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Using branching path simulations in critical thinking of pain management among nursing students: Experimental study
Journal Pre-proof Using branching PATH simulations in critical thinking of pain management among nursing students: Experimental study
Mohammad Rababa, Dina Masha'al PII:
S0260-6917(19)31203-1
DOI:
https://doi.org/10.1016/j.nedt.2019.104323
Reference:
YNEDT 104323
To appear in:
Nurse Education Today
Received date:
7 August 2019
Revised date:
17 November 2019
Accepted date:
23 December 2019
Please cite this article as: M. Rababa and D. Masha'al, Using branching PATH simulations in critical thinking of pain management among nursing students: Experimental study, Nurse Education Today(2019), https://doi.org/10.1016/j.nedt.2019.104323
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© 2019 Published by Elsevier.
Journal Pre-proof USING BRANCHING PATH SIMULATIONS IN CRITICAL THINKING OF PAIN MANAGEMENT AMONG NURSING STUDENTS: EXPERIMENTAL STUDY Mohammad Rababa1 and Dina Masha’al1 1- Assistant Professor, Department of Adult Health Nursing, Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan. Corresponding author:
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Mohammad Rababa PO Box 3030 University of Science and Technology Irbid, Jordan Mobile: (+962)779511515 Fax: (+962)27201000 Email: [email protected]
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Funding support This study was funded by Jordan University of Science and Technology (grant number 20180061).
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Conflict of interest None
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Ethical approval The IRB approval (#20170622) was obtained from the Institutional Review Board of Jordan University of Science and Technology (JUST). Written informed consent was obtained from each participant prior to data collection. The researchers emphasized the confidentiality and privacy of the data and the voluntary participation in the study.
Acknowledgement Special thanks to Jordan University of Science and Technology for funding and facilitating the conduction of this study. We Also want to thank Mr. Ahmad Hayajneh and Dr. Ahmed Al-Smadi for proofreading the whole manuscript. Author Contribution MR; Conceptualization, project administration, data analysis and writing. DM; data analysis and writing.
Journal Pre-proof Abstract Background: Nursing education has to promote nursing students’ critical thinking skills especially those who are going to work with people with dementia suffering from pain. Therefore, nursing education needs to incorporate new and effective teaching methods in nursing curricula for critical thinking skills promotion. Branching path simulation is an
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interactive learning tool which helps students; (1) to make decisions about treatment options for patients and get feedback immediately and (2) to demonstrate and promote their critical
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thinking skills in a safe and supported environment before dealing with complex and real-life
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case scenarios.
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Objectives: The present study aimed to examine the effectiveness of branching path simulation
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in promoting the critical thinking skills of undergraduate nursing students. Methods: This an equivalent control group pretest-posttest experimental study was done in
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2019 on 102 undergraduate nursing students who had registered in both practical and
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theoretical courses of Advanced Adult Health Nursing. A pretest posttest experimental design
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with concurrent control group and random assignment to the treatment/nontreatment variable was used and a convenience sample of 102 nursing students was recruited in this study. The students were randomly assigned and divided into two equal intervention and control groups and each group attended different training sessions. The control group was trained by traditional lectures while the intervention group was trained by branching path simulation. The researcher used a demographic questionnaire and the Critical Thinking Self-Assessment Scale (CTSAS) for data collection.
Journal Pre-proof Results: After the training sessions, the mean scores of the CTSAS and its subscales domain in the intervention group were significantly higher than the control group. Conclusions: Branching path simulation is an effective teaching method to promote students’ critical thinking skills. Future studies are recommended to examine the effect of branching path simulation on other nursing students learning outcomes.
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Keywords: Critical thinking; Interactive learning; Simulation; Nursing students; Nursing
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education
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Background Critical thinking (CT) is not a simple, automatic or linear process, but has been defined consensually according to the American Philosophical Association (APA) as “a purposeful, selfregulatory judgment which results in interpretation, analysis, evaluation and inference”
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(Facione, 1990, p. 2). Also, according to the conceptual framework for core cognitive and subscales (Nair & Stamler, 2013), the core cognitive and subscales of critical thinking skills (CTS)
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include inference, interpretation, explanation, self-regulation, analysis, and evaluation.
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However, CT in nursing is viewed as a nursing process, which includes assessment and nursing
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diagnosis, planning, nursing interventions, and evaluation (Azizi-Fini, Hajibagheri, & Adib-
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Hajbaghery, 2015). While this perspective of CT may be useful for teaching and multiple clinical purposes, it fails to adequately describe the processes of CT used by nurses in some
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complicated and challenging clinical situations (Azizi-Fini et al., 2015). These clinical situations
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are usually underdetermined, ambiguous, and complex (Lasater & Nielsen, 2009). Therefore,
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nurses using the nursing process may have difficulty defining these clinical situations, interpreting their meanings, and responding appropriately. Problems of Nursing CT About Pain in PWD Pain management in people with dementia (PWD) is still a challenging clinical situation (Rababa, 2018). Nurses caring for PWD still have problems of CT about pain assessment and treatment. These problems significantly impact the core cognitive components of CT process as described by Nair and Stamler (2013) and APA (Facione, 1990). According to Achterberg et al. (2013), nurses do not reach to a clear inference about the presentation of illnesses in PWD due
Journal Pre-proof to the complexity of pain assessment in PWD as well as their inability to communicate. Lack of clear inferences limits nurses’ CTS when making decisions about assessment and treatment of pain in PWD (Achterberg et al., 2013). Therefore, nurses often use a trial-and-error process to manage pain in PWD by just administering unjustified or unsupported interventions and observing the response of PWD to these interventions (Sheilds et al., 2013).
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Achterberg et al. (2013) also found that nurses held numerous false interpretations and explanations of pain in PWD, impeding their CTS. For example, a recent study showed that
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believing only in nurses’ own false interpretations about pain in PWD, instead of reliable
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objective data, affected their CT about pain management (Rababa, 2018). According to
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Achterberg et al., there are many misconceptions related to pain in PWD including: (a) pain is a
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normal part of aging and dementia; (b) dementia cause pain insensitivity; (c) PWD do not feel pain; (d) analgesics have dangerous side effects if prescribed for PWD; or (e) the lack of self-
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reporting of pain in PWD means no pain (Achterberg et al.). According to Cameron,
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Fetherstonhaugh, Bauer, and Tarzia (2018), nurses having misconceptions related to pain in
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PWD may have lack of self-regulation and misinterpret the cues of pain in PWD. Having misconceptions limits the ability of leaners to identify their own flaws in thinking and impedes the desire to promote their own quality of CT (Nair & Stamler, 2013). According to Papp et al. (2014), critical thinkers understand complex connections between concepts to create reasonable analysis to explain observed phenomena. Accordingly, when nurses are able to use analytic thought process through a logical and systematic approach of questioning and inference, they are able to apply their CTS for clinical decision-making processes (Monroe, Parish, & Mion, 2015). However, nurses have been found to use an
Journal Pre-proof intuitive approach rather than analytic thought process when assessing and managing pain in PWD (Gilmore-Bykovskyi & Bowers, 2013). According to Lasater and Nielsen (2009) , nurses come to clinical situations with biases that strongly influence their evaluation of arguments about the clinical situations. According to Feng, Chen, Chen, and Pai (2010), nurses’ CT is the product of both bottom-up input, and top-
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down processing, wherein nurses’ biases may impact upon the CT. When making a clinical pain assessment based on observation, it is important to be aware of biases that may
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confound nurses’ CT (Lasater & Nielsen, 2009). Nevertheless, nurses display substantial biases
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in their CT of patients' pain and consistently underestimate the pain of PWD (Feng et al.,
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2010).
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Theoretical Framework of CT
A whole host of research has been done on nursing CT models, all of which come from
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perspectives that are based on analytical thought processes (Lauri & Salentara, 2002).
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Analytical thought process has been defined as a process of problem solving that involves
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separation of a whole into its constituent parts in order to study the parts and the relations between parts (Lauri & Salentara, 2002). The Response to Certainty of Pain (RCP) model has been chosen to guide this study because it uses analytical thought process to guide the nursing CT of pain assessment and management in PWD (Gilmore-Bykovskyi & Bowers, 2013). The RCP model is briefly outlined in Figure 1. The RCP model provides an explanation of how the level of nurses’ certainty may predict the level of pain and agitation in nursing home residents with dementia. The RCP model suggests that when nurses are certain about pain in PWD they just need to do brief self-report
Journal Pre-proof assessment and then promptly administer analgesics. When nurses are not certain about pain, they need to do additional assessment (behavioral and functional assessment) and then the treatment of pain may be delayed (Gilmore-Bykovskyi & Bowers, 2013). Branching Pathway Simulation Branching path simulation (BPS) is an interactive learning method included case
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scenarios that guide the user through a step-by-step decision-making process (Kovach & Rababa, 2014). BPS has been proposed as a very feasible and effective learning tool as the
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increasing number of student population limits their encounter with real patients in the clinical
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settings (Bateman, Allen, Kidd, Parsons, & Davies, 2012), as well as its effectiveness in
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endorsing CTS (Kovach & Rababa, 2014). The BPS was found to be very successful in identifying
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the nurses who need more training and capturing most common weakness areas before dealing with real patients (Kovach & Rababa, 2014). The BPS help students to interact at different
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stages of problem solving. The BPS gives them the opportunity to make decisions according to
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their level of skills and knowledge and get feedback immediately (Kiili, 2005), which help them
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to demonstrate their CTS in a safe and supported environment before dealing with complex and real-life case scenarios (Johnston, MacArthur, & Manion, 2013). According to Lebowitz and Klug (2012), there are three types of BPS: short, moderate and long branches. In this study, the researcher used short branches as: (1) they are the easier to use; (2) they quickly reconnect the user to the main branch of CT and action process; and (3) they provide the users an immediate feedback on their decisions and give them an opportunity for correction. Immediate feedback is a key principle in learning process. Learners appreciate immediate feedback because it helps them to expect their performance, determine their level
Journal Pre-proof of understanding, adjust their fallacy, improve performance, and implement new strategies to achieve the learning aims (Pennaforte et al., 2016). Accordingly, the purpose of this study is to examine the efficacy of BPS to improve the CTS of nursing students about pain assessment and management in PWD. Research Questions
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(1) What is the level of nursing students’ CTS prior to and after the training session? (2) Is there a difference in students’ CTS measured by the CTSAS before and after the
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training session for both control and treatment groups?
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(3) Is there a difference in the CTS measured by the CTSAS between students who were
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trained by traditional lectures (TL) and those who were trained by BPS?
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(4) What are the predictors of CTS in nursing students?
Design, Sample, Setting
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Method
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A pretest posttest experimental design with concurrent control group and random
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assignment to the treatment/nontreatment variable was used and a convenience sample of 102 nursing students was recruited in this study. Sample size was determined by doing G-Power analysis using A-priori Sample Size Calculator for t-test (Cohen, Cohen, West, & Aiken, 2003) to calculate the sample size. Given an alpha level of 0.05, an anticipated effect size of 0.5, the desired statistical power level of 0.8, and allocation ratio N2/N1 of 1, the minimum required sample size for each group is 51 with a total sample size of 102 subjects. The inclusion criteria of the study were undergraduate-nursing students who are (1) registered in both practical and theoretical courses of Advanced Adult Health Nursing, and (2) in a good academic standing with
Journal Pre-proof GPA equal to or more than 2.5 out of 4. The study was conducted at Jordan University of Science and Technology/ College of Nursing. Ethical Considerations The IRB approval (#20170622) was obtained from the Institutional Review Board of Jordan University of Science and Technology (JUST). Written informed consent was obtained from each participant prior to data collection. The researchers emphasized the confidentiality and
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privacy of the data and the voluntary participation in the study.
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Instruments
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The independent variable was the training sessions about pain management in PWD.
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The training session of the treatment group included BPS and vignettes. The training session of
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the control group included TL and vignettes. Four pain vignettes were provided for each group. These vignettes described different clinical case scenarios about pain management in PWD and
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developed according to pain trajectories as outlined in the RCP model. The students responded
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to theses vignettes as being trained either in the TL or by using BPS. The student recorded their
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responses in data collection sheets provided by the researcher. The dependent variable was the CTS measured by the Critical Thinking Self-Assessment Scale (CTSAS) (Nair, Hellsten, & Stamler, 2017). Although there are several CT assessment tools other than the CTSAS, they are associated with limited accessibility, psychometric challenges, inconsistency of results, and cost of reproduction. In addition, the CTSAS is the first self-assessment tool of CT that enables the learners not only to measure their CTS but also actively involved in managing and improving their CTS (Nair et al., 2017). The CTSAS measures the core cognitive of CTS as described by APA definition of CT (Facione, 1990). The CTSAS has six subscales including inference, self-regulation, analysis, evaluation, interpretation,
Journal Pre-proof and explanation. The CTSAS has 115 multiple-choice items with a total score ranged from 0 to 690. Each item has seven responses including: 0= “Never”; 1= “Rarely”, 2= “ Occasionally”; 3= “ Usually”; 4= “ Often”; 5= “Frequently”; and 6= “ Always”. Higher scores indicate better CTS. In the original study, the scale had good content validity (I-CVI ≥ .7 to .938 ) and reliability scores (Cronbach’s alpha > 0.7-0.85). In this study the CTSAS had a satisfactory reliability scores (Cronbach’s alpha = 0.81).
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Procedure
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The researcher developed the BPS of the pain trajectories in PWD as illustrated (guided
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by) in the RCP model. A detailed description of the model was provided in the introduction
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section of this study and other research studies (Gilmore-Bykovskyi & Bowers, 2013; Rababa,
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2018). The researchers used their clinical expertise and reviewed the literature to conclude that the following thinking processes: (1) inference, (2) self-regulation, (3) analysis, (4) evaluation,
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(5) interpretation, and (6) explanation are key components for assessing CTS. These
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components are the core CTS that are based on the APA definition of CTS and informed by the
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conceptual framework for core cognitive and subscales of CTS developed by Nair and Stamler (2013). This conceptual framework is shown in Figure 2. These six thinking processes, which are critical components of the RCP, were incorporated (or integrated in) into the BPS and clinical case scenarios or vignettes. An example of these case scenarios is mentioned below: ‘A 96-year-old person with severe dementia, a female on one day was screaming and crying during the morning care. She had been in the nursing home for 23 months, was non-ambulatory, had communication deficit (aphasia), and she had bilateral ankle and
Journal Pre-proof knee pain. In addition to crying, she consistently screamed “oooh, oooh, oooh,” when changed her position, she started to be non-cooperative to the care and looked very sad and depressed when approached. The nurse interpreted these odd behaviors as anxiety and responded by providing her care slowly with other nurses’ help’. Five experts from the college of nursing reviewed each case and recommended some
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modifications which were integrated into the final drafts used. The final draft of cases was handled to a software developer to develop computer-based (electronically-produced) BPS. An
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example of a BPS that involves using the steps of RCP model is outlined in Figure 3.
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The procedure included multiple training sessions about pain assessment and
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management in PWD. These training sessions included the use of TL (for the control groups),
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and BPS (for the intervention group). Also, a presentation and discussion of multiple clinical case scenarios and vignettes related to pain in PWD were done for both groups during the
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training sessions. The researcher used vignettes to train the students to (a) correctly respond to
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the trajectories of the RCP and (b) consistently document their responses on CTS on the data
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collection sheets. There were 6 one-hour training sessions over two weeks given for both BPS and TL groups. Before the training sessions started, the researcher measured the CTS of the students in both groups using the pretest CTSAS. For the control group, TLs were administered in a regular classroom, while the researcher with technician’s assistance runs the BPSs for the intervention group in the computer lab of the nursing college. At the completion of the training sessions, the researchers distributed the post-test CTSAS to both groups to measure their CTS. A variety of innovate teaching and learning strategies were used to protect the learning rights of students in TL group. These strategies included the use of slide presentations with
Journal Pre-proof diagrams, video clips, flow charts, and case scenarios. The content of the slide presentations was not different from that used in BPS group. However, the amount of interactive learning and speed of feedback were different from BPS group. In addition, the researchers utilized vignettes in both groups. Data analysis
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Data analysis was conducted using SPSS (25.0 Version) , a statistical software program. Descriptive statistics, t-test, one-way ANOVA, and regressions were computed. An alpha level
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of 0.05 was used to determine statistical significance of all inferential tests used. The
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assumptions of each statistical test used were checked before running the tests. Descriptive
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statistics were used to describe the sample characteristics and students’ scores on both pretest
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and posttest CTSAS. To measure the difference in students’ scores on both pretest and posttest CTSAS between groups, independent t-tests were used. To measure the difference in students’
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CTS measured by the CTSAS between pretest and posttest scores for both groups, paired t-tests
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students’ CTS.
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were used. Multiple regression was used to examine the possible predictors of nursing
Description of Participants
The number of nursing students participated in this study was 102 with no exclusion of any student. The average age of students was 21.80 (0.25). The majority of students were female (80.4%), single (90.2%), unemployed (95.1%), senior (84.3%), lived in the same household with their parents (91.2%), and did not have a family member diagnosed with dementia or lived in a nursing home (90.3%). The average of their accumulative GPA was 3.05(0.56). The level of nursing students’ CTS is poor either in the BPS (M=337.67, SD=13.44) or TL (M= 309.77,
Journal Pre-proof SD=15.11) group prior to the training sessions. Detailed descriptive statistics of students’ characteristics is summarized in Table 1. [Please insert Table 1 here] Comparisons Between Groups According to the independent-sample t test, there were no significant differences in the mean scores of CTSAS between the groups (BPS and TL) before the training sessions. However,
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these mean scores were significantly different between the groups after the training sessions (p <
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0.05). Moreover, the results of the paired-sample t test revealed that the mean scores of CTSAS
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significantly changed after BPS in the intervention group during the study (p < 0.05). However,
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the results of the paired-sample t test showed that the mean scores of CTSAS insignificantly changed after TL in the control group (p > 0.05). Detailed statistics of these comparisons is
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summarized in Table 2.
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[Please insert Table 2 here] Predictors of Students’ CTS
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A multiple linear regression was calculated to predict students’ scores on posttest CTSAS
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based on selected demographics. As seen in Table 3, an insignificant regression equation was found either in BPS or TL group (F (3,47) = 4.21, p= 0.456) and (F (3,47) = 3.54, p= 0.442), respectively. [Please insert Table 3 here] Advantages and Disadvantages of BPS Also, the data collection sheets included two open-ended questions about the advantages and disadvantages of BPS. All students answered these two questions. The most common answers on the advantages of BPS include: (1) “effective guidance” , (2) “brainstorming
Journal Pre-proof promotion”, (3) “understanding how to interpret the cues”, (4) “quick inference”, (5) “ability to know the incorrect answers”, (6) “attention and concentration promotion”, (7) “prompt correction”, and (8) “interactive learning”. In contrary, the most common answers on the disadvantages of BPS include: (1) “time-consuming”, (2) “less teacher involvement”, and (3) “greater time of students’ preparation”. Discussion
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The findings of the study revealed significant increase of students’ mean scores of total
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CTSAS and its subscales in the BPS group. These findings affirm the effectiveness of BPS in
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improving students’ CTS. Similarly, a previous recent study on nurses also revealed that BPS
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was associated with better outcomes (Kovach & Rababa, 2014). Kovach and Rababa found that staff training sessions on pain treatment in PWD using BPS significantly improved treatment
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fidelity. Also, a recent study on students also found the positive impact of the branching story
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approach, which is informed by the same principles as BPS, on learning outcomes (Liu & Alduraby, 2017). The significant improvement of students’ CTS using BPS in this study can be
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explained by the fact that the approach of BPS is informed by immediate feedback and analytic
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decision-making learning theories and the principles of behaviorism and cognitivism (Kovach & Rababa, 2014). Analytic decision-making uses a step-by-step analytic thought process to deepen the information used for decision-making. The immediate feedback provided by BPS elaborated on the errors made by the students and provided explanation for these errors (Scheeler, Congdon, & Stansbery, 2010). The learning experience using BPS energized students’ enthusiasm in reading all pertinent information and make decisions accordingly (Liu & Alduraby, 2017). Nursing students in this study were eager to read all case scenario details. In BPS, learners felt empowered with
Journal Pre-proof the branch options and they were satisfied about the learning experience (Kovach & Rababa, 2014). The participation level of the students in actively make decisions related to pain management in PWD has been increased when using BPS in comparison to TL. Also, nursing students got focused more in reading all pertinent details as they were enthusiastic about the next level of branch. They became more serious about understanding and interpreting the cues provided in the case scenario to come up with evidence-based inferences. BPS provides a good
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opportunity for students to be actively engaged in the learning process with minimal interrupting
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causal chatting with their classmates (Bateman et al., 2012). The students in this study became
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more passionate about sharing their decisions after the intervention ended which promoted
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brainstorming. We asked the students in this study to be actively involved in individual interactive learning activities such as analytic decision-making of clinical scenarios.
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Incorporating BPS in nursing curricula as a learning strategy for undergraduate students allows
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authoring, editing and playing of multiple cases of decision making (Bateman et al., 2012). The findings of this study revealed no significant improvement in students’ mean scores
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of total CTSAS and its subscales in TL group. Consistently, another recent study found that TL
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cannot enhance students’ CTS (Choi, Lindquist, & Song, 2014). There are many disadvantages related to TL that may impede the CTS in nursing students. Although TL is the most widely used teaching method, it fails to improve students’ skills of decision making, CT, problem solving, and self-directing learning skills (Meibodi et al., 2013). TL lacks the active involvement of students in the class and makes the teachers work as information suppliers instead of facilitators, which limits their roles in improving the CTS of students (Dehghanzadeh & Jafaraghaee, 2018). The association between students’ GPA and their CTS was not found statistically significant in both TL and BPS groups. This finding is consistent with previous research studies
Journal Pre-proof that found no significant associations between nursing students’ CTS and their GPA (Mousazadeh et al., 2016). This interesting finding could be explained by the fact that the undergraduate nursing education in Jordan values and appreciates memorization of knowledge rather than demonstration of CTS (Jawarneh, Iyadat, Al-Shudaifat, & Khasawneh, 2008). Despite the great attention that Western nursing school have given to CT as a crucial component of nursing education, CT has been given a little attention in Jordanian nursing schools (Al Hadid,
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2012). Nursing students in Jordan have not received any formal education in their undergraduate
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program about CTS (Al Hadid, 2012). Even though nursing instructors taught their students that
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CT is a key principle in nursing career, there is no single course in nursing curricula specialized
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in developing or promoting CTS (Bataineh & Alazzi, 2009). Moreover, the exam system in Jordanian nursing schools is lacking. The exams are multiple choices questions with no chance
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for students to think out of the box (Bataineh & Alazzi, 2009).
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The nursing students in this study declared that BPS has benefits in improving their CT. Similarly, nurses participated in an earlier study stated that the ability of BPS in identifying the
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errors in making decisions and providing rational for those incorrect decisions was very helpful
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in endorsing their decision-making skills (Kovach & Rababa, 2014). Students in a recent study who had experienced branching stories, which is based on the same principles of learning theory and philosophy of action as BPS, found very effective in promoting their learning process and outcomes (Huang, Reynolds, & Candler, 2007). According to Kovach and Rababa (2014), using BPS provides the learners a great chance to recognize their mistakes in making decisions for correction before encountering a real clinical case. The “correct” branches associate with a process of CT and decisions the learner makes for the clinical case. The justification for incorrect and correct decisions helps the learners improve their CTS. The learners can make significant
Journal Pre-proof decisions in BPS and identify the consequences and justifications of those decisions, when still being returned back to the prerequisite branch of the decision tree. Therefore, assessing students’ CTS before being encountering a real clinical case saves effort, money and time, as well as avoids medical errors caused by poor CTS (Jacklin, Maskrey, & Chapman, 2018). As reported by students, there are some challenges associated with incorporating BPS into the CT process. Developing BPS, which needs careful attention to possible decision
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trajectories as well as the theoretical framework that inform these trajectories, is time and money
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consuming. However, the technical support provided by the central computer labs of nursing
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schools can be used to develop web-based BPSs that can be easily connected to multiple
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operating systems and accessible by a wide segment of nursing cohorts. Also, BPS can be easily tailored to fit different clinical case scenarios. Furthermore, the high prevalence of computer
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literacy and anxiety among Jordanian nursing students (Akhu-Zaheya, Khater, Nasar, &
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Khraisat, 2011) explains the disadvantage of huge time of preparation for BPS as reported by students in this study. Also, according to Bataineh and Alazzi (2009), TL was the dominant
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with it.
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teaching method used in the nursing education in Jordan and students were more comfortable
This is first study to examine the effectiveness of a new teaching strategy like BPS to improve the CTS related to pain assessment and management in PWD. However, the use of BPS in this study had some challenges such as the need for computer lab technicians, the cost of developing BPSs, the limited number of nursing instructors specialized in pain assessment in PWD, and the overcrowded classrooms with limited space. Moreover, assessment of CTS related to pain in PWD was done using a general measurement tool. It is recommended to replicate the study using a questionnaire specifically measures the CTS related to pain assessment in PWD.
Journal Pre-proof Furthermore, conducting the study on a relatively small sample size, in a single academic institution, and in one geographical area may limit the generalizability of findings. Conclusion This study implies that while TL is not associated with a significant improvement in the CTS of nursing students, BPS significantly improves their CTS. BPS effectively and promptly detects learners’ errors and provides justification for corrections. Of course, students’ GPA has
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no significant effect on the CTS. It is time for nurse educators to incorporate BPS as an effective
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recommended to have more reliable findings.
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teaching method and reliable measure of students’ academic performance. Future studies are
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Cohen, J., Cohen, P., West, S. G., & Aiken, L. S. (2003). Categorical or nominal independent variables. Applied multiple regression/correlation analysis for the behavioral sciences (3rd ed.). Mahwah, NJ: Lawrence Erlbaum Associates, Inc, 302-353. Dehghanzadeh, S., & Jafaraghaee, F. (2018). Comparing the effects of traditional lecture and flipped classroom on nursing students' critical thinking disposition: a quasi-experimental study. Nurse Education Today, 71, 151-156. Facione, P. A. (1990). The California Critical Thinking Skills Test--College Level. Technical Report# 2. Factors Predictive of CT Skills.
Journal Pre-proof Feng, R. C., Chen, M. J., Chen, M. C., & Pai, Y. C. (2010). Critical thinking competence and disposition of clinical nurses in a medical center. Journal of Nursing Research, 18(2), 7787. Gilmore-Bykovskyi, A. L., & Bowers, B. J. (2013). Understanding nurses’ decisions to treat pain in nursing home residents with dementia. Research in Gerontological Nursing, 6(2), 127138.
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Jacklin, S., Maskrey, N., & Chapman, S. (2018). Improving shared decision making between
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Medical Education, 4(2), e10088, https://doi.org/10.2196/10088 Jawarneh, M., Iyadat, W., Al-Shudaifat, S., & Khasawneh, L. (2008). Developing Critical Thinking
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Skills of Secondary Students in Jordan Utilizing Monro and Slater Strategy, and
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McFarland Strategy. International Journal of Applied Educational Studies, 3(1), 82-91. Johnston, B., MacArthur, E., Manion, B. F. (2013). The role of technology and digital gaming in
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nurse education. Nursing Standard. 27(28), 35-38. Kiili, K. (2005). Digital game-based learning: towards an experiential gaming model. The Internet and Higher Education,8(1), 13-24. Kovach, C. R., & Rababa, M. (2014). Using branching simulations in treatment fidelity plans. Research in Gerontological Nursing, 7(5), 216-223. Lasater, K., & Nielsen, A. (2009). Reflective journaling for clinical judgment development and evaluation. Journal of Nursing Education, 48(1), 40-44.
Journal Pre-proof Lauri, S., & Salanterä, S. (2002). Developing an instrument to measure and describe clinical decision making in different nursing fields. Journal of Professional Nursing, 18(2), 93100. Lebowitz, J., & Klug, C. (2012). Interactive Storytelling for Video Games: Proven Writing Techniques for Role Playing Games, Online Games, First Person Shooters, and more. Routledge.
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Liu, J., & Alduraby, H. (2017). Using the branching story approach to motivate students’ ınterest
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in reading. International Electronic Journal of Elementary Education, 6(3), 463-478.
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Monroe, T. B., Parish, A., & Mion, L. C. (2015). Decision factors nurses use to assess pain in
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nursing home residents with dementia. Archives of Psychiatric Nursing, 29(5), 316-320.
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Mousazadeh, S., Momennasab, M., Bakhtiari, T., & Reisi, M. (2016). Nursing students' disposition toward critical thinking and its relationship with their academic
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Nair, G. G., Hellsten, L. M., & Stamler, L. L. (2017). Accumulation of content validation
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evidence for the Critical Thinking Self-Assessment Scale. Journal of Nursing Measurement, 25(1), 156-170. Nair, G. G., & Stamler, L. L. (2013). A conceptual framework for developing a critical thinking self-assessment scale. Journal of Nursing Education, 52(3), 131-138. Papp, K. K., Huang, G. C., Clabo, L. M. L., Delva, D., Fischer, M., Konopasek, L., ... & Gusic, M. (2014). Milestones of critical thinking: a developmental model for medicine and nursing. Academic Medicine, 89(5), 715-720.
Journal Pre-proof Pennaforte, T., Moussa, A., Loye, N., Charlin, B., & Audétat, M. C. (2016). Exploring a new simulation approach to improve clinical reasoning teaching and assessment: randomized trial protocol. JMIR Research Protocols, 5(1), e26. https://doi.org/10.2196/resprot.4938 Rababa, M. (2018). The association of nurses' assessment and certainty to pain management and outcomes for nursing home residents in Jordan. Geriatric Nursing, 39(1), 66-71. https://doi.org/10.1016/j.gerinurse.2017.06.015 PMID:28743558
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(2013). Pain Assessment: the roles of physician certainty and curiosity. Health Communication, 28(7), 740-746.
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Thurlings, M., Vermeulen , M., Bastiaens, T., & Stijnen, S. (2013). Understanding feedback: a
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learning theory perspective. Educational Research Review, 9, 1–15 Zhou, H., Liu, M., Zeng, J., & Zhu, J. (2016). Selection of nursing teaching strategies in
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mainland China: a questionnaire survey. Nurse Education Today, 39, 147-151.
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Table 1. Comparison Between TL And BPS Groups Based on Selected Students’ Professional and Sociodemographic Characteristics TL BPS Professional/Sociodemographic Characteristics N % N % Female 40 76.9% 42 80.8% Gender Male 12 14.3% 10 18.6% Single 50 96.2% 49 94.2% Marital status Married 2 3.8% 3 5.8% Junior 18 34.6% 15 28.8% Level of education Senior 34 65.4% 40 76.9% Employed 4 7.9% 3 5.8% Employment status Unemployed 48 92.1% 49 94.2% With family 35 67.3% 33 63.4% Living status Away from Home 17 32.7% 19 6.6% 2 3.8% 5 9.6% Have a family with dementia Yes or live in NHs No 50 96.2% 47 90.4% Mean SD Mean SD Age 20.80 .30 20.77 .52 Accumulative GPA 2.91 .42 2.98 .47
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TL= Traditional Lecture; BPS= Branching Path Simulation; NHs= Nursing Homes; GPA= Grade Point Average
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Before
After b P value M (SD)
TL
55.6(5.57)
88.4(4.11)
.330
BPS
54.7(4.45)
117(5.92)
<.001*
.220
.004*
——
48.83(3.87) 49.28(3.41)
83.12(3.17) 105.12(3.26)
.340 .021*
.346
.030*
——
21.57(4.78) 20.51(5.56)
49.12(8.12) 72.56(5.70)
.750 .006*
.340
.040*
60.57(6.77) 72.45(4.55)
96.67(5.12) 128.66(3.22)
.067
.003*
53.47(4.67) 70.45(3.65)
98.11(4.12) 129.76(4.22)
.077
.013*
.184
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.650 <.001*
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49.73(3.67) 50.28(6.35)
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a P value TL BPS Analysis a P value TL BPS Evaluation a P value TL BPS Inference a P value TL BPS Explanation a P value TL Self-regulation BPS a P value TL Overall CTSAS BPS a P value
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M (SD)
.560 .010*
84.22(3.57) 107.42(4.16)
.540 .011*
.049*
——
309.77(15.11 ) 499.64(14.78 ) .970 337.67(13.44 ) 660.52(10.57 ) <.001*
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Interpretation
Group
CTSAS
.132
<.001*
——
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a: The independent-sample t test; b: The paired-sample t test ; *Significant difference at 𝑝 <0.05 TL= Traditional Lecture; BPS= Branching Path Simulation; CTSAS= Critical Thinking Self-Assessment Scale
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Table 3: Summary of Multiple Regression with Posttest CTSAS Scores in Both Groups Groups β .096
TL t .011
p .424
Have a PWD or live in NHs in Family
.273
.187
Cumulative GPA R2 F
.357 .248 3.54
Age
.344
β .176
BPS t .219
p .604
.117
.363
.044
.077
.102
.351 .256 4.21
.221
.082
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Predictor Variable
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TL= Traditional Lecture; BPS= Branching Path Simulation; CTSAS= Critical Thinking Self-Assessment Scale ; PWD= People with Dementia NHs= Nursing Homes; GPA= Grade Point Average.
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Figure 3: An Example of BPS
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CRediT author statement Mohammad Rababa: Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Roles/Writing – original draft; Writing – review & editing. Dina Masha’al: Data curation; Formal analysis; Roles/Writing – original draft; Writing – review & editing,
Figure 1
Figure 2
Figure 3
Mohammad Rababa, Dina Masha'al PII:
S0260-6917(19)31203-1
DOI:
https://doi.org/10.1016/j.nedt.2019.104323
Reference:
YNEDT 104323
To appear in:
Nurse Education Today
Received date:
7 August 2019
Revised date:
17 November 2019
Accepted date:
23 December 2019
Please cite this article as: M. Rababa and D. Masha'al, Using branching PATH simulations in critical thinking of pain management among nursing students: Experimental study, Nurse Education Today(2019), https://doi.org/10.1016/j.nedt.2019.104323
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
© 2019 Published by Elsevier.
Journal Pre-proof USING BRANCHING PATH SIMULATIONS IN CRITICAL THINKING OF PAIN MANAGEMENT AMONG NURSING STUDENTS: EXPERIMENTAL STUDY Mohammad Rababa1 and Dina Masha’al1 1- Assistant Professor, Department of Adult Health Nursing, Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan. Corresponding author:
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Mohammad Rababa PO Box 3030 University of Science and Technology Irbid, Jordan Mobile: (+962)779511515 Fax: (+962)27201000 Email: [email protected]
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Funding support This study was funded by Jordan University of Science and Technology (grant number 20180061).
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Conflict of interest None
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Ethical approval The IRB approval (#20170622) was obtained from the Institutional Review Board of Jordan University of Science and Technology (JUST). Written informed consent was obtained from each participant prior to data collection. The researchers emphasized the confidentiality and privacy of the data and the voluntary participation in the study.
Acknowledgement Special thanks to Jordan University of Science and Technology for funding and facilitating the conduction of this study. We Also want to thank Mr. Ahmad Hayajneh and Dr. Ahmed Al-Smadi for proofreading the whole manuscript. Author Contribution MR; Conceptualization, project administration, data analysis and writing. DM; data analysis and writing.
Journal Pre-proof Abstract Background: Nursing education has to promote nursing students’ critical thinking skills especially those who are going to work with people with dementia suffering from pain. Therefore, nursing education needs to incorporate new and effective teaching methods in nursing curricula for critical thinking skills promotion. Branching path simulation is an
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interactive learning tool which helps students; (1) to make decisions about treatment options for patients and get feedback immediately and (2) to demonstrate and promote their critical
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thinking skills in a safe and supported environment before dealing with complex and real-life
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case scenarios.
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Objectives: The present study aimed to examine the effectiveness of branching path simulation
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in promoting the critical thinking skills of undergraduate nursing students. Methods: This an equivalent control group pretest-posttest experimental study was done in
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2019 on 102 undergraduate nursing students who had registered in both practical and
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theoretical courses of Advanced Adult Health Nursing. A pretest posttest experimental design
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with concurrent control group and random assignment to the treatment/nontreatment variable was used and a convenience sample of 102 nursing students was recruited in this study. The students were randomly assigned and divided into two equal intervention and control groups and each group attended different training sessions. The control group was trained by traditional lectures while the intervention group was trained by branching path simulation. The researcher used a demographic questionnaire and the Critical Thinking Self-Assessment Scale (CTSAS) for data collection.
Journal Pre-proof Results: After the training sessions, the mean scores of the CTSAS and its subscales domain in the intervention group were significantly higher than the control group. Conclusions: Branching path simulation is an effective teaching method to promote students’ critical thinking skills. Future studies are recommended to examine the effect of branching path simulation on other nursing students learning outcomes.
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Keywords: Critical thinking; Interactive learning; Simulation; Nursing students; Nursing
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education
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Background Critical thinking (CT) is not a simple, automatic or linear process, but has been defined consensually according to the American Philosophical Association (APA) as “a purposeful, selfregulatory judgment which results in interpretation, analysis, evaluation and inference”
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(Facione, 1990, p. 2). Also, according to the conceptual framework for core cognitive and subscales (Nair & Stamler, 2013), the core cognitive and subscales of critical thinking skills (CTS)
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include inference, interpretation, explanation, self-regulation, analysis, and evaluation.
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However, CT in nursing is viewed as a nursing process, which includes assessment and nursing
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diagnosis, planning, nursing interventions, and evaluation (Azizi-Fini, Hajibagheri, & Adib-
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Hajbaghery, 2015). While this perspective of CT may be useful for teaching and multiple clinical purposes, it fails to adequately describe the processes of CT used by nurses in some
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complicated and challenging clinical situations (Azizi-Fini et al., 2015). These clinical situations
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are usually underdetermined, ambiguous, and complex (Lasater & Nielsen, 2009). Therefore,
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nurses using the nursing process may have difficulty defining these clinical situations, interpreting their meanings, and responding appropriately. Problems of Nursing CT About Pain in PWD Pain management in people with dementia (PWD) is still a challenging clinical situation (Rababa, 2018). Nurses caring for PWD still have problems of CT about pain assessment and treatment. These problems significantly impact the core cognitive components of CT process as described by Nair and Stamler (2013) and APA (Facione, 1990). According to Achterberg et al. (2013), nurses do not reach to a clear inference about the presentation of illnesses in PWD due
Journal Pre-proof to the complexity of pain assessment in PWD as well as their inability to communicate. Lack of clear inferences limits nurses’ CTS when making decisions about assessment and treatment of pain in PWD (Achterberg et al., 2013). Therefore, nurses often use a trial-and-error process to manage pain in PWD by just administering unjustified or unsupported interventions and observing the response of PWD to these interventions (Sheilds et al., 2013).
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Achterberg et al. (2013) also found that nurses held numerous false interpretations and explanations of pain in PWD, impeding their CTS. For example, a recent study showed that
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believing only in nurses’ own false interpretations about pain in PWD, instead of reliable
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objective data, affected their CT about pain management (Rababa, 2018). According to
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Achterberg et al., there are many misconceptions related to pain in PWD including: (a) pain is a
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normal part of aging and dementia; (b) dementia cause pain insensitivity; (c) PWD do not feel pain; (d) analgesics have dangerous side effects if prescribed for PWD; or (e) the lack of self-
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reporting of pain in PWD means no pain (Achterberg et al.). According to Cameron,
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Fetherstonhaugh, Bauer, and Tarzia (2018), nurses having misconceptions related to pain in
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PWD may have lack of self-regulation and misinterpret the cues of pain in PWD. Having misconceptions limits the ability of leaners to identify their own flaws in thinking and impedes the desire to promote their own quality of CT (Nair & Stamler, 2013). According to Papp et al. (2014), critical thinkers understand complex connections between concepts to create reasonable analysis to explain observed phenomena. Accordingly, when nurses are able to use analytic thought process through a logical and systematic approach of questioning and inference, they are able to apply their CTS for clinical decision-making processes (Monroe, Parish, & Mion, 2015). However, nurses have been found to use an
Journal Pre-proof intuitive approach rather than analytic thought process when assessing and managing pain in PWD (Gilmore-Bykovskyi & Bowers, 2013). According to Lasater and Nielsen (2009) , nurses come to clinical situations with biases that strongly influence their evaluation of arguments about the clinical situations. According to Feng, Chen, Chen, and Pai (2010), nurses’ CT is the product of both bottom-up input, and top-
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down processing, wherein nurses’ biases may impact upon the CT. When making a clinical pain assessment based on observation, it is important to be aware of biases that may
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confound nurses’ CT (Lasater & Nielsen, 2009). Nevertheless, nurses display substantial biases
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in their CT of patients' pain and consistently underestimate the pain of PWD (Feng et al.,
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2010).
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Theoretical Framework of CT
A whole host of research has been done on nursing CT models, all of which come from
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perspectives that are based on analytical thought processes (Lauri & Salentara, 2002).
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Analytical thought process has been defined as a process of problem solving that involves
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separation of a whole into its constituent parts in order to study the parts and the relations between parts (Lauri & Salentara, 2002). The Response to Certainty of Pain (RCP) model has been chosen to guide this study because it uses analytical thought process to guide the nursing CT of pain assessment and management in PWD (Gilmore-Bykovskyi & Bowers, 2013). The RCP model is briefly outlined in Figure 1. The RCP model provides an explanation of how the level of nurses’ certainty may predict the level of pain and agitation in nursing home residents with dementia. The RCP model suggests that when nurses are certain about pain in PWD they just need to do brief self-report
Journal Pre-proof assessment and then promptly administer analgesics. When nurses are not certain about pain, they need to do additional assessment (behavioral and functional assessment) and then the treatment of pain may be delayed (Gilmore-Bykovskyi & Bowers, 2013). Branching Pathway Simulation Branching path simulation (BPS) is an interactive learning method included case
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scenarios that guide the user through a step-by-step decision-making process (Kovach & Rababa, 2014). BPS has been proposed as a very feasible and effective learning tool as the
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increasing number of student population limits their encounter with real patients in the clinical
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settings (Bateman, Allen, Kidd, Parsons, & Davies, 2012), as well as its effectiveness in
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endorsing CTS (Kovach & Rababa, 2014). The BPS was found to be very successful in identifying
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the nurses who need more training and capturing most common weakness areas before dealing with real patients (Kovach & Rababa, 2014). The BPS help students to interact at different
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stages of problem solving. The BPS gives them the opportunity to make decisions according to
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their level of skills and knowledge and get feedback immediately (Kiili, 2005), which help them
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to demonstrate their CTS in a safe and supported environment before dealing with complex and real-life case scenarios (Johnston, MacArthur, & Manion, 2013). According to Lebowitz and Klug (2012), there are three types of BPS: short, moderate and long branches. In this study, the researcher used short branches as: (1) they are the easier to use; (2) they quickly reconnect the user to the main branch of CT and action process; and (3) they provide the users an immediate feedback on their decisions and give them an opportunity for correction. Immediate feedback is a key principle in learning process. Learners appreciate immediate feedback because it helps them to expect their performance, determine their level
Journal Pre-proof of understanding, adjust their fallacy, improve performance, and implement new strategies to achieve the learning aims (Pennaforte et al., 2016). Accordingly, the purpose of this study is to examine the efficacy of BPS to improve the CTS of nursing students about pain assessment and management in PWD. Research Questions
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(1) What is the level of nursing students’ CTS prior to and after the training session? (2) Is there a difference in students’ CTS measured by the CTSAS before and after the
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training session for both control and treatment groups?
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(3) Is there a difference in the CTS measured by the CTSAS between students who were
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trained by traditional lectures (TL) and those who were trained by BPS?
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(4) What are the predictors of CTS in nursing students?
Design, Sample, Setting
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Method
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A pretest posttest experimental design with concurrent control group and random
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assignment to the treatment/nontreatment variable was used and a convenience sample of 102 nursing students was recruited in this study. Sample size was determined by doing G-Power analysis using A-priori Sample Size Calculator for t-test (Cohen, Cohen, West, & Aiken, 2003) to calculate the sample size. Given an alpha level of 0.05, an anticipated effect size of 0.5, the desired statistical power level of 0.8, and allocation ratio N2/N1 of 1, the minimum required sample size for each group is 51 with a total sample size of 102 subjects. The inclusion criteria of the study were undergraduate-nursing students who are (1) registered in both practical and theoretical courses of Advanced Adult Health Nursing, and (2) in a good academic standing with
Journal Pre-proof GPA equal to or more than 2.5 out of 4. The study was conducted at Jordan University of Science and Technology/ College of Nursing. Ethical Considerations The IRB approval (#20170622) was obtained from the Institutional Review Board of Jordan University of Science and Technology (JUST). Written informed consent was obtained from each participant prior to data collection. The researchers emphasized the confidentiality and
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privacy of the data and the voluntary participation in the study.
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Instruments
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The independent variable was the training sessions about pain management in PWD.
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The training session of the treatment group included BPS and vignettes. The training session of
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the control group included TL and vignettes. Four pain vignettes were provided for each group. These vignettes described different clinical case scenarios about pain management in PWD and
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developed according to pain trajectories as outlined in the RCP model. The students responded
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to theses vignettes as being trained either in the TL or by using BPS. The student recorded their
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responses in data collection sheets provided by the researcher. The dependent variable was the CTS measured by the Critical Thinking Self-Assessment Scale (CTSAS) (Nair, Hellsten, & Stamler, 2017). Although there are several CT assessment tools other than the CTSAS, they are associated with limited accessibility, psychometric challenges, inconsistency of results, and cost of reproduction. In addition, the CTSAS is the first self-assessment tool of CT that enables the learners not only to measure their CTS but also actively involved in managing and improving their CTS (Nair et al., 2017). The CTSAS measures the core cognitive of CTS as described by APA definition of CT (Facione, 1990). The CTSAS has six subscales including inference, self-regulation, analysis, evaluation, interpretation,
Journal Pre-proof and explanation. The CTSAS has 115 multiple-choice items with a total score ranged from 0 to 690. Each item has seven responses including: 0= “Never”; 1= “Rarely”, 2= “ Occasionally”; 3= “ Usually”; 4= “ Often”; 5= “Frequently”; and 6= “ Always”. Higher scores indicate better CTS. In the original study, the scale had good content validity (I-CVI ≥ .7 to .938 ) and reliability scores (Cronbach’s alpha > 0.7-0.85). In this study the CTSAS had a satisfactory reliability scores (Cronbach’s alpha = 0.81).
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Procedure
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The researcher developed the BPS of the pain trajectories in PWD as illustrated (guided
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by) in the RCP model. A detailed description of the model was provided in the introduction
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section of this study and other research studies (Gilmore-Bykovskyi & Bowers, 2013; Rababa,
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2018). The researchers used their clinical expertise and reviewed the literature to conclude that the following thinking processes: (1) inference, (2) self-regulation, (3) analysis, (4) evaluation,
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(5) interpretation, and (6) explanation are key components for assessing CTS. These
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components are the core CTS that are based on the APA definition of CTS and informed by the
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conceptual framework for core cognitive and subscales of CTS developed by Nair and Stamler (2013). This conceptual framework is shown in Figure 2. These six thinking processes, which are critical components of the RCP, were incorporated (or integrated in) into the BPS and clinical case scenarios or vignettes. An example of these case scenarios is mentioned below: ‘A 96-year-old person with severe dementia, a female on one day was screaming and crying during the morning care. She had been in the nursing home for 23 months, was non-ambulatory, had communication deficit (aphasia), and she had bilateral ankle and
Journal Pre-proof knee pain. In addition to crying, she consistently screamed “oooh, oooh, oooh,” when changed her position, she started to be non-cooperative to the care and looked very sad and depressed when approached. The nurse interpreted these odd behaviors as anxiety and responded by providing her care slowly with other nurses’ help’. Five experts from the college of nursing reviewed each case and recommended some
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modifications which were integrated into the final drafts used. The final draft of cases was handled to a software developer to develop computer-based (electronically-produced) BPS. An
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example of a BPS that involves using the steps of RCP model is outlined in Figure 3.
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The procedure included multiple training sessions about pain assessment and
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management in PWD. These training sessions included the use of TL (for the control groups),
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and BPS (for the intervention group). Also, a presentation and discussion of multiple clinical case scenarios and vignettes related to pain in PWD were done for both groups during the
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training sessions. The researcher used vignettes to train the students to (a) correctly respond to
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the trajectories of the RCP and (b) consistently document their responses on CTS on the data
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collection sheets. There were 6 one-hour training sessions over two weeks given for both BPS and TL groups. Before the training sessions started, the researcher measured the CTS of the students in both groups using the pretest CTSAS. For the control group, TLs were administered in a regular classroom, while the researcher with technician’s assistance runs the BPSs for the intervention group in the computer lab of the nursing college. At the completion of the training sessions, the researchers distributed the post-test CTSAS to both groups to measure their CTS. A variety of innovate teaching and learning strategies were used to protect the learning rights of students in TL group. These strategies included the use of slide presentations with
Journal Pre-proof diagrams, video clips, flow charts, and case scenarios. The content of the slide presentations was not different from that used in BPS group. However, the amount of interactive learning and speed of feedback were different from BPS group. In addition, the researchers utilized vignettes in both groups. Data analysis
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Data analysis was conducted using SPSS (25.0 Version) , a statistical software program. Descriptive statistics, t-test, one-way ANOVA, and regressions were computed. An alpha level
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of 0.05 was used to determine statistical significance of all inferential tests used. The
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assumptions of each statistical test used were checked before running the tests. Descriptive
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statistics were used to describe the sample characteristics and students’ scores on both pretest
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and posttest CTSAS. To measure the difference in students’ scores on both pretest and posttest CTSAS between groups, independent t-tests were used. To measure the difference in students’
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CTS measured by the CTSAS between pretest and posttest scores for both groups, paired t-tests
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students’ CTS.
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were used. Multiple regression was used to examine the possible predictors of nursing
Description of Participants
The number of nursing students participated in this study was 102 with no exclusion of any student. The average age of students was 21.80 (0.25). The majority of students were female (80.4%), single (90.2%), unemployed (95.1%), senior (84.3%), lived in the same household with their parents (91.2%), and did not have a family member diagnosed with dementia or lived in a nursing home (90.3%). The average of their accumulative GPA was 3.05(0.56). The level of nursing students’ CTS is poor either in the BPS (M=337.67, SD=13.44) or TL (M= 309.77,
Journal Pre-proof SD=15.11) group prior to the training sessions. Detailed descriptive statistics of students’ characteristics is summarized in Table 1. [Please insert Table 1 here] Comparisons Between Groups According to the independent-sample t test, there were no significant differences in the mean scores of CTSAS between the groups (BPS and TL) before the training sessions. However,
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these mean scores were significantly different between the groups after the training sessions (p <
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0.05). Moreover, the results of the paired-sample t test revealed that the mean scores of CTSAS
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significantly changed after BPS in the intervention group during the study (p < 0.05). However,
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the results of the paired-sample t test showed that the mean scores of CTSAS insignificantly changed after TL in the control group (p > 0.05). Detailed statistics of these comparisons is
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summarized in Table 2.
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[Please insert Table 2 here] Predictors of Students’ CTS
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A multiple linear regression was calculated to predict students’ scores on posttest CTSAS
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based on selected demographics. As seen in Table 3, an insignificant regression equation was found either in BPS or TL group (F (3,47) = 4.21, p= 0.456) and (F (3,47) = 3.54, p= 0.442), respectively. [Please insert Table 3 here] Advantages and Disadvantages of BPS Also, the data collection sheets included two open-ended questions about the advantages and disadvantages of BPS. All students answered these two questions. The most common answers on the advantages of BPS include: (1) “effective guidance” , (2) “brainstorming
Journal Pre-proof promotion”, (3) “understanding how to interpret the cues”, (4) “quick inference”, (5) “ability to know the incorrect answers”, (6) “attention and concentration promotion”, (7) “prompt correction”, and (8) “interactive learning”. In contrary, the most common answers on the disadvantages of BPS include: (1) “time-consuming”, (2) “less teacher involvement”, and (3) “greater time of students’ preparation”. Discussion
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The findings of the study revealed significant increase of students’ mean scores of total
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CTSAS and its subscales in the BPS group. These findings affirm the effectiveness of BPS in
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improving students’ CTS. Similarly, a previous recent study on nurses also revealed that BPS
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was associated with better outcomes (Kovach & Rababa, 2014). Kovach and Rababa found that staff training sessions on pain treatment in PWD using BPS significantly improved treatment
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fidelity. Also, a recent study on students also found the positive impact of the branching story
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approach, which is informed by the same principles as BPS, on learning outcomes (Liu & Alduraby, 2017). The significant improvement of students’ CTS using BPS in this study can be
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explained by the fact that the approach of BPS is informed by immediate feedback and analytic
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decision-making learning theories and the principles of behaviorism and cognitivism (Kovach & Rababa, 2014). Analytic decision-making uses a step-by-step analytic thought process to deepen the information used for decision-making. The immediate feedback provided by BPS elaborated on the errors made by the students and provided explanation for these errors (Scheeler, Congdon, & Stansbery, 2010). The learning experience using BPS energized students’ enthusiasm in reading all pertinent information and make decisions accordingly (Liu & Alduraby, 2017). Nursing students in this study were eager to read all case scenario details. In BPS, learners felt empowered with
Journal Pre-proof the branch options and they were satisfied about the learning experience (Kovach & Rababa, 2014). The participation level of the students in actively make decisions related to pain management in PWD has been increased when using BPS in comparison to TL. Also, nursing students got focused more in reading all pertinent details as they were enthusiastic about the next level of branch. They became more serious about understanding and interpreting the cues provided in the case scenario to come up with evidence-based inferences. BPS provides a good
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opportunity for students to be actively engaged in the learning process with minimal interrupting
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causal chatting with their classmates (Bateman et al., 2012). The students in this study became
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more passionate about sharing their decisions after the intervention ended which promoted
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brainstorming. We asked the students in this study to be actively involved in individual interactive learning activities such as analytic decision-making of clinical scenarios.
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Incorporating BPS in nursing curricula as a learning strategy for undergraduate students allows
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authoring, editing and playing of multiple cases of decision making (Bateman et al., 2012). The findings of this study revealed no significant improvement in students’ mean scores
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of total CTSAS and its subscales in TL group. Consistently, another recent study found that TL
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cannot enhance students’ CTS (Choi, Lindquist, & Song, 2014). There are many disadvantages related to TL that may impede the CTS in nursing students. Although TL is the most widely used teaching method, it fails to improve students’ skills of decision making, CT, problem solving, and self-directing learning skills (Meibodi et al., 2013). TL lacks the active involvement of students in the class and makes the teachers work as information suppliers instead of facilitators, which limits their roles in improving the CTS of students (Dehghanzadeh & Jafaraghaee, 2018). The association between students’ GPA and their CTS was not found statistically significant in both TL and BPS groups. This finding is consistent with previous research studies
Journal Pre-proof that found no significant associations between nursing students’ CTS and their GPA (Mousazadeh et al., 2016). This interesting finding could be explained by the fact that the undergraduate nursing education in Jordan values and appreciates memorization of knowledge rather than demonstration of CTS (Jawarneh, Iyadat, Al-Shudaifat, & Khasawneh, 2008). Despite the great attention that Western nursing school have given to CT as a crucial component of nursing education, CT has been given a little attention in Jordanian nursing schools (Al Hadid,
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2012). Nursing students in Jordan have not received any formal education in their undergraduate
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program about CTS (Al Hadid, 2012). Even though nursing instructors taught their students that
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CT is a key principle in nursing career, there is no single course in nursing curricula specialized
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in developing or promoting CTS (Bataineh & Alazzi, 2009). Moreover, the exam system in Jordanian nursing schools is lacking. The exams are multiple choices questions with no chance
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for students to think out of the box (Bataineh & Alazzi, 2009).
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The nursing students in this study declared that BPS has benefits in improving their CT. Similarly, nurses participated in an earlier study stated that the ability of BPS in identifying the
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errors in making decisions and providing rational for those incorrect decisions was very helpful
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in endorsing their decision-making skills (Kovach & Rababa, 2014). Students in a recent study who had experienced branching stories, which is based on the same principles of learning theory and philosophy of action as BPS, found very effective in promoting their learning process and outcomes (Huang, Reynolds, & Candler, 2007). According to Kovach and Rababa (2014), using BPS provides the learners a great chance to recognize their mistakes in making decisions for correction before encountering a real clinical case. The “correct” branches associate with a process of CT and decisions the learner makes for the clinical case. The justification for incorrect and correct decisions helps the learners improve their CTS. The learners can make significant
Journal Pre-proof decisions in BPS and identify the consequences and justifications of those decisions, when still being returned back to the prerequisite branch of the decision tree. Therefore, assessing students’ CTS before being encountering a real clinical case saves effort, money and time, as well as avoids medical errors caused by poor CTS (Jacklin, Maskrey, & Chapman, 2018). As reported by students, there are some challenges associated with incorporating BPS into the CT process. Developing BPS, which needs careful attention to possible decision
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trajectories as well as the theoretical framework that inform these trajectories, is time and money
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consuming. However, the technical support provided by the central computer labs of nursing
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schools can be used to develop web-based BPSs that can be easily connected to multiple
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operating systems and accessible by a wide segment of nursing cohorts. Also, BPS can be easily tailored to fit different clinical case scenarios. Furthermore, the high prevalence of computer
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literacy and anxiety among Jordanian nursing students (Akhu-Zaheya, Khater, Nasar, &
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Khraisat, 2011) explains the disadvantage of huge time of preparation for BPS as reported by students in this study. Also, according to Bataineh and Alazzi (2009), TL was the dominant
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with it.
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teaching method used in the nursing education in Jordan and students were more comfortable
This is first study to examine the effectiveness of a new teaching strategy like BPS to improve the CTS related to pain assessment and management in PWD. However, the use of BPS in this study had some challenges such as the need for computer lab technicians, the cost of developing BPSs, the limited number of nursing instructors specialized in pain assessment in PWD, and the overcrowded classrooms with limited space. Moreover, assessment of CTS related to pain in PWD was done using a general measurement tool. It is recommended to replicate the study using a questionnaire specifically measures the CTS related to pain assessment in PWD.
Journal Pre-proof Furthermore, conducting the study on a relatively small sample size, in a single academic institution, and in one geographical area may limit the generalizability of findings. Conclusion This study implies that while TL is not associated with a significant improvement in the CTS of nursing students, BPS significantly improves their CTS. BPS effectively and promptly detects learners’ errors and provides justification for corrections. Of course, students’ GPA has
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no significant effect on the CTS. It is time for nurse educators to incorporate BPS as an effective
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na
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recommended to have more reliable findings.
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teaching method and reliable measure of students’ academic performance. Future studies are
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Table 1. Comparison Between TL And BPS Groups Based on Selected Students’ Professional and Sociodemographic Characteristics TL BPS Professional/Sociodemographic Characteristics N % N % Female 40 76.9% 42 80.8% Gender Male 12 14.3% 10 18.6% Single 50 96.2% 49 94.2% Marital status Married 2 3.8% 3 5.8% Junior 18 34.6% 15 28.8% Level of education Senior 34 65.4% 40 76.9% Employed 4 7.9% 3 5.8% Employment status Unemployed 48 92.1% 49 94.2% With family 35 67.3% 33 63.4% Living status Away from Home 17 32.7% 19 6.6% 2 3.8% 5 9.6% Have a family with dementia Yes or live in NHs No 50 96.2% 47 90.4% Mean SD Mean SD Age 20.80 .30 20.77 .52 Accumulative GPA 2.91 .42 2.98 .47
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TL= Traditional Lecture; BPS= Branching Path Simulation; NHs= Nursing Homes; GPA= Grade Point Average
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Before
After b P value M (SD)
TL
55.6(5.57)
88.4(4.11)
.330
BPS
54.7(4.45)
117(5.92)
<.001*
.220
.004*
——
48.83(3.87) 49.28(3.41)
83.12(3.17) 105.12(3.26)
.340 .021*
.346
.030*
——
21.57(4.78) 20.51(5.56)
49.12(8.12) 72.56(5.70)
.750 .006*
.340
.040*
60.57(6.77) 72.45(4.55)
96.67(5.12) 128.66(3.22)
.067
.003*
53.47(4.67) 70.45(3.65)
98.11(4.12) 129.76(4.22)
.077
.013*
.184
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.650 <.001*
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49.73(3.67) 50.28(6.35)
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a P value TL BPS Analysis a P value TL BPS Evaluation a P value TL BPS Inference a P value TL BPS Explanation a P value TL Self-regulation BPS a P value TL Overall CTSAS BPS a P value
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M (SD)
.560 .010*
84.22(3.57) 107.42(4.16)
.540 .011*
.049*
——
309.77(15.11 ) 499.64(14.78 ) .970 337.67(13.44 ) 660.52(10.57 ) <.001*
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Interpretation
Group
CTSAS
.132
<.001*
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a: The independent-sample t test; b: The paired-sample t test ; *Significant difference at 𝑝 <0.05 TL= Traditional Lecture; BPS= Branching Path Simulation; CTSAS= Critical Thinking Self-Assessment Scale
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Table 3: Summary of Multiple Regression with Posttest CTSAS Scores in Both Groups Groups β .096
TL t .011
p .424
Have a PWD or live in NHs in Family
.273
.187
Cumulative GPA R2 F
.357 .248 3.54
Age
.344
β .176
BPS t .219
p .604
.117
.363
.044
.077
.102
.351 .256 4.21
.221
.082
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Predictor Variable
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TL= Traditional Lecture; BPS= Branching Path Simulation; CTSAS= Critical Thinking Self-Assessment Scale ; PWD= People with Dementia NHs= Nursing Homes; GPA= Grade Point Average.
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Figure 3: An Example of BPS
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CRediT author statement Mohammad Rababa: Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Roles/Writing – original draft; Writing – review & editing. Dina Masha’al: Data curation; Formal analysis; Roles/Writing – original draft; Writing – review & editing,
Figure 1
Figure 2
Figure 3