1. Critical Thinking Strategies Case Study
Angela Broughton, Claudette Johnson, Deborah Knutson, Eileen Padilla & Danica Stout
Grand Canyon University
NUR: 649E Nursing Education Seminar II
Professor Jacquie Lisicki
May 22, 2013
Team Yellow will be presenting a critical thinking strategy case study concentrating on an education plan for a Congestive Heart Failure patient.
Evaluation of educational and clinical outcomes is essential in measuring effectiveness of an educational plan. Provision of fair and reasonable clinical evaluation is one of the most important and challenging role for educators (Billings & Halstead, 2012). Educator’s ability to provide meaningful, honest and constructive evaluation is vital in nursing. The outcome of clinical evaluation is to provide safe patient care. The authors of this presentation will present learning objectives in planning education for Congestive Heart Failure patients. The authors will also discussion evaluation methods for objectives, outline the advantages and disadvantages of selected evaluation methods, and discuss acceptable outcomes to demonstrate critical thinking.

2. Learner Objectives
Upon completion of the program, participants will be able to:
Describe the pathophysiology of CHF and how the diagnosis of CHF is determined.
The interaction between the participants and instructor warrants the need to develop specific learning objectives. Once the needs assessment was completed, she was able to identify the parameters she wanted to assess and develop a plan to conduct the assessment (Grand Canyon University (GCU), 2010). The goal is for students to learn how to learn and continue learning. Using Blooms taxonomy ABCD method of writing objectives, educators can look at both the B (behavior) and D (degree) to see if the objective was meet (Carmichael & Farrell, 2012).

3. Learner Objectives
Explain the difference between systolic and diastolic heart failure and the importance of assessing left ventricular function in suspected CHF patients

4. Describe the role of appropriate medications for CHF patients
Learner Objectives
Describe the role of appropriate medications for CHF patients
Identify the components of appropriate discharge planning for CHF patients.
The D (degree) gives the learner the standard or measures that the educator will use to determine if the objective was achieved. Educators can also look at the learners’ behavior (B) to assess if the learner is demonstrating critical thinking. Critical thinking has been attained if the “learner is able to apply the goals and objectives in analyzing, evaluating and applying the information learned in solving problems”. (Carmichael & Farrell, 2012).

5. Evaluation Methods for Objectives
Observation
Participation
When teachers observe students behavior and responses they are better able to evaluate learning and potential problems. Vetter & Reusser (2009) state teachers must increase their professional observational skills to understand and be effective for maximum student learning. Classroom observation includes body posture and eye contact while online learning observation is done by determining and evaluating participation in the forums and turning in assignments.
Assigned reading and weekly questions in the discussion forums will give the instructor opportunity to observe both students' learning and participation levels. Participation in the forums allows students to grow and learn to use their voice as professionals by increasing knowledge and establishing decision-making processes, (Vetter & Reusser, 2009) . This method will be used in evaluating student learning of diagnosing CHF, explaining the difference between systolic and diastolic heart failure along with the importance of assessing left ventricular function in suspected CHF patients.

6. Evaluation Methods for Objectives
Pre/Post Test
Diagram fill-in
A pretest will evaluate prior knowledge and a posttest will evaluate learning achieved during the course. The instructor can evaluate the pretest scores and alter the course in ways that will fit the learning needs of the students. The pretest also gives the student an idea of the areas in which they are both weak and strong thus enabling them to concentrate more on areas of weakness. The posttest informs both the student and instructor of learning achieved. Studies have shown this method can increase long-term memory, (Ari, 2009).
Fill-in-the-blank diagrams or open-ended inquiry learning, have been shown to develop critical thinking skills when learning and applying science content, (Anderson & Contino, 2010). This method will be used in evaluating students' learning of the pathophysiology of Chronic Heart Failure (CHF).

7. Evaluation Methods for Objectives
Interactive Case Scenarios
Simulation Lab
Case Scenarios or Case Studies can be done alone, in groups, or with a simulation mannequin. Simulation experiences offer students the opportunity to practice various case scenarios with the ability to stop and ask questions and develop hands-on skills in a safe environment. The instructor can also stop the exercise to emphasize a point. This allows the focus to be on the learner/student rather than the patient. Simulation labs offer the student an opportunity to develop technical skills, practice critical thinking, learn to delegate during a crisis, and practice various situations that may not arise during clinical (Pacsi, 2008). Students will also be required to answer questions regarding medication and identify the components of appropriate discharge planning for CHF patients using case scenarios.
The use of simulation mannequins allows instructors to supplement the clinical experience by allowing students to practice responding to highs-risk situations without incurring real-life risk to patients. Simulation provides instructors opportunity and means to meet curriculum objects when patient experiences are not readily available in the frequency or acuity needed, (Founds, Zewe, & Scheuer, 2011). Students will be required to pass a mock simulation with a score of 90% or higher.

8. Evaluation Advantages & Disadvantages
Observation
Participation
Advantages
Easy preparation
Inexpensive
Immediate Feedback
Disadvantages
Evaluator bias
Perceived threatening
Advantages
Immediate feedback
Assess Attitude and Values
Immediate mediation
Disadvantages
Potential for distorted data
Biased Opinion
Costly
Stressful
Observation
Classroom observations are the most common source of evidence used in nursing education. Observation is directly visualizing the task or behavior being evaluated (Billings & Halstead, 2012). In clinical setting it is valuable in evaluating clinical performance, competency in skill and monitoring attitudes and values including practices in the classroom (Oermann, Yarbrough, Saewert, Ard, & Charasika, 2009).
Observation allows for immediate feedback and remediation opportunities (Polit & Beck, 2009). However, it can be time consuming and increase demands in scheduling observers to complete the task. Without the same person judging everyone’s performance, observation can lead to inconsistent evaluation and biased opinions (Billings & Halstead, 2012), thus skewing results. In addition, if one is being watched, one may inadvertently distort data accuracy. To the learner, direct observation can increase stress and may hinder performance.
To address the disadvantages of this mode of evaluation, educators and students must have clear understanding of the objective and expected behavior. Prior preparation from both the student and educator may also relieve stress and enable one to be fairly assessed. Criteria for competency must be clearly known for observation to succeed.
Participation/ Discussion 
Participation to group discussion allows for participation by everyone. Participation’s advantage in evaluation process lies in the fact that this setting is less intimidating and more comfortable for its participants (Billings & Halstead, 2012). With the group present, consensus is also easy to reach in this setting. It allows for all hearing the same information to prevent misunderstanding. The forum allows for clarification and questions to be answered resulting in immediate feedback and correction of situation if necessary (Billings & Halstead, 2012). The group setting allows for information to be given to a large group, thus, less demand for educators. Because of the large audience, the discussion can lead to the risk of being side tracked (Billings & Halstead, 2012). It is a disadvantage for students who are quiet and reserved.  
The educator’s evaluation of participation need to be objective and educators also need to carefully be cognizant of the group’s purpose. Educators need to define the class purpose, redirect team goes off track and prompt response from less assertive students (Billings & Halstead, 2012).

9. Evaluation Advantages & Disadvantages
Pre & Post Test
Diagram
Advantages
Efficient assessment
Assess performance and knowledge
Disadvantages
Creates pressure and stress
Lack of confidence
Illness day of exam not true measure of knowledge
Advantages
Good for visual students
Compact way to convey information
Interesting, convincing, forceful
Quick way to visualize information
Disadvantages
Advantage to artistic students
Frustrating for concrete learners
Time consuming & technical
Costly
Pre & Post test
Purpose of the test should be defined and areas of coverage outline. Tests are assessment of knowledge (Cognitive skill) obtained during the class (Billings & Halstead, 2012). It evaluates student knowledge and achievement of outcomes as well as teaching effectiveness. Testing pre and post allows for documentation of progress and assessment of program. As pretest are used to assess baseline knowledge and plan topics to be covered, post-test provides learning opportunity to review rationales (Billings & Halstead, 2012) and gain insight to the weakness and strength for future class planning ( Flannelly, 2001 ).
Each type of tests format (True or false, matching items, interpretive, essay) have specific purpose, advantages and disadvantages. Testing is an efficient way to assess knowledge while providing written documentation of meeting a set outcome. Its disadvantage centers on the creation of stress and pressure especially in students who may not be good test takers or lack confidence (Clifton & Schriner, 2010). The student not feeling well the day of the test might be assessed negatively, which can indicate the exam, is not a true measure of accumulative knowledge (Billings & Halstead, 2012).
Diagram Concept
Diagrams are wonderful visual aides to convey information. It is interesting compact way to show relationship of large information and data (Billings & Halstead, 2012). Showing this relationship is an effective way to convince an audience of data concept. It provides powerful information that can trend data in a compact way. However, because it caters to a defined learning style, it presents an issue to concrete learners. Diagrams are time consuming to put together and produce (Billings & Halstead, 2012). Its technicalities may not be a skill of all students thus, handicapping their ability to fully participate. In addition to time, it can be costly as well.
Educators need to assess when this information is most beneficial, its powerful media can surely help in comparing and showing beginning knowledge and progress students make (Hill, 2006). Educators must be sensitive to the abilities of its students as to prevent a disadvantage in evaluating progress and ability.

10. Evaluation Advantages & Disadvantages
Interactive Case Scenarios
Simulation Lab
Advantages
Participatory
Assess problem solving skills
Application of knowledge and skill
Disadvantages
Lack of relevance to situation for some
Insufficient information causes inaccurate result
Advantages
Realistic, Interactive
Immediate Specific Feedback
Integrate theory and practice
Promotes independence
Disadvantages
Expensive- costly software and demand trained staff
Limited group per scenario
Scheduling and Logistic issues
Limiting to some students
Interactive Scenario/ Case Studies
According to Billings & Halstead (2012), case studies allow for analytical and problem solving skills to be assessed. Its interactive ability allows for complex issues and topics to be explored. The discussion of situations allows for students who may not experience the situation to obtain new knowledge.
Students, however, who may be unfamiliar with the situations discussed, might make students feel disconnected and lost, thus finding it irrelevant. The information exchanged may not have sufficient information or facts and can lead to inappropriate results (Williams & Beatle, 2008). For new inexperience nurses not having fundamental exposure to subject matter may find case scenarios not beneficial or relatable.
Educators must define or provide clarity to instructions and clarify or provide background to the situation. In some instances, outlining the norm might help inexperience nurses relate to the issues presented. Defining the problem, the situation and the roles of people discussed can improve engagement and understanding of case scenarios (Billings & Halstead, 2012).
Simulation Lab
Simulation is an event or situation made to resemble clinical practice as closely as possible. The goals of simulation to teach concepts; to allow risk-free practice; and to teach, practice, and/or evaluate critical-thinking skills. Because its practice is close to the real situation, it allows for realistic interaction and assessment of skill (Reed, 2010) and immediate and specific feedback of performance (Billings & Halstead, 2012). An excellent skills assessment for clinical competence, simulation. Simulation is an excellent teaching strategy for many skills. Learning in adults is most effective when the environment is both participative and interactive. Simulation also allows educators to assess the student’s ability to integration of theory into practice (Billings & Halstead, 2012).
Simulations advantages include encouraging independence, critical thinking skills and decisions and integration of theory and practice are readily assessed (Garrett, McPhee, & Jackson, 2010). Its disadvantages are in the financial and logistic arena. Simulation applications are financially expensive. Additionally, it requires trained staff to perform coupled by the fact that it can only be effectively done in small groups’ increases the need for even more staff (Jeffries, 2007). Some disadvantages are not preventable but educators must ensure that simulation is suited for subject matter. Educators must also plan an alternative educational plan to meet objective should simulation fail.

11. Acceptable Outcomes Pre & Post Designed Testing- Cognitive Domain
Does not pre-determine how a student can learn, however can determine knowledge base
Analyzes conclusions drawn from the information in lecture form.
Assesses knowledge learned in the class (in post testing).
Using pre-testing to determine depth and breadth of understanding of CHF the learner will be tested up front before lecture. designed teaching after listening to lecture. “Assisting learning requires that a senior learner (adult, teacher) provide the learner with the necessary support to allow the learner to eventually solve the problem. The senior learner gradually diminishes instruction as the student gains independence” (Billings, D. & Halstead, J. 2012, p.217). Using a pre-test work base can help the Educator determine where the student’s background of learning is at. When the lecture is completed and conclusion testing is given, anyone who should have a hard time with this test is probably not going to be your cognitive learner.

12. Acceptable Outcomes Observation & Simulation- Psychomotor Domain
Teach, learn and practice
Safe environment
Encourages close interaction in learning
Ultimate level is at skill performance-automatic without practice needed.
Psychomotor or kinesthetic learning is learning better with hands on experiences. The Educator must give a lecture or small based group formation talk. Then the instructor should give a demonstration on what skill is to be learned. Learning resources such as picture based skills would be a great handout to give at the beginning of the instructions. What would be expected at this time is that the student can demonstrate, to some proficiency, that they have attained the knowledge to practice this skill in the future. This type of learning provides the student with a way to learn a technique other than on humans. Mannequins are made in all sized and materials for different reasons; to use these do not endanger the student or a patient in a facility.
Small groups of less than five should be used so that any individual can view work performed on the mannequin at any time, and be within hearing distance to hear of student-instructor feedback. Earlier it was described that the student may perform additional skill work on the technique passed until they feel as though they have almost reached a high amount of proficiency. At that point the skills lab coordinator, if the student has performed the skill well, should be checked off in clinicals until proficiency and comfort have made contact.

13. Acceptable Outcomes Participation/Discussion- Audio Domain
Active learning should be encouraged
Discuss CHF in a report of the consequences on diet and medication non-compliance
Discuss in this same report that patient contribution and taking action in diet and medications make a big difference in how they feel.
The use of participation and discussion in the classroom can enhance the audio learner. For this papers purpose we will still use the need to learn about CHF. A DVD will be used as a home health nurse makes her rounds, and as she comes across Mr. J. a 64 year old Caucasian male with a history of smoking 2 packs of cigarettes over the last 40 years. In the movie the nurse goes into the patients home and notices immediately he is out of breath, and as he sits down on his recliner she also views his ankles which are very edematous. She asked the patient if he is still on the medications since she last saw him (one week ago), he states that he had to quit taking a couple of medications due to a lack of funds and did not contact the physician. These medications happened to be Lisinopril 20 mg. with 15mg of HCTZ, for his blood pressure and edema. He also had to quite taking his digoxin, which helps his cardiac output. The combination of these two drugs set up Mr. J. for a severe case of CHF. Upon assessment she assesses his state of mind, in case there is less oxygen in the blood. She takes his blood pressure and he is in severe hypertension ( 215/118). She also notices that he has a wet cough, the last time he coughed she asked to see the napkin- it appeared frothy and pink, a classic sign of CHF as well. As she assesses him further the nurse also finds that his fingers are so edematous that he can no longer take off his rings. She checked his feet and ankles and he was at 3+ pitting edema bilaterally. She calls his physician and he asks her to go ahead and have him taken to Methodist Hospital where he has admitting privileges where the patient was admitted for exacerbation of CHF secondary to medication non-compliance. This is the end of the video.
Now is the time for an active discussion around the room. However, it is still relevant for the a open ended questionnaire to be filled out regarding the above vignette. Thirty minutes is given to answer all 5 questions. Afterwards, all tests are picked up and then an open discussion is facilitated by the educator asking particular questions about medications, why was the ankles so edematous? Many discussions and even tales of loved ones who were living or no longer with us were perused over before this part of the class came to an end.

14. Assessment Model for Evaluation Design
CIPP Decision-Oriented Evaluation Framework
The CIPP (Context, Input, Process, and Product) Decision-Oriented evaluation framework would be appropriate to implement as an evaluation model for this critical thinking case scenario, objectives, and evaluation methods including: observation, participation, pre/post testing, diagrams, fill-in, case studies, and simulation. The CIPP model measures the weaknesses and strengths of an entire program, identifies the needs of the target population, identifies options, and provides evidence of beneficial results or lack thereof (Billings & Halstead, 2012). This is a decision-making evaluation framework, thus, the information gathered from this evaluation of the case study and learning activities will be useful in continually improving information to enhance learning about the diagnosis, pathophysiology, medications, and discharge planning related to Congestive Heart Failure.
Context
Input
Process
Product

15. CIPP Evaluation Model Context Evaluation Identify target population
Needs assessment (pre/post testing, observation)
Textbook knowledge applied to practice
According to Billings & Halstead (2012), context evaluation identifies the target population and assesses it’s needs. Nursing students in an academic setting are the target population. These learners may be cognitive, psychomotor, or auditory learners. The needs of these students in relation to their knowledge regarding CHF could be assessed using prior information such as surveys, pre/post-test scores, or even focus groups in which observation could be utilized. Hall, Daly & Madigan (2010), describe context as the critical thinking behind nursing students’ decisions and actions in the clinical setting and questions how well students bridge textbook knowledge into clinical practice. Simulation gives learners a chance to apply information learned in a non-threatening environment and would be an appropriate evaluation method to determine whether learners are grasping content related to the pathophysiology, differences between systolic and diastolic heart failure, and identifying medications to treat CHF.

16. CIPP Evaluation Model Input Evaluation Identifies & assesses:
System capabilities
Alternative program strategies
Procedural designs for implementation
Student plan of care & interventions
Input evaluation is the second part of this framework. Input evaluation identifies and assesses system capabilities, alternative program strategies, and procedural designs for implementing these strategies (Billings & Halstead, 2012). The ability of nursing educators to provide education and adequately explain learning activities and evaluation strategies for our chosen objectives will be important in evaluating this case study. Furthermore, assessing the timeframe that educators have to explain the objectives and variety of evaluation methods as well as answer questions will need to be considered when evaluating this case study. Alternative strategies could be considered if there are barriers to certain educators delivering content or evaluating students. For example, if it is identified by several educators or students that pre and post-testing is not a valuable tool and does not appeal to different types of learners, it may be decided that this evaluation method is no longer valid and may need to be revised. Action plans would then be implemented to help solve these dilemmas. Hall, Daly & Madigan (2010) further expand on input evaluation and consider the ability of the nursing student to develop a plan of care including appropriate nursing interventions. Their input regarding the information presented in the case study and alternative treatment modalities and interventions that are chosen by the student are evaluated along with the overall program. Using case studies and simulation will determine if the nursing student can develop an appropriate plan of care. In addition, the student’s ability to plan a patient’s discharge and educate on the important components of discharge planning in CHF patients would be appropriately assessed during this portion of the CIPP assessment model for evaluation design.

17. CIPP Evaluation Model Process Evaluation Detects defects
Advantages vs. disadvantages
Evaluate performance, time management, documentation
Simulation-Educators can observe & intervene
Process evaluation is the third component of this framework. Process evaluation detects defects in the design or implementation of the procedure (Billings & Halstead, 2012). Weighing the previously discussed advantages and disadvantages of each evaluation method will help to identify any defects in how objectives are introduced and learning is evaluated. For example, in the previous slides we have identified that the use of diagrams as an evaluation method caters to a defined learning style and presents barriers to concrete learners. Using the CIPP evaluation model has helped to carefully look at the advantages and disadvantages of the process behind each evaluation method. Furthermore, process evaluation can help to question a student’s performance of procedures, time management skills, and their ability to document pertinent patient information (Hall, Daly & Madigan, 2010). Essentially, educators will evaluate student’s learning by determining whether the student can choose correct diagnostic testing related to CHF, medications used to treat the disease, and organize these thoughts appropriately to show that time management is considered and correct documentation will occur. This process can be evaluated most appropriately by using simulation, where educators can observe each process and intervene when appropriate.

18. CIPP Evaluation Model Product Evaluation
Collect description/Analysis of Outcomes
Prioritization of goals and outcomes
Interpret results
Finally, product evaluation is the final assessment portion of this framework. Product evaluation is a collection of descriptions and analyses of outcomes and correlates them to the objectives, context, input, and process information, resulting in the interpretation of results (Billings & Halstead, 2012). The acceptable outcomes for the undergraduate nursing students are the demonstration that critical thinking has been used. Many different evaluation methods are included in order to introduce the topic of CHF to nursing students and enhance their critical thinking skills. Hall, Daly & Madigan (2010), found that CIPP product evaluation considers the student’s prioritization of patient goals and their patients’ outcomes during the clinical experience. Although clinical experiences are not utilized or discussed, the goal of the evaluation methods that are used is to enhance student knowledge, critical thinking, and application of the material learned in order to effectively treat CHF patients. Students will be evaluated through pre and post-testing to prove that information has been learned. In addition, prioritization of goals and outcomes related to CHF patients will be interpreted in a final simulation evaluation where students can apply information and put it into practice. Interpreting whether this outcome is achieved will be included in the final product evaluation.

19. Conclusion
Evaluation is accomplished through observation, participation, pre/post testing, diagrams, case studies, and simulation.
Effective evaluation strategies must consider the purpose, advantages and disadvantages of the evaluation tool.
CIPP Evaluation Framework-measures weaknesses/strengths, provides alternative options/information for decision makers
Evaluation of student learning will be accomplished through the use of observation, participation, pre- and post-test scores, a fill-in-the-blanks heart diagram, and interactive case scenarios with use of a simulation mannequin.
Effective evaluation strategies must consider the purpose, advantages and disadvantages of the evaluation tool. The use of appropriate assessment tools is instrumental in assessing data, knowledge and skill of learners (Billings & Halstead, 2012). Evaluation tools must meet patient outcome goals.
Models that are used as evaluation frameworks reflect closely the aspects of nursing education and practice that are being evaluated (Billings & Halstead, 2012). The use of the CIPP Decision-Oriented Model provides useful information identifying different components of educational strategies that are useful to enhance the critical thinking of target populations as well as those that are not. Furthermore, different evaluation options are identified and this model is used specifically to provide information to decision-makers about whether alternatives in current evaluation methods used should be considered.

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