(Ass): INSTRUCTOR RESOURCES

INSTRUCTOR RESOURCES2TABLE OF CONTENTSTable of Contents ……………………………………………………………………………………………….2The aim of this resource package …………………………………………………………………………..3What is clinical reasoning? ……………………………………………………………………………………3Why is clinical reasoning important? ……………………………………………………………………….3The clinical reasoning process ……………………………………………………………………………….4The clinical reasoning cycle …………………………………………………………………………………..5Questioning assumptions ……………………………………………………………………………………..5The clinical reasoning process with descriptors …………………………………………………………6The phases of the clinical reasoning process with examples …………………………………………7Responses from educators that can be used to encourage, facilitate and promoteeffective clinical reasoning ……………………………………………………………………………………8Critical thinking – Habits of the mind ………………………………………………………………………9Glossary of Terms …………………………………………………………………………………………….11Clinical reasoning errors …………………………………………………………………………………….13References ……………………………………………………………………………………………………..14Resources ……………………………………………………………………………………………………….15Acknowledgements …………………………………………………………………………………………..16Copyright © 2009School of Nursing and MidwiferyFaculty of Health, University of Newcastle3THE AIMS OF THIS RESOURCE PACKAGEWHAT IS CLINICAL REASONING?In the literature the terms clinical reasoning, clinical judgment, problem solving, decisionmaking and critical thinking are often used interchangeably. In this learning package weuse the term clinical reasoning to describe the process by which nurses (and otherclinicians) collect cues, process the information, come to an understanding of a patientproblem or situation, plan and implement interventions, evaluate outcomes, and reflect onand learn from the process (Hoffman, 2007; Kraischsk & Anthony, 2001; Laurie et al.,2001). The clinical reasoning process is dependent upon a critical thinking „disposition‟(Scheffer & Rubenfeld, 2000) and is influenced by a person‟s attitude, philosophicalperspective and preconceptions (McCarthy, 2003). Clinical reasoning is not a linearprocess but can be conceptualised as a series or spiral of linked and ongoing clinicalencounters.WHY IS CLINICAL REASONING IMPORTANT?Nurses with effective clinical reasoning skills have a positive impact on patient outcomes.Conversely, those with poor clinical reasoning skills often fail to detect impending patientdeterioration resulting in a “failure-to-rescue” (Aiken, Clarke, Cheung, Sloane, & Silber,2003). This is significant when viewed against the background of increasing numbers ofadverse patient outcomes and escalating healthcare complaints (NSW Health, 2006).According to the NSW Health Incident Management in the NSW Public Health System2007 (2008) the top three reasons for adverse patient outcomes are: failure to properlydiagnose, failure to institute appropriate treatment, and inappropriate management ofcomplications. Each of these is related to poor clinical reasoning skills. The Quality inAustralian Healthcare Study (Wilson et al, 1995) found that “cognitive failure” was a factorin 57% of adverse clinical events and this involved a number of features including failure tosynthesise and act on clinical information. Education must begin at the undergraduate levelto promote recognition and management of the deteriorating patient, the use of escalationsystems and effective communication (Bright, Walker, and Bion, 2004).Contemporary learning and teaching approaches do not always facilitate the developmentof a requisite level of clinical reasoning skills. While universities are committed to theeducation of nurses who are adequately prepared to work in complex and challengingclinical environments, health services frequently complain that graduates are not „workready‟. A recent report from NSW Health Patient Safety and Clinical Quality Programme(2006) described critical patient incidents that often involved poor clinical reasoning bygraduate nurses. This report parallels the results of the Performance Based DevelopmentSystem, a tool employed to assess nurses‟ clinical reasoning, which showed that 70 perThe aims of these resources are to:

Define the process of clinical reasoningExplain and justify why nursing students need to learn clinical reasoningDescribe and exemplify the process of clinical reasoning
4cent of graduate nurses in the United States scored at an „unsafe‟ level. Although thesenurses had good content knowledge and adequate procedural skills, they frequently lackedthe clinical reasoning skills needed to respond appropriately in critical situations (delBueno, 2005). In Australia results are not dissimilar. The Australian Nursing and MidwiferyCouncil (ANMC, 2005) Competency Standards for the Registered Nurse list “criticalthinking and analysis” as one of its four key domains and nursing students are assessedagainst these standards. At the University of Newcastle results collated over a four yearperiod (2004-2007) indicate that only a small number (< 15 per cent, n = 162) of 1086 thirdyear nursing students demonstrated appropriate clinical reasoning and critical thinkingskills during clinical competency assessment. The reasons for this are multidimensionalbut include the difficulties beginning nurses encounter when differentiating between aclinical problem that needs immediate attention and one that is less acute (del Bueno,1994); and a tendency to make errors in time sensitive situations where there is a largeamount of complex data to process (O‟Neill, 1994).In clinical practice experienced nurses engage in multiple clinical reasoning episodes foreach patient in their care. An experienced nurse may enter a patient‟s room andimmediately observe significant data, draw conclusions about the patient and initiateappropriate care. Because of their knowledge, skill, and experience the expert nurse mayappear to perform these processes in a way that seems automatic or instinctive. However,clinical reasoning is a learnt skill (Higuchi & Donald, 2002; Kamin, O‟Sullivan, Deterding &Younger, 2003). For nursing students to learn to manage complex clinical scenarioseffectively, it is essential to understand the process and steps of clinical reasoning. Nursngstudents need to learn rules that determine how cues shape clinical decisions and theconnections between cues and outcomes (Benner, 2001). Clinical reasoning is challengingand requires a different approach to that used when learning routine nursing procedures.Learning to reason effectively does not happen serendipitously. It requires determinationand active engagement in deliberate practice for continued learning; it also requiresreflection, particularly on activities designed to improve performance (Ericsson, Whyte andWard, 2007).THE CLINICAL REASONING PROCESSA diagram of the clinical reasoning framework is shown in Figure 1. In this diagram thecycle begins at 1200 hours and moves in a clockwise direction. The circle represents theongoing and cyclical nature of clinical interventions and the importance of evaluation andreflection. There are eight main steps or phases in the clinical reasoning cycle. However,the distinctions between the phases are not clear cut. While clinical reasoning can bebroken down into the steps of: look, collect, process, decide, plan, act, evaluate andreflect, in reality, the phases merge and the boundaries between them are often blurred.While each phase is presented as a separate and distinct element in this diagram, it isimportant to remember that clinical reasoning is a dynamic process and nurses oftencombine one or more phases or move back and forth between them before reaching a‘Thinking like a nurse’ is a form of engaged moral reasoning. Educational practices must helpstudents engage with patients with a deep concern for their well being. Clinical reasoning mustarise from this engaged, concerned stance, always in relation to a particular patient and situationand informed by generalised knowledge and rational processes, but never as an objective,detached exercise (Tanner, 2006, p.209).5decision, taking action and evaluating outcomes. It is also important that students learn torecognise, understand and work though each phase, rather than making assumptionsabout patient problems and initiating interventions that have not been adequatelyconsidered. In Figure 2 the phases of the clinical reasoning process are described in moredetail and in Table 1 examples of the process are provided.QUESTIONING ASSUMPTIONSPreconceptions and assumptions such as “most indigenous people are alcoholics”; MiddleEastern women tend to have a low pain threshold”; and “elderly people often havedementia”, can influence the clinical reasoning process (Alfaro-LeFevre, 2009). McCarthy‟s(2003) theory of situated clinical reasoning explains how nurses‟ personal philosophiesabout aging influence how they manage older hospitalised patients experiencingsymptoms of delirium. In McCarthy‟s study nurses‟ beliefs caused them to process clinicalsituations and act in particular ways. Their overarching philosophies served asperspectives that conditioned the ways in which they judged and ultimately dealt with olderpatients experiencing acute confusion. In another study by McCaffery, Rolling Ferrell andPaseo (2000) nurses‟ opinions of their patients and their personal beliefs about painsignificantly influenced the quality of their pain assessment and management. Thus, inpreparation for clinical reasoning nursing students must be provided with opportunitiesto reflect on and question their assumptions and prejudices; as failure to do so maynegatively impact their clinical reasoning ability and consequently patient outcomes.Figure 1: The clinical reasoning cycleDescribe or list facts,context, objects orpeople.Review current information (e.g. handover reports,patient history, patient charts, results ofinvestigations and nursing/medical assessmentspreviously undertaken).Gather new information (e.g. undertake patientassessment)Recall knowledge (e.g. physiology, pathophysiology,pharmacology, epidemiology, therapeutics, culture,context of care, ethics, law etc)Interpret: analyse data to come to anunderstanding of signs or symptoms.Compare normal Vs abnormal.Discriminate: distinguish relevantfrom irrelevant information; recogniseinconsistencies, narrow down theinformation to what is most importantand recognise gaps in cues collected.Relate: discover new relationships orpatterns; cluster cues together toidentify relationships between them.Infer: make deductions or formopinions that follow logically byinterpreting subjective and objectivecues; consider alternatives andconsequences.Match current situation to pastsituations or current patient to pastpatients (usually an expert thoughtprocess).Predict an outcome (usually anexpert thought process).Synthesise facts andinferences to make adefinitive diagnosis ofthe patient‟s problem.Describe what you wantto happen, a desiredoutcome, a time frame.Evaluate theeffectiveness of andactions outcomes. Ask:“has the situationimproved now?”Select a course of actionbetween differentalternatives available.Contemplate what youhave learnt from thisprocess and what youcould have donedifferently.Figure 2: The clinical reasoning process with descriptorsTABLE 1: THE PHASES OF THE CLINICAL REASONINGPROCESS WITH EXAMPLES
Process
Description
Example
Consider thepatientsituation
Describe or list facts, context,objects or people.
This 60 year old patient is in ICUbecause he had an abdominal aorticaneurysm (AAA) surgery yesterday.
Collect cues/information
Review current information (e.g.handover reports, patient history,patient charts, results ofinvestigations and nursing/medicalassessments previously undertaken)
He has a history of hypertension and hetakes betablockersHis BP was 140/80 an hour ago
Gather new information (e.g.undertake patient assessment)
I‟ve checked his BP and it is now110/60, Temp 384.Epidural running @ 10ml/hr
Recall knowledge (e.g. physiology,pathophysiology, pharmacology,epidemiology, therapeutics, culture,context of care, ethics, law etc)
BP is related to fluid status.Epidurals can drop the BP because theycause vasodilation.In ICU we have standing orders forepidural management.
Processinformation
Interpret: analyse data to come to anunderstanding of signs or symptoms.Compare normal Vs abnormal.
His BP is low, especially for a person who isnormally hypertensive.
Discriminate: distinguish relevantfrom irrelevant information; recogniseinconsistencies, narrow down theinformation to what is most importantand recognise gaps in cues collected.
His temp is up a bit but I‟m not too worriedabout it – I‟m more concerned about his BPand pulse.I‟d better check his urine output and his O2sats.
Relate: discover new relationships orpatterns; cluster cues together toidentify relationships between them.
His hypotension, tachycardia and oliguriacould be signs of impending shock.His BP went down after we increased theepidural.
Infer: make deductions or formopinions that follow logically byinterpreting subjective and objectivecues; consider alternatives andconsequences.
His BP could be low because of blood lossduring surgery or because of the epidural.
Match current situation to pastsituations or current patient to pastpatients (usually an expert thoughtprocess)
AAAs often have hypotension post op
Predict an outcome (usually anexpert thought process)
If I don‟t give him more fluids he couldgo into shock.
8
Identifyproblem /issue
Synthesise facts and inferences tomake a definitive diagnosis of thepatient‟s problem.
He is hypovolaemic and the epiduralhas worsened the BP by causingvasodilation.
Establishgoals
Describe what you want to happen, adesired outcome, a time frame.
I want to improve his haemodynamicstatus – get his BP up and urine outputback to normal over the next hour.
Take action
Select a course of action betweendifferent alternatives available
I will ring the doctor to get an order toincrease his IV rate and to give aramineif needed.
Evaluate
Evaluate the effectiveness ofoutcomes and actions. Ask: “has thesituation improved now?”
His BP is up for now but we will need tokeep an eye on it as he may still needaramine a bit later. His urine output isaveraging > 30mL/hr now.
Reflect onprocess andnew learning
Contemplate what you have learntfrom this process and what you couldhave done differently.
Next time I would …I should have …If I had …I now understand …
Adapted from Hoffman (2007); Alfaro-LeFevre (2009); Andersen (1991)Responses from educators that can be used to encourage, facilitateand promote effective clinical reasoning:Let‟s explore this.Let‟s think this through.Now let‟s consider all the possible options/solutions/outcomes.Show me how you came to that decisionWalk me through your thinking about this.That is one option; let‟s explore some others.What are some possible outcomes of this approach?That is a good thought/answer/response/idea … let‟s expand on it.Let‟s consider some alternativesLet‟s figure this out.Tell me about what you‟ve leant so far.Great question!Where would we find the answer to that?Let‟s try that one again.Why don‟t you lead us through that process?It‟s not just about the right answer it‟s about learning the processGood try … have another go.Now that you‟ve worked that out let‟s try ….OK. You are on the right track. Let‟s try something a little more challenging now.Have you considered what could happen if …That is correct in this situation and for this person but what if …What do you think about ….How do you know that to be true … on what do you base your answer?Adapted from Rubenfeld and Scheffer (2006, p. 82)9TABLE 2: Critical Thinking – ‘Habits of the Mind’The clinical reasoning process is dependent upon a critical thinking „disposition‟ (Scheffer &Rubenfeld, 2000). The table below lists the attributes needed for clinical thinking and clinicalreasoning.
Habit
Description
Example
Confidence
Assurance of one‟s reasoningabilities
My thinking was on track;I reconsidered and still thought I‟dmade the right decision;I knew my conclusion was wellfounded.
Contextualperspective
Considerate of the wholesituation, includingrelationships, background,situation and environment
I took in the whole picture;I was mindful of the situation;I considered other possibilities;I considered the circumstances.
Creativity
Intellectual inquisitiveness usedto generate, discover orrestructure ideas; the ability toimagine alternatives
I let my imagination go;I thought „outside of the box‟;I tried to be visionary
Flexibility
Capacity to adapt,accommodate, modify orchange thoughts, ideas andbehaviours
I moved away from traditionalthinking;I redefined the situation and startedagain;I questioned what I was thinking andtried a new approach;I adapted to the new situation.
Inquisitiveness
Eagerness to learn by seekingknowledge and understandingthrough observation andthoughtful questioning in orderto explore possibilities andalternatives
I burned with curiosity;I needed to know more;My mind was racing with questions;I was so interested.
Intellectualintegrity
Seeking the truth throughsincere, honest processes, evenif the results are contrary toones assumptions or beliefs
Although it went against everything Ibelieved I needed to get to the truth;I questioned my biases andassumptions;I examined my thinking;I was not satisfied with my originalconclusion.
Intuition
Insightful patterns of knowingbrought about by previousexperience and patternrecognition
I had a hunch;While I couldn‟t say why, I knewfrom last time this happened that …
Open-mindedness
Receptiveness to divergentviews and sensitivity to ones‟biases, preconceptions,assumptions and stereotypes
I tried not to judge;I tried to be open to new ideas;I tried to be objective;I listened to other perspectives.
Perseverance
Pursuit of learning anddetermination to overcomeobstacles
I was determined to find out;I would not accept that for ananswer;I was persistent.
Reflective
Contemplation of assumptions,thinking and action for the
I pondered my reactions, what I haddone and thought;
10
purpose of deeperunderstanding and selfevaluation.
I wondered what I could have/shouldhave done differently;I considered what I would dodifferently next time;I considered how this would influencemy future practice.
(Adapted from Scheffer and Rubenfeld, 2000, p. 358; Rubenfeld and Scheffer, 2006, p. 16-24)11GLOSSARY OF TERMS
Term
Definition
Analyse
Separation into components: the breaking down of the whole into its parts(deductive reasoning).
Clinical reasoning
The process by which nurses (and other clinicians) collect cues, processthe information, come to an understanding of a patient problem orsituation, plan and implement interventions, evaluate outcomes, andreflect on and learn from the process.
Critical thinking
A complex collection of cognitive skills and affective habits of the mind
Cues
Identifiable physiological or psychosocial changes experienced by thepatient, perceived through history or assessment and understood inrelation to a specific body of knowledge and philosophical beliefs. Cuesalso include the context of care and the surrounding clinical situation.
Data
A piece or pieces of information about health status
Discriminate
To use good judgement ; to note or observe a difference accurately; todistinguish relevant from irrelevant information; to recogniseinconsistencies; to narrow down the information to what is most importantand recognise gaps in cues collected
Evaluate
To make a judgement about the worth or value of something
Facilitator
A person who guides the learning experience
Fidelity
Degree of realism
„Failure to rescue‟
Mortality of patients who experience a hospital acquired complication
Goals
A desired outcome and a guidepost to the selection of nursinginterventions
High fidelity Humanpatient simulation (HPS)manikins
Realistic with embedded software that can be remotely controlled bycomputer to allow for individualised, programmed scenarios, real-timeinteractions and cue response. They allow the operator to setphysiological parameters and respond to students‟ interventions withchanges in voice, heart rate, blood pressure and other physiologicalsigns. Examples include Laerdal SimManTM and METITM manikins.
HPS
human patient simulation
Information andCommunicationTechnology (ICT)
Any technology that has the capacity to accumulate, retrieve, control,convey or accept information by electronic means
Inconsistency
Something that contradicts something else or that is not in keeping with it;not regular or predictable
Infer
To make deductions or form opinions that follow logically by interpretingsubjective and objective data; to consider alternatives and consequences
Interpret
Analyse data to come to an understanding ; to explain or tell the meaning of;present in understandable terms
12
Low fidelity HPS manikins
Simple task trainers such as IV arms and resuscitation torsos, andanatomically correct full body static manikins that replicate the externalanatomy and joint movement of humans, but have no interactive capacity
Match
Information or cues that correspond to each other or cluster togethernaturally
Medium fidelity HPSmanikins
Full body manikins that have embedded software that is controlled by anexternal, hand held device. They have the capacity to have set breathsounds, heart sounds, pulse and blood pressure, and are also capable ofcoughing, moaning or basic verbal communication. An example isLaerdal‟s Nursing AnneTM with VitalSim capability.
Outcome
A measurable change in a client‟s status in response to nursing care
PDA
Personal digital assistant (handheld computer)
Predict
To envisage or foresee something that may happen
Recall
To remember or recollect a past situation or piece of knowledge
Reflection
A critical review of practice with a view to refinement, improvement orchange; the process of looking back and the careful consideration of anexperience; to explore the understanding of what one did and why andthe impact it has on themselves and others
Relate
To connect or link ; to discover new relationships or patterns; to cluster cuestogether to identify relationships between them.
„Rescue‟
The ability to recognise deteriorating patients and to interveneappropriately
Simulation
An attempt to replicate, to varying degrees, a clinical situation, in order toteach or assess nursing skills and knowledge
Synthesis
The putting together of parts into the whole (inductive reasoning).The integration of new knowledge with previous knowledge, to form a„new whole‟
13CLINICAL REASONING ERRORS
Error
Definition
Anchoring
The tendency to lock onto salient features in the patient‟spresentation too early in the clinical reasoning process, and failing toadjust this initial impression in the light of later information.Compounded by confirmation bias.
Ascertainment bias
When a nurse‟s thinking is shaped by prior assumptions andpreconceptions, for example ageism, stigmatism and stereotyping
Confirmation bias
The tendency to look for confirming evidence to support a nursingdiagnosis rather than look for disconfirming evidence to refute it,despite the later often being more persuasive and definitive.
Diagnostic momentum
Once labels are attached to patients they tend to become stickier andstickier. What started as a possibility gathers increasing momentumuntil it become definite and other possibilities are excluded.
Fundamentalattribution error
The tendency to be judgemental and blame patients for their illnesses(dispositional causes) rather than examine the circumstances(situational factors) that may have been responsible. Psychiatricpatients, those from minority groups and other marginalised groupstend to be at risk of this error.
Overconfidence bias
A tendency to believe we know more than we do. Overconfidencereflects a tendency to act on incomplete information, intuition orhunches. Too much faith is placed on opinion instead of carefullycollected cues. This error may be augmented by anchoring.
Premature closure
The tendency to apply premature closure to the decision makingprocess, accepting a diagnosis before it has been fully verified. Thiserror accounts for a high proportion of missed diagnosis.
Psych-out error
Psychiatric patients are particularly vulnerable to clinical reasoningerrors, especially fundamental attribution errors. Co-morbidconditions may be overlooked or minimalised. A variant of this erroroccurs when medical conditions (such as hypoxia, delirium,electrolyte imbalance, head injuries etc.) as misdiagnosed aspsychiatric conditions.
Unpacking principle
Failure to collect all the relevant cues in establishing a differentialdiagnosis may result in significant possibilities being missed. Themore specific a description of an illness that is received, the morelikely the event is judged to exist. If an inadequate patient history istaken unspecified possibilities may be discounted
Adapted from Croskerry, P. (2003). The importance of cognitive errors in diagnosis andstrategies to minimize them. Academic Medicine. 78(8), 1-6..14REFERENCESAiken, L.H., Clarke, S.P., Cheung, R.B., Sloane, D.M. and Silber, J.H. (2003) Educationallevels of hospital nurses and surgical patient mortality. JAMA. 290 (12), 1617–1620.Alfaro-LeFevre, R. (2009). Critical thinking and clinical judgement: A practical approach tooutcome-focused thinking. (4th ed.). St Louis: Elsevier.Andersen, B. (1991). Mapping the terrain of the discipline. In G. Gray and R. Pratt (eds).Towards a discipline of nursing. (Pp. 95-124) Melbourne: Churchill LivingstoneAustralian Nursing and Midwifery Council (ANMC) (2005) National Competency Standardsfor the Registered Nurse, accessed at http://www.anmc.org.au on 28 November 2008.Benner, P. (2001). From novice to expert: Excellence and power in clinical nursingpractice. Upper Saddle River, N.J. Prentice Hall.Bright, D., Walker, W. and Bion, J. (2004). Outreach – a strategy for improving the care ofthe acutely ill hospitalized patient. Critical Care Medicine, 2004. 8(1), pg. 33-40.del Bueno, D. (2005) A crisis in critical thinking. Nursing Education perspectives. 26, (5),278-283.del Bueno, D. (1994). Why can‟t new grads think like a nurse? Nurse Educator. 19, 9-11.Ericsson,K., Whyte, A. and Ward. J. (2007). Expert performance in nursing: reviewingresearch on expertise in nursing within the framework of the expert-performanceapproach. Advances in Nursing Science. 30 (1), 58-71.Higuchi Smith, K.. and Donald, J. (2002).Thinking processes used by nurses in clinicaldecision-making. Journal of Nursing Education, 41(4), 145–154.Hoffman, K. (2007).Unpublished PhD thesis, A comparison of decision-making by “expert”and “novice” nurses in the clinical setting, monitoring patient haemodynamic statuspost abdominal aortic aneurysm surgery. University of Technology, Sydney.Incident Management in the NSW Public Health System 2007 July to December. (2008).Clinical Excellence Commission. NSW Health.Kamin, C., O‟Sullivan, P., Deterding, R. and Younger, D. (2003). A comparison of criticalthinking in groups of third-year medical students in text, video and virtual casemodalities. Academy of Medicine, 78(2), 204–211.Kraischsk, M. and Anthony, M. (2001) Benefits and outcomes of staff nurses‟ participationin decision-making. The Journal of Nursing Administration, 31(1), 16–23.Lauri, S., Salantera, S., Chalmers, K., Ekman, S., Kim, H., Hesook, S., Kapelli, S. andMacLeod, M. (2001). An exploratory study of clinical decision-making in five countries.Image–Journal of Nursing Scholarship. 33(1), 83–90.McCaffery, M., Rolling Ferrell, B. and Paseo, C. (2000). Nurses‟ personal opinions aboutpatients‟ pain and their effect on recorded assessments and titration of opioid doses. PainManagement Nursing. 1(3, 79-87.McCarthy, M. 2003. Detecting Acute Confusion in Older Adults: Comparing ClinicalReasoning of Nurses Working in Acute, Long-Term, and Community Health CareEnvironments. Research in Nursing and Health 26, 203–21215NSW Health (2006) Patient Safety and Clinical Quality Program: Third report on incidentmanagement in the NSW Public Health System 2005-2006, NSW Department ofHealth. Sydney.O‟Neill, E. 1994. The influence of experience on community health nurses‟ use of thesimilarity heuristic in diagnostic reasoning. Scholarly Inquiry for Nursing Practice, 8,261-217Rubenfeld, M. and Scheffer,B. (2006). Critical Thinking Tactics for Nurses. Boston: Jonesand BartlettScheffer, B. and Rubenfeld, M. (2000). A consensus statement on critical thinking innursing. Journal of Nursing Education, 39, 352-359Tanner, C. (2006). Thinking like a nurse: A research-based model of clinical judgement innursing. Journal of Nursing Education, 45(6), 204-211Wilson, R. (1995). The Quality in Australian Health Care Study. Medical Journal ofAustralia. 163, pg. 458-471.RESOURCESAlfaro-LeFevre, R. (2009). Critical thinking and clinical judgement: A practical approach tooutcome-focused thinking. (4th ed.). St Louise: Elsevier.Foundation for Critical Thinkinghttp://www.criticalthinking.org/starting/nurse_health.cfmhttp://www.criticalthinking.org/courses/Youtube_critical_thinking.cfmPaliadelis, P. Developing clinical judgment: A case scenario approach. Melbourne:Cengage.Rubenfeld, M. and Scheffer,B. (2006). Critical Thinking Tactics for Nurses. Boston: Jonesand BartlettTeaching Smart Learning Easy Web Site – Alfaro-LeFevrehttp://www.AlfaroTeachSmart.com/16ACKNOWLEDGEMENTSSupport for the development of this resource has been provided by the Australian Learning andTeaching Council Ltd, an initiative of the Australian Government Department of Education,Employment and Workplace Relations. The views expressed in this resource do notnecessarily reflect the views of the Australian Learning and Teaching Council.This project was also funded by a University of Newcastle Teaching and Learning Grant.Project TeamAssociate Professor Tracy Levett-Jones, PhD, RN, MEd & Work, BN, DipAppSc(Nursing), Senior Lecturer,Deputy Head of School (Teaching and Learning), The University of NewcastleDr Kerry Hoffman, PhD, RN, MN, Grad.Dip. Ed, Dip. HlthSc (Nursing), BSc, Lecturer, University of Newcastle.Dr Sharon Bourgeois, Sharon Bourgeois, PhD, RN, MEd, MA, BA, FCN, FCRNA, Senior Lecturer and AssociateHead of School, University of Western Sydney.Raelene Kenny, RN, MN, Grad Dip. Nursing (Critical Care), Grad Cert Ed (Adult & Org Learning), Grad CertTerTeach, PhD candidate, Lecturer, The University of Newcastle.Dr Jennifer Dempsey, Doctor of Nursing, RN, RPN, MNurs. Studies, GradDip(Nursing), Lecturer, Director ofClinical Education, The University of Newcastle.Noelene Hickey, RN, BHlthSc(Nurs), GDipContEd, MN, MPET. PhD candidate, Lecturer, Site co-ordinator of theBN Program at Ourimbah Campus, Liaison Officer for the Indigenous BN students at The University of Newcastle.Dr Sharyn Hunter, PhD, RN, BSc (Hons), Grad Cert Advanced Practice Aged Care and Tertiary Teaching,Lecturer, Student Academic Conduct Officer, The University of Newcastle.Dr Sarah Jeong, PhD, RN., MN, BN, Grad. Dip. Adv. Prac., Lecturer, Master of Nursing Advanced PracticeProgram Convenor, International Student Liaison Officer, The University of Newcastle.Carol Norton, RN, CM, BHSc(Nursing), MMid, Lecturer, The University of Newcastle.Jan Roche, RN, BHlthSc(Nurs), Grad Cert ICU, Lecturer, clinical assessor and Master Philosophy (Nursing)candidate, The University of Newcastle.Carol Arthur, BN, Dip App Sc (Nursing) RN, ICU/CCU Cert, Master Philosophy (Nursing) candidate, Lecturer andclinical assessor, The University of Newcastle.Samuel Lapkin, BN (Hons), PhD candidate, The University of Newcastle.Karen Jeffrey, Honours student, The University of Western Sydney.Expert PanelJennifer Burrows, Clinical Nurse Consultant, Stroke, NSCCAHSJaqueline Colgan, Clinical Nurse Consultant, Cardiac Services, NSCCAHSLinda Ritchard, Clinical Nurse Consultant, Hunter Integrated Pain Service, HNEASHAlex Keene, graduate, The University of NewcastleGemma Carty, graduate, The University of Newcastle17Kylie Dunstan, graduate, The University of NewcastleThomas Quinn, graduate, The University of NewcastleRachel Craig, graduate, The University of NewcastleReference GroupGeoff Wilson, Chair Network of Clinical Coordinators (NCC), Director of Clinical Schools, Department of Nursing andMidwifery/Faculty of Science, University of Southern Qld.Professor Gerry Farrell, Representing the Council of Deans of Nursing and Midwifery (Australia and New Zealand),Head, Division of Nursing and Midwifery, Faculty of Health Science, La Trobe UniversityProfessor Leanne Aitken, Professor of Critical Care Nursing, Griffith University and Princess Alexandra Hospital.Professor Tracy Bucknall, Chair in Nursing, Cabrini-Deakin Centre for Nursing Research.Roy Brown, Senior Lecturer, Bachelor of Nursing Programme Coordinator, School of Nursing, Midwifery andIndigenous Health, University of Wollongong.Associate Professor Anthony Williams, Head of School, School of Architecture & Built Environment, Universityof Newcastle.Michelle Kelly PhD candidate, Lecturer, Program Manager, Curriculum Technologies Integration, The University ofTechnologyClint Moloney, PhD Candidate, Lecturer University of Southern Qld , Associate Director, Australian Centre forRural and Remote Evidence Based Practice, Toowoomba and Darling Downs Health Service District.Dr Ashley Kable, Deputy Head of School (Research), School of Nursing and Midwifery, The University of Newcastle.Professor Christine Duffield, Centre for Health Services Management, University of TechnologyDr Kerry Reid-Searl, Senior lecturer at CQUniversity Australia in the Department of Health Innovation.Dr Mee Young Park, International Student Support Coordinator, Division of Nursing and Midwifery, School ofHealth Sciences, RMIT UniversityProfessor Elaine Duffy, Professor/Head of School, School of Nursing & Midwifery, Charles Sturt University.

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