Using critical incident Using critical incident technique to promote technique to promote

students reflections skills in a students reflections skills in a transatlantic nurse education transatlantic nurse education

projectproject

Dr. Kim A. Critchley, University of Prince Edward Island Dr. Kim A. Critchley, University of Prince Edward Island CanadaCanada

Dr. Liisa Koskinen, Savonia University of Applied Dr. Liisa Koskinen, Savonia University of Applied SciencesSciencesFinlandFinland

International ProjectInternational Project

Inequalities in Access to Health Care Inequalities in Access to Health Care for Rural Communities – Funded for Rural Communities – Funded

through Canada – EU Program for through Canada – EU Program for Cooperation in Higher Education and Cooperation in Higher Education and

Training Training (October 2004 – September 2007)(October 2004 – September 2007)

International PartnersInternational Partners

• CanadaCanada Mount Royal College Calgary – Pam Nordstrom and Mount Royal College Calgary – Pam Nordstrom and

Maureen MitchellMaureen Mitchell Universite de Moncton – France Chasse and France Universite de Moncton – France Chasse and France

MarquisMarquis University of Prince Edward Island – Kimberley Critchley University of Prince Edward Island – Kimberley Critchley

and Barbara Campbelland Barbara Campbell

• EUEU England, Bournemouth University – Ann Hemingway and England, Bournemouth University – Ann Hemingway and

Eileen RichardsonEileen Richardson Sweden, Uppsala University – Clara Aarts and Eva Sweden, Uppsala University – Clara Aarts and Eva

BergknutBergknut Finland, Savonia University of Applied Sciences – Liisa Finland, Savonia University of Applied Sciences – Liisa

KoskinnenKoskinnen Estonia, Tallinn Health College – Tiina JohansooEstonia, Tallinn Health College – Tiina Johansoo

Project ObjectivesProject Objectives

• To foster student exchange in different To foster student exchange in different health care disciplines.health care disciplines.

• To establish a network of scholars and To establish a network of scholars and practicing health care professionals practicing health care professionals working toward the enhancement of joint working toward the enhancement of joint curricula.curricula.

• To promote increased cooperation and To promote increased cooperation and exchange of ideas among the partner exchange of ideas among the partner communities.communities.

Academic OpportunitiesAcademic Opportunities

• Increase student mobility Increase student mobility -from October 2004 to September -from October 2004 to September

2007, 24 2007, 24 EU and 40 Canadian students EU and 40 Canadian students would would undertake an exchange visit for undertake an exchange visit for 12 weeks.12 weeks.

• Enhancement of joint modules of training Enhancement of joint modules of training in association with the partner institutions in association with the partner institutions and communities.and communities.

• Observation of all involvement in Observation of all involvement in International work methods and culture.International work methods and culture.

Project OutcomesProject Outcomes

• Seamless credit transfer for students Seamless credit transfer for students among consortium partner among consortium partner institutions.institutions.

• Faculties working together in the Faculties working together in the enhancement of new joint curricula.enhancement of new joint curricula.

• Opportunities for students to work Opportunities for students to work toward achieving proficiency in a toward achieving proficiency in a second language.second language.

• Web-based joint training.Web-based joint training.

Project Outcomes (con’t)Project Outcomes (con’t)

• Development of a model for the professional Development of a model for the professional recognition and certification of programs.recognition and certification of programs.

• Increased cross-cultural understanding through Increased cross-cultural understanding through student mobility and on-line communication.student mobility and on-line communication.

• Stimulated interest among health care students Stimulated interest among health care students in foreign language and cross-cultural study.in foreign language and cross-cultural study.

• Greater understanding of the strengths of each Greater understanding of the strengths of each consortium partner and opportunities to share consortium partner and opportunities to share resources.resources.

• Opportunities for students and faculty to work Opportunities for students and faculty to work and conduct research.and conduct research.

Opportunity for ResearchOpportunity for Research• This presentation presents one This presentation presents one

example of research conducted as a example of research conducted as a result of the Canada-EU Mobility result of the Canada-EU Mobility Project.Project.

Critical incident techniqueCritical incident technique

• Originates from the 1950’s (John Originates from the 1950’s (John Flanagan)Flanagan)

• Is a learning/teaching methodIs a learning/teaching method

• Is a research data collection methodIs a research data collection method

CRITICAL INCIDENT ANALYSIS RECORD SHEET (for EU/Canada

exchange students)Sit down at least three times during your

exchange trip and choose one critical incident that has taken place recently and explore it in detail. Critical incidents are

brief descriptions written by learners about meaningful events in their lives (Brookfeld 1990). Any experience you

encounter during your exchange trip may be a critical incident and therefore a situation you can reflect upon. In the other words: incidents happen but a

critical incident is produced by the way you look at a situation; a critical incident is your interpretation of the significance

of the event. Here are some key steps for organising you’re reflecting and writing.

1 1 IdentifyIdentify the event or occurrence with as much specificity as possible - the the event or occurrence with as much specificity as possible - the problem to be solved, issues involved, etc. You may not have precise ideas problem to be solved, issues involved, etc. You may not have precise ideas on this when you start writing. Just start writing.on this when you start writing. Just start writing.

2 2 DescribeDescribe the relevant details and circumstances surrounding the event so the relevant details and circumstances surrounding the event so that you and the tutor who reads your entry will understand what that you and the tutor who reads your entry will understand what happened. happened. What? When? How? Why? Where?What? When? How? Why? Where?

3 3 ListList the people involved, describe them and their relationship to you and to the people involved, describe them and their relationship to you and to each other.each other.

4 4 DescribeDescribe your role in the situation - what you did, how you acted. your role in the situation - what you did, how you acted.

5 5 AnalyseAnalyse the incident. How well or badly did you understand the situation? the incident. How well or badly did you understand the situation? How did you handle it? What would you do differently the next time? Why?How did you handle it? What would you do differently the next time? Why?

6 6 AnalyseAnalyse this incident in terms of its impact on you and explain why this incident in terms of its impact on you and explain why you view it as critical in relation to rural inequalities in health or a you view it as critical in relation to rural inequalities in health or a specific area of the Ottawa Charter. How does it relate to your specific area of the Ottawa Charter. How does it relate to your particular objective(s)? What have you learned from the particular objective(s)? What have you learned from the experience? How has your perspective on your own role and that experience? How has your perspective on your own role and that of others been changed and/or reinforced?of others been changed and/or reinforced?

Can critical incidents method Can critical incidents method be used in educating reflective be used in educating reflective practitioners in nursing?practitioners in nursing?• The method The method

– Supports learners’ critical thinking and Supports learners’ critical thinking and experiential learning (Niemi 2003, Mikkonen 2005)experiential learning (Niemi 2003, Mikkonen 2005)

– Helps learners’ personal (Silkelä 2001; Merikivi Helps learners’ personal (Silkelä 2001; Merikivi 2003) and professional development (Turunen 2003) and professional development (Turunen 2002)2002)

– Assists learners integration of nursing theory into Assists learners integration of nursing theory into practice (Koskinen, Jokinen & Mikkonen 2007) practice (Koskinen, Jokinen & Mikkonen 2007)

– Improves learners’ reflection skills (Koskinen et al Improves learners’ reflection skills (Koskinen et al 2007) 2007)

The studyThe study

• Aim: Aim: – To describe students learning from the incidentsTo describe students learning from the incidents– To stimulate discussion on the usefulness of the method To stimulate discussion on the usefulness of the method

in intercultural nursing educationin intercultural nursing education

• Data collectionData collection– Critical incidents (n=92) written by 18 Canadian and 13 Critical incidents (n=92) written by 18 Canadian and 13

British, Estonian, Finnish and Swedish students (n=31)British, Estonian, Finnish and Swedish students (n=31)

• Data analysisData analysis– Stage 1: data reduction in seven ”research centres”. The Stage 1: data reduction in seven ”research centres”. The

data were in English, Estonian and Swedish.data were in English, Estonian and Swedish.– Stage 2: data reduction, data display, conclusion and Stage 2: data reduction, data display, conclusion and

verification (Miles & Huberman 1994). The data were in verification (Miles & Huberman 1994). The data were in English. English.

Results: The chosen incidents Results: The chosen incidents were contexts, events, were contexts, events, situations or experiencessituations or experiences

• that were unfamiliar in comparing to the familiarthat were unfamiliar in comparing to the familiar

• that either showed examples of lack of cultural awareness in that either showed examples of lack of cultural awareness in care or demonstration of culturally sensitive care care or demonstration of culturally sensitive care

• that either showed examples of good nursing care or lack of that either showed examples of good nursing care or lack of good nursing caregood nursing care

• that were pivotal both personally and professionally “the that were pivotal both personally and professionally “the extreme as life altering occurrences”extreme as life altering occurrences”

• that were related to cultural differences that interfere with the that were related to cultural differences that interfere with the students’ moral values, beliefs, communication abilities and the students’ moral values, beliefs, communication abilities and the professionalism in giving nursing careprofessionalism in giving nursing care

Importance of Importance of cultural awareness of cultural awareness of health care health care professionalsprofessionals

Impact of income, Impact of income, social status, and social status, and rural issues in rural issues in inequalities in health inequalities in health and well-beingand well-being

Impact of lifestyle in Impact of lifestyle in health and well-beinghealth and well-being

Dilemma of good/bad; Dilemma of good/bad; right/wrong in health care right/wrong in health care (ethical issues)(ethical issues)

Experiencing particular Experiencing particular clinic, clinic,

programme, service programme, service

system or method system or method

Witnessing Witnessing

unacceptable/warmunacceptable/warm

nurse-patient interactionnurse-patient interaction

Impressive personal Impressive personal cultural cultural

experienceexperience

Personal confusion in a Personal confusion in a

difficult and unexpected difficult and unexpected

nursing situationnursing situation

Dress code and safety Dress code and safety nursing practicesnursing practices

Experiencing Experiencing communication and communication and culture barrier inculture barrier in

Estonia, Finland and Estonia, Finland and SwedenSweden

Cultural differences in Cultural differences in nursing role and nursing role and nurses awareness nurses awareness and knowledge of and knowledge of health promotion and health promotion and sickness prevention sickness prevention strategiesstrategies

EU students EU students Both studentsBoth students Canadian Canadian studentsstudents

Table 1. Learning areas the chosen incidents were related with.

Results: In their critical Results: In their critical incidents the students’ showed incidents the students’ showed increased awarenessincreased awareness• about personal and professional self and about personal and professional self and

own emotionsown emotions• about the importance of non-verbal about the importance of non-verbal

communication in nursing carecommunication in nursing care• about cultural differences in nursing role about cultural differences in nursing role

and nursing careand nursing care• about cultural differences in health about cultural differences in health

programmes, services and methodsprogrammes, services and methods• about societal inequalities about societal inequalities

Implications for intercultural Implications for intercultural nursing educationnursing education • Critical incident method can be used in fostering nursing Critical incident method can be used in fostering nursing

student’ learning and reflection skills in the context of student’ learning and reflection skills in the context of intercultural education intercultural education

1.1. Make sure that the learning objectives are shared between Make sure that the learning objectives are shared between the project partners and students before they leave and the project partners and students before they leave and throughout the exchange – more discussion and support on throughout the exchange – more discussion and support on ”what to expect” ”what to expect”

2.2. Increase dialogue about each incident either with the home or Increase dialogue about each incident either with the home or host instructorhost instructor

3.3. Extend the time spent in each clinical and community setting Extend the time spent in each clinical and community setting – more time to bridge the cultural and language barrier and – more time to bridge the cultural and language barrier and move from observer to the actual patient contactsmove from observer to the actual patient contacts

Implications…Implications…

4.4. Possibly owing to the shortness of the Possibly owing to the shortness of the intercultural visits, the students viewed host intercultural visits, the students viewed host culture’ s health service either through ‘rose-culture’ s health service either through ‘rose-tinted spectacles’ or ‘negative eyes’. These tinted spectacles’ or ‘negative eyes’. These can be seen as consistent with the can be seen as consistent with the phenomenon of superiority or reversal in phenomenon of superiority or reversal in Bennett’s (1993) study of intercultural Bennett’s (1993) study of intercultural sensitivity – instructors might be valuable for sensitivity – instructors might be valuable for recognizing this phenomenon, in order to be recognizing this phenomenon, in order to be able to encourage further cultural self-able to encourage further cultural self-examination among the studentsexamination among the students

To ConcludeTo Conclude• Students were able to participate, enjoy Students were able to participate, enjoy

and learn from this cultural exchange and learn from this cultural exchange including the critical incident writing including the critical incident writing