centre for open learning of mathematics, science, computing and technology (colmsct) assessing...

Centre for Open Learning of Mathematics, Science, Computing and Technology (COLMSCT)

Assessing clinical decision making skills using an online

interactive tool

Ali Wyllie & Verina Waights Faculty of Health and Social Care

COLMSCT CETL Fellows

Open CETL Conference: Building bridges 24-25th September 2008

2Centre for Open Learning of Mathematics, Science, Computing and Technology (COLMSCT)

Outline

Context of Project

Quality eLearning experience

Outline characteristics of CDM tool

Demo CDM

Findings to date

Looking to the future


Background

Nurses make clinical decisions in response to changes in each patient's condition, which may occur within very small time-frames

The ability to make clinical judgements depends on both a sound theoretical background and good decision-making skills

Clinical decisions are strongly influenced by the context in which they are made (Bucknall 2000)

As the complexity of decision tasks increases, so context-specific knowledge determines the effectiveness of decision-making (Botti & Reeve 2003)


Aims

to develop a web-based tool to provide decision-making opportunities, building on Laurillard (2002): who suggests that:

‘Traditional modes of assessment of knowledge are seen as inadequate because they fail to assess students‘ capability in the authentic activities of their discipline’.

to assess nursing students’ decision-making skills in a context-driven virtual environment.


Quality eLearning for learner enagagement

Boud and Prosser’s (2002) principles for designing a high quality learning environment suggests learning activities should:

support learner engagement - build on prior knowledge

acknowledge the learning context – integral with study

seek to challenge learners – active participation

provide practice – through individual and/or group activities


Pedagogical approach Based on principles of case-based learning design and

experiential learning (Kolb 1984).

Students’ options are scaffolded

Learning is student - led and asynchronous

Feedback is contexual, individualised to student’s learning journey and timely (Nicol and Milligan 2007: 72, Principle 6)

Intention is to assist students to practice in risk-free environment until ready to practice in work setting.


Research methods Students’ perceptions of their decision-making skills and

efficacy of the tool will be evaluated through:

• Individual completion of an online questionnaire to enable quantitative and qualitative evaluation

• Qualitative output from video observation and ‘Think aloud’ techniques with students’ interacting in the IET Userlab


Case study: patient with a leg ulcer Context: Miss Alice Phelps, a (fictitious) 80 year old lady

with an ulcer on her left lower leg.

Realistic: case prepared in collaboration with a practice nurse to mimic reality

Ethical: consent obtained from the ‘real’ patient and anonymity assured

Relevant: Wound healing and clinical decision-making are integral components of Nursing Programme of study.


Case study – patient with leg ulcer


Narrative• The story evolves over a series of consultations depending on

the treatment the patient receives.

• At each stage students consult resources to find out about their patient’s condition.

• They determine the best treatment from 3 available options.

• Their decisions result in the patient progressing through successive consultations until an end point is reached.

• They are encouraged to have a second attempt at the maze if their first attempt is unsuccessful.

• Images of the consultations and patient’s final outcome create a visual narrative within the maze


Practice ResourcesThe students have a range of media resources to consult:

Audios of consultations between the nurse and patient

Photos of leg ulcers

Instruction sheets on possible treatments

Patient charts and records

Patient records

Laboratory reports

Links to the BNF (British National Formulary)


Reflective Log

The Reflective Log captures each decision point and the student’s reasons for their choice.

At the end of each attempt the student can review their pathway and reflect on their decisions and reasoning.

The final attempt additionally provides author feedback on decision-making at each stage.


Example Feedback in Reflective logReflective log

Miss Alice Phelps, a lively and independent 80 year old lady came to the surgery on 17th February with an ulcer on her left lower leg. How would you help her? You chose: A. Take a swab and apply a viscopaste dressingWhy: The wound assessment chart indicates a venous ulcerFeedback: The correct decision here would be to apply a viscopaste dressing and take a swab to check for infection. It would also be an acceptable decision to apply a silver dressing to prevent infection. Algae-based dressings are unsuitable in this instance because they are used to absorb exudates and Miss Alice Phelps’ ulcer has only low levels of exudate.

Miss Alice Phelps has returned to your clinic. You chose: A. Prescribe penicillin and apply a viscopaste dressingWhy: It needs an antibiotic and penicillin is broad spectrum.Feedback: The correct decision here would be to prescribe erythromycin and apply a viscopaste dressing as there are bacteria present in the ulcer. Although S.aureus is sensitive to penicillin as well as to erythromycin, you should not prescribe penicillin to Miss Phelps because her records show that she is allergic to penicillin.


ScoringScoring at each decision point depends on the type of decision

as outlined below and whether it is the first or second attempt:

For example:

1st attempt: a 5 b 3 c 0 2nd attempt: a 3 b 2 c 0

The final score is an average of the two attempts at the maze.


Demo

http://learn.open.ac.uk/mod/resourcepage/view.php?id=79337&superfluous=357


Findings to date - score11 students completed tool/27 students partly completed tool

Average score (%)

Number of students

Score decreased over 2 attempts

Score stayed the same over 2 attempts

Score increased over 2 attempts

40 - 49 1 X

50 -59 2 XX

60 -69 3 X XX

70 -79

80 -89 2 XX

90-99 3 X XX


Findings to date - questionnaire

Strongly agree

Agree Neutral Disagree Strongly disagree

Tool

1)Easy to use 5 2

2)Realistic 4 3 1

Resources

3)Explored all thoroughly

6 2

4)Cursory glance only

4 1 2 1

5)Variety was valuable

3 5

6)They made learning memorable

3 4 1


Strongly agree


Reflective Log

1) Easy to use 4 4

2)Useful to reflect during tasks

2 6

3)Useful to discuss with other students

2 4 2

4)Useful learning tool

2 4 2


Strongly agree


Learning experience

1) New information re decision-making

4 4

2) New information re leg ulcers

2 5 1

3) Better prepared for practice

3 4 1

4) Useful for self-assessment

5 2 1

5) Useful for group discussion

3 4 1

6) Could feed into TMA

4 2 2


Very Quite Neutral Not very Not at all

Motivating

1) Context 4 3 1

2) Log 1 6 1

3)Audios 3 3

4)Images 6 1 1

5) Texts 6 1 1

6) Linked questions

3 5

7) Case study 3 4


Strongly agree


Decision-making

1) Range of resources reflects practice

5 3

2) Useful in other practice areas

4 3 1

3) Useful to have another attempt after ‘real’ practice experience

3 4 1


Students felt using CDM tool:• Increased their confidence in decision-making and caring for leg ulcers - support learner engagement

‘a very helpful tool in confidence-building’ ‘helped a great deal - more please!’

• Would assist in their practice - acknowledge the learning context

‘I found that it made you think about what you are doing for the patient’.

•Seek to challenge learners – active participation

‘very keen to expand my new skills, these questions taxed me!’


Looking toward the futureThe approach piloted in this project can be applied in part or

whole in other courses, programmes or disciplines.

The tool can be combined with other VLE tools, such as online discussion forums and voting tools, to create flexible and collaborative learning and assessment sequences.

The Reflective Log can become part of a TMA.

Our findings are being used to inform future assessment strategies within HSC. We are particularly interested in: Contextualised CMA questions; Narratives; Embedded multiple media; Case-based CMAs; Decision-Making;


Contact

If you are interested in our work we can be contacted on:

Ali Wyllie ([email protected])

Verina Waights ([email protected])

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