The impact of deliberate reflection with WISE-MD™ modules on surgical clerkship students’ critical thinking: a prospective, randomized controlled pilot study

Figures & data

Figure 1 WISE-MD™ study flowchart.

Note: Reproduced from Terrien JM, Hale JF, Cahan M, Quirk M, Sullivan K, Lewis J. The impact of deliberate reflection with WISE-MD™ modules on critical thinking of nurse practitioner students: a prospective, randomized controlled pilot study. J Nurs Educ Pract. 2016;6(1):55.³⁹
Abbreviations: AAA, abdominal aortic aneurysm; SC, surgical clerkship; WISE-MD™, Web Initiative in Surgical Education.

Table 1 Deliberate reflection think-aloud instructions for thyroid nodule module

	Check Box
(1) Before the thyroid nodule module begins, press record and respond to the following questions:
1a. What are your initial thoughts on patients with thyroid nodule?
1b. What kind of experience have you had with patients with thyroid nodules?
1c. How confident are you in working with patients with thyroid nodules (1–10)?
1d. How informed are you about the subject matter (1–10)
(2) Before viewing the history section of the module, press record and respond to the following questions:
2a. What will you be looking for in the history – what will help you differentiate?
2b. What characteristics of the complaint or problem are most important to be clear about and why?
2c. What are some possible pitfalls in the communication that you want to avoid?
2d. Are there assumptions or biases in your thinking that you want to avoid?
(3) After viewing the history section of the module, press record and respond to the following questions:
3a. What was the most important finding and what does it mean?
3b. What strategies did the provider use to achieve his or her goals?
3c. What else could the diagnosis be and why?
(4) Before viewing the PE section of the module, press record and respond to the following questions:
4a. What signs will you be looking for and why?
4b. How will the PE help understand your history findings?
(5) After viewing the PE section of the module, press record and respond to the following questions:
5a. What signs confirmed the diagnosis and why?
5b. How do the PE and history (HX) findings fit together?
5c. Are there any other explanations for the findings?
(6) Before viewing the lab and images section of the module, press record and respond to the following question:
6a. What are the most important tests to order and why?
(7) Before viewing the decision-making section of the module, press record and respond to the following questions:
7a. What do you think you would say to the patient knowing what you know now about the case? What possible treatment
methods would you consider?
7b. How did you arrive at this conclusion?
7c. How do you think the patient is feeling about his or her treatment?
7d. How would you communicate to him or her?
(8) After viewing the surgery section of the module, press record and respond to the following questions:
8a. Having seen the surgery, what complications if any might you now anticipate?
8b. Having seen the surgery, how would you explain the symptoms of pain back to the patient?
8c. Having seen the surgery, what if anything might you have done differently in the history and PE?
(9) After finishing the thyroid module, press record and respond to the following questions on a scale of 1 (least confident/informed)
to 10 (most confident/informed):
9a. How confident are you in working with patients presenting with thyroid nodules?
9b. How informed do you feel now about managing a patient presenting with a thyroid nodule?

Note: Adapted from Terrien JM, Hale JF, Cahan M, Quirk M, Sullivan K, Lewis J. The impact of deliberate reflection with WISE-MD™ modules on critical thinking of nurse practitioner students: a prospective, randomized controlled pilot study. J Nurs Educ Pract. 2016;6(1):55.³⁹

Abbreviation: PE, physical examination.

Table 2 Critical-thinking categories, subcategories, and explanations

Category	Subcategory	Explanation
Takes perspective	None	Considering the patient’s, doctor’s, and nurse’s perspectives
Considers alternatives	None	What else could it be? Have I considered other options? Have I been thorough?
Makes associations	Describes	Simply what I am seeing? What does it look like?
	Compares	What are the differences between helpful and non-helpful evidence? Taking things apart to rule in or rule out.
	Prioritizes/evaluates	What evidence/information (visual, verbal, and so on) is important? Prioritize evidence.
		What is important with or without the explanation/rationale?
		What is not important with/without explanation/rationale (justifying certain actions)?
	Integrates	How do data from multiple sources (history, epidemiology, PE, labs and images) fit together – confirming or refuting? How am I putting things together and synthesizing, eg, how do various thoughts/concepts fit with each other?
Anticipates outcomes	Examines assumptions	What was I taking for granted? Was I presupposing anything? Are there ways I usually think about this that are not helpful?
	Predicts outcomes	What will I be looking for? What does the future hold? Statements made with or without underlying reasoning or information used for prediction.
	Considers pitfalls	What negative outcomes do I need to watch out for? What are the possible “pitfalls” or dangers in thinking and/or communicating? What do not I want to miss (eg, pertinent negatives)?
Self-assesses thinking process	Assesses self-confidence	How sure am I? What are my reservations?
	Considers experience	What have I seen and done in the past?
	Evaluates learning style	Considers learning style that works best or is preferred and what does not work, and so on

Note: Reproduced from Terrien JM, Hale JF, Cahan M, Quirk M, Sullivan K, Lewis J. The impact of deliberate reflection with WISE-MD™ modules on critical thinking of nurse practitioner students: a prospective, randomized controlled pilot study. J Nurs Educ Pract. 2016;6(1):55.³⁹

Abbreviation: PE, physical examination.

Table 3 Critical-thinking outcomes by category and subcategory, with examples

Category	Subcategory	Selected quotations from SC students’ narrative from the two DR modules
Takes perspective	None	I think the patient is probably concerned. Any time a patient has a mass of unknown origin, there is always a concern about cancer. It would be important to educate the patient that even if this is a cancer, most types are fairly treatable. Also let her know there are many benign etiologies as well.
Considers alternatives	None	The things to be considered in the differential include possible gastroenteritis, bowel inflammatory disease, diverticulitis, possibly cholecystitis or pancreatitis and also consider intussusception and volvulus. It could also be gynecological pain, including pelvic inflammatory disease, ectopic pregnancy, ovarian cysts, endometriosis, as well as urologic symptoms; it could be a kidney stone or cystitis or pyelonephritis.
Makes associations	Describes	Again, the physician used strategies that started with open-ended questions to get the history of the patient, and then focused questions which were not discussed previously and ultimately history as well of the events that helped the physician narrow the differential down to appendicitis.
	Compares	…we will be looking at the skin, whether it is moist and warm, or cool and dry, hair course or brittle versus fine…reflexes increased could be a tip off for hyperthyroidism, and if decreased, it could be hypothyroidism
	Prioritizes/evaluates	Important lab tests to order include TSH and T3 levels: TSH is the regulatory hormone that increases or decreases thyroid function, and T3 is the amount of thyroid hormone present. If T3 is high, then TSH should be low; both of these help delineate at what level, whether it be hypothalamus, pituitary, thyroid. Given the physical exam findings included a thyroid nodule, I would think that a thyroid is a main cause of her problems.
	Integrates	For appendicitis: the history along with the fact that the patient had marked right lower quadrant tenderness to light palpation and transmission of tenderness with increased pressure. The psoas sign was positive as the thigh was extended on the right side and the obturator sign was also positive with external rotation of the leg so all of these together with the benign pelvic exam point to a diagnosis of appendicitis. The liver furthermore was not enlarged so it’s unlikely that this pain is coming from the gall bladder and the right upper quadrant was nontender to palpation. Appendicitis seems to fit best.
Anticipates outcomes	Examines assumptions	I think a lot of people hear right lower quadrant pain and automatically think of appendicitis, so it would be important to consider other possible diagnoses such as small bowel obstruction, other causes of peritonitis, ectopic pregnancy, and some type of ovarian cyst or abscess.
	Predicts outcomes	Appendicitis can be a surgical emergency that needs to be addressed relatively quickly. In terms of the pathophysiology, I am thinking about the risk of appendicitis leading to perforation and subsequent abscess formation or generalized peritonitis.
	Considers pitfalls	Given the patient is a 32-year-old woman with right lower quadrant pain, one should always be concerned for an ectopic pregnancy or some issue related to OB/GYN. These are important to consider because something like an ectopic pregnancy can be life threatening, if it’s not diagnosed correctly.
Self-assesses thinking process	Assesses self-confidence	Given the patient’s presentation and her physical exam and imaging findings, I would feel confident letting the patient know that she has appendicitis.
	Considers experience	I saw several cases of appendicitis while on my general surgery rotation and I was surprised that some of the patients were fairly comfortable when they came in with appendicitis.
	Evaluates learning style	I really like it when they have graphics and pictures of exactly where they’re showing. I feel like so much of my studying, I spend a lot of time Google imaging things and trying to find a good picture and so much time is wasted like that and I feel like it’s just so helpful when those graphics are put together and it’s just so nice to visualize everything.

Note: Adapted from Terrien JM, Hale JF, Cahan M, Quirk M, Sullivan K, Lewis J. The impact of deliberate reflection with WISE-MD™ modules on critical thinking of nurse practitioner students: a prospective, randomized controlled pilot study. J Nurs Educ Pract. 2016;6(1):55.³⁹

Abbreviations: DR, deliberate reflection; SC, surgical clerkship.

TerrienJMHaleJFCahanMQuirkMSullivanKLewisJThe impact of deliberate reflection with WISE-MD™ modules on critical thinking of nurse practitioner students: a prospective, randomized controlled pilot studyJ Nurs Educ Pract20166155

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