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The CDM results changed minimally between the Pre and Post-intervention stages for all participant groups. Additionally, the group which scored the highest (BSc (Hons) Suburban) and lowest (BSc (Hons) Inner London) Clinical Decision-Making Nursing Scale (CDMNS) subscale scores at the Pre and Post-intervention stages, remained unchanged (Table 39). These findings possibly suggest that despite participating in a higher academic level of theoretical learning and clinical placement teaching on the final year of the course in addition to participating in this study and completing the CDMNS questionnaires on two occasions, there were negligible changes to students’ perception of their CDM ability. This possibly suggests that CDM strategies that students develop earlier on the academic course remain consolidated throughout their undergraduate learning experience. It is also possible that students’ CDM ability may be sedimented hence not be very receptive to change as compared to changes detected in their ATL preference between the data collection points.
Subscale findings that contributed to the statistical significance for the BSc (Hons) Inner London participants CDM scores at the Pre-intervention point were not detected at the Post-intervention stage. It is also worth noting that subscales that contributed to the samples’ highest and lowest subscale value also fluctuated between the two data collection points. Prior to the research intervention, subscale ‘Canvassing for Objectives and Values’ had the highest score and following the research intervention, the subscale ‘Evaluation of Consequences' displayed the highest score (Table 39). In relation to the description of the subscales (Section 3.5.1), these changes may have resulted from students focusing on the final semester theory modules which concentrate on the leadership and management requirements of the qualified nurse. Thus, the in-depth exploration of the professional role transition elements emphasised in these culminating components of the adult nursing course, facilitated by students ‘Seeking to understand’ the learning content through the medium of the deep approach, possibly contributed to an upsurge in professional development demonstrated by ‘Evaluating (the) Consequences’ of their actions. It is considered that at the start of the final year
when the Pre-intervention data-collection took place, a focus on professional values and views on diversity in relation to students’ professional development was emphasised in comparison to the Post-intervention data collected at the end of the academic year. It is during this period that all nursing students re-confirm their allegiance to the University’s Directional Statement for Professional Conduct for Healthcare students. Therefore, having recently attended taught sessions on the expected norms and behaviours when working with patients and clients may have indirectly influenced participants’ perceptions of their CDM.
The change in the dominant CDMNS subscale to ‘Evaluation of Consequences’ at the Post-Intervention point is possibly due participants’ heightened awareness of the outcomes of their actions. Cathy’s expression that was mirrored by Andy is clear that students feel that they have to “practice defensively ... need to cover yourself ... as you are scared of making mistakes”. In addition to participating in this study, this may have resulted from students realising their imminent course completion and the approaching change in their professional role status. In support of this argument, Cathy contributed that “... reviewing the patient’s file and checking the patient’s history cannot be taken for granted”. Lisa emphasised that “prioritising your actions is key when seeing to the patient”. “Remaining impartial by stepping back, in order to take everything into account when making a decision”, was crucial to George. Cathy also volunteered that “... managing your time and delegating when problem-solving”, is also important. Her professional development is clearly illustrated in her advancing from being delegated to in her student capacity, to delegating to other team members, as the professional nurse. This forthcoming role transition is also accompanied with revised responsibilities and accountability founded on autonomous practice (See Section 1.1-2). Kelly was explicit that this involves being the “... advocate for the patient” as you are responsible for the “patient’s care”. Bailey emphasised that, “we need to respond immediately ... so we must know what we’re doing”. At this stage in their professional development, participants’ expressions illustrate an agentic awareness that their practice should be patient-focussed. Patient safety was strongly emphasised by several participants (Cathy, Andy, Violet, Bailey, George) as having a fundamental significance on the care patients received with Andy stressing that “... safety first for our patients therefore we need to learn to get better at this!” Violet’s view that she was getting “better at making decisions” was
also echoed by George. Thus, recognition that actions arising from their decisions may have an untoward effect on their patients, for which they will be accountable, may have caused students to place greater emphasis with a heightened awareness of the consequences of the decision, when answering the CDMNS questionnaire at the end of the academic year.
6.3.1. Clinical decision-making and approaches to learning correlation
The research findings illustrate a fundamental focus of the impact the deep approach has on clinical decision-making. Not only has this study measured and evaluated the range of CDM perceptions across the sample but it has established beyond reasonable doubt a correlation exists between the deep approach and the acquisition of what Hargreaves and Fullan (2013) term decisional capital. This is the growth of awareness of the consequences of the decision and the evaluation of those consequences that Benner (2001) refers to as the “deep understanding of the total situation” (p. 32). The findings in this research clearly indicate that the growth of decisional capital is open to influence and can be nurtured through the movement between domains in the approaches to learning.
To answer the research question, ‘Do nursing students’ approaches to learning impact on their clinical decision making?’ (Section 2.18), the analytical framework detailed in Chapter 4 (Sections 4.4-5 and 4.7) was followed. This included the calculation of the ATL and CDM scores for each participant group as well as the identification of each individual participant’s approaches to learning and CDM score at the Pre and Post-intervention points. A purposive sample of all participants who indicated a preference for the strategic and surface approaches at the Pre- intervention stage, participated in a study specific educational research intervention. Therefore, in line with the longitudinal methodology (Chapter 2), each participant’s approaches to learning and CDM ability as measured by the Clinical Decision Making Nursing Scale (CDMNS) (Jenkins, 1985) was tracked on entry to and on completion of the final year of the adult nursing course.
In line with the sequence of statistical tests in Chapter 5, Spearman’s Rank Order analysis was performed to determine whether a correlation between the sample’s
approaches to learning and CDM scores was present. The results confirm that statistically significant relationships existed between the sample’s approaches to learning and CDM scores at both the Pre and Post-intervention stages. Thereby, in addition to answering both the research question and Hypothesis 1 (Sections 2.17 and 18), this outcome confirms that with this sample, the ATL that a student adopts, impacts on their CDM. Cathy felt that “... all learning to make better decisions, increases confidence ... increases our student voice and helps us be better nurses”. Similar comments from Kelly, Violet and George support these findings.
6.3.2. Pre-intervention CDM and ATL Correlation
Analysis of the Pre-Intervention data revealed that participants who adopted the strategic approach, had the best CDM ability (Figure 6). Participants who adopted the surface approach displayed the weakest CDM ability in comparison to students who adopted the other ATLs (Figure 6). This outcome suggests that on entry to the final year, participants whose learning behaviours encompassed managing their time, being alert to the assessment strategy, organising their study time, monitoring how effective their learning and were motivated to pass the module with high marks, were also making better clinical decisions in comparison to other participants in this sample. Therefore, at the start of the research study, students who were goal oriented were the best clinical decision-makers in relation to delivering patient-care.
The significant findings of the surface approach being inversely proportional to students’ CDM, runs parallel to Hasnor et al (2013), Reid et al (2007) and Cano’s (2005) findings, where the increased use of the surface approach resulted in decreased academic achievement. Thus, the findings in this study endorses previous evidence that in addition to a surface approach dominance resulting in lower academic achievement, CDM proficiency was weaker in comparison to students who adopt alternate ATLs. Ultimately, these findings strengthen this study’s overall aim of encouraging students to reorient their ATL away from the surface approach.
6.3.3. Post-intervention CDM and ATL Correlation
The Post-intervention results changed in comparison to the Pre-intervention analyses. Findings revealed that participants’ CDM score was directly proportional to the deep approach. Therefore, at the Post-intervention data collection, students who adopted the deep approach displayed a better CDM ability than students who adopted either the strategic or surface approaches. These outcomes suggest that at this stage students who actively sought to understand the course material and related recently learned content to previous knowledge and experiences as well as engaged in critical evaluation of the learning material (Table 1), were more competent clinical decision-makers compared to students who adopted the strategic and surface approach. In line with the relational learning at University in preparing students to make clinical decisions, Participant Lisa who adopted the deep approach at the Pre and Post-intervention stages, was emphatic that “... knowledge gained at University is very important cos [sic] for me, it’s constantly guiding decisions when taking care of my patients”.
The surface approach and CDM correlation remained unchanged from the Pre- intervention analysis. The reoccurrence of this finding at both data collection stages indicates that clinical decisions made by learners whose dominant learning mode is the surface approach are not as robust as learners who strive to understand their learning and adopt the deep approach. This outcome further supports that students whose fundamental aim is to achieve the best grades possible and who are predisposed towards the strategic approach, also tend to make less well-informed or incorrect clinical decisions in comparison to learners who actively engage in the learning dimensions of the deep approach. In spite of Kelly orienting from the surface to the strategic approach at the Post-intervention stage, she held strong views that, “... it’s easy to make hasty decisions as we don’t have much experience ... we’re not always sure it’s the right thing to do ... making decisions about patients is hard!”. Participants also felt that whilst on placement, “... there’s lot to take in and think about” which caused them to be “... unsure of most decisions they make”. Students’ statements demonstrate feelings of uncertainty regarding the correctness of their decisions. Participants’ feelings of this productive uncertainty resonated with Hammond’s et al (1967) claim that decisions are made in “conditions of uncertainty”
(p. 41) as discussed in Chapter 2 (Section 2.11). Moreover, when faced with a lack of confidence, students rely on alternative sources for guidance when making decisions as participants expressed that they seek “advice from mentors, after all they know better”. Kelly, who initially adopted the surface approach but progressed to the strategic approach, felt that this “... allows for sharing of responsibility between the student and the mentors, so the responsibility is not all ours right now ... I guess it will be us soon that students will ask”. A similar view was held by Andy. Thus, despite learners who adopted the strategic and surface approaches participating in the research intervention, these learners appear not to have exercised judgement nor recognised the shortcomings or substandard effectiveness of their dominant ATL (Deakin Crick et al, 2015). Consequently, this probable lack of meta-cognitive monitoring may have prevented them from implementing the strategies covered in the research intervention or re-orientating to the deep approach. However, students’ agency in recognising the importance of improving their CDM ability prior to embracing their professional nurse role as expressed by Andy, may have already instigated a renewed engagement with their learning, alternative to their initial ATL, in order to improve their decision-making in practice.