarios via LCD projector for group discussion $1000 honorarium each

Amount $3000

To record professional-grade podcasts at Van Pelt Library for upload to iTunes University ($800 for expert from Boston, $400 for expert from Newark, NJ) To disseminate research findings to improve critical thinking methodology in nursing education Existing scenarios will need to be adapted to properly fit the proposed critical thinking, branching logic format

$1200

$400 $200 $2000

$1000 $2200 $10000.00

Future Plans and Sustainability This project will supply needed preliminary data for a planned Phase I R43 Small Business Innovation in Research (SBIR) grant to the National Institute of Nursing Research. The program announcement (PHS, 2010) seeks development of technologies to deliver bioethics research to nurses in practice.

 

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Disclosure David Perlman, Ph.D., the author of this proposal and the undergraduate ethics instructor, is the President and Founder of E4 – Eclipse Ethics Education Enterprises, LLC and inventor of the Crucial Choices™ learning format. Dr. Perlman’s work at E4 and the development of the Crucial Choices™ learning format has been independent of his work at Penn, and therefore requires licensing of the technology and materials for use in this and subsequent educational activities. Works Cited 1. Adams, B. L. (1999). Nursing education for critical thinking: An integrative review. Journal of Nursing Education, 38, 111-119. 2. Adams, M. H., Stover, L. M., & Whitlow, J. F. (1999). A longitudinal evaluation of baccalaureate nursing students' critical thinking abilities. Journal of Nursing Education, 38, 139-141. 3. Alfaro-LeFevre, R. (2004). Critical thinking and clinical judgment: A practical approach (3rd ed.). Philadelphia: W. B. Saunders. 4. American Association of Colleges of Nursing (AACN). (2008). Essentials for Baccalaureate Education for Professional Nursing Practice. Washington, DC: AACN. 5. AACN. (2009). Commission on Collegiate Nursing Education (CCNE) Standards for Accreditation of Baccalaureate and Graduate Degree Nursing Programs. Washington, DC: AACN. 6. Angel, B. F., Duffey, M., & Belyea, M. (2000). An evidence-based project for evaluating strategies to improve knowledge acquisition and critical-thinking performance in nursing students. Journal of Nursing Education, 39, 219-228. 7. Bandman, E. L., & Bandman, B. (1995). Critical thinking in nursing (2nd ed.). Norwalk, CT: Appleton and Lange. 8. Beckie, T. M., Lowry, L. W., & Bamett, S. (2001). Assessing critical thinking in baccalaureate nursing students: A longitudinal study. Holistic Nursing Practice, 15(3), 18-26. 9. Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing. Menlo Park, CA: Addison-Wesley. 10. Benner, P., Sutphen, M., Leonard, V., Day, L., & Shulman, L.S. (2009). Educating Nurses: A Call for Radical Transformation. Jossey-Bass. 11. Brown, J. M., Alverson, E. M., & Pepa, C. A. (2001). The influence of a baccalaureate program on traditional, RN-BSN, and accelerated students' critical thinking abilities. Holistic Nursing Practice, 15, 4-8. 12. Brunt, B.A. (2005). Critical thinking in nursing: An integrated review. The Journal of Continuing Education in Nursing, 36(2), 60-67. 13. Buechner, J. (2006). Ways of Reasoning: Tools and Methods for Thinking Outside the Box. New Brunswick, NJ: Hansen Press. 14. Fletcher JC, Spencer EM, Lombardo PA, Fletcher’s Introduction to Clinical Ethics, 3rd edition, Frederick, MD: University Publishing Group, 2005. 15. Halpern, D.F. (2007). The nature and nurture of critical thinking. In Critical Thinking in Psychology, (Robert F. Sternberg, Ed.), Cambridge, UK: Cambridge University Press. 16. Hickman, J. S. (1993). A critical assessment of critical thinking in nursing education. Holistic Nursing Practice, 7(3), 36-47. 17. Kintgen-Andrews, J. (1991). Critical thinking and nursing education: Perplexities and insights. Journal of Nursing Education, 30, 152-157. 18. Martin, C. (2002). The theory of critical thinking of nursing. Nursing Education Perspectives, 23, 243-247. 19. Maynard, C. A. (1996). Relationship of critical thinking ability to professional nursing competence. Journal of Nursing Education, 35, 12-18. 20. Miller, M. A., & Malcom, N. S. (1990). Critical thinking in the nursing curriculum. Nursing and Health Care, 11, 67-73. 21. Rubenfeld, M. G., & Scheffer, B. K. (2001). Critical thinking: What is it and how do we teach it? In J. M. Dochterman & H. K. Grace, (Eds.), Current issues in nursing (6th ed., pp. 125-132). St. Louis, MO: Mosby. 22. Saucier, B. L., Stevens, K. R., & Williams, G. B. (2000). Critical thinking outcomes of computer-assisted instruction versus written nursing process. Nursing and Health Care Perspective, 21, 240-246. 23. Vaughan-Wrobel, B. C., O'Sullivan, P., & Smith, L. (1997). Evaluating critical thinking skills of baccalaureate nursing students. Journal of Nursing Education, 36, 485-488.