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Evidence-Based Improvement Model for Writing & Critically Thinking
Mary K. Kirkpatrick, EdD, RN
School of Nursing

Improvement means to make health care or other professions better through the use of BEST evidence. Improvement is a universal, trans-disciplinary concept that can be applied to a person’s personal life, work, career, environment, education, health care, etc.  BEST evidence in health care refers to guidelines, reviews (quantitative & qualitative), meta-analyses, consensus/position statements, and opinion of experts in the discipline. Use of BEST evidence in health care education and practice is supported by the major health care professional organizations (Institute of Medicine, National League for Nurses-NLN, Sigma Theta Tau International, American Association of College Nurses). Following a brief introduction of the improvement model and theoretical basis for the improvement learning process, this paper will illuminate a process that can be used trans-disciplinary or across many disciplines to promote writing, thinking and lifelong learning.

Learner Profile

The learners in this activity are nursing students who have completed both research and statistic courses. They are in their senior year of a geriatric nursing course. Nursing students are expected to use evidenced based education and practice. Nursing expects learners to use the APA format for referencing and communicating appropriately in oral and written form.

Improvement Model

The improvement model is a four step process of plan, do, study, and act, known as the PDSA Model and commonly used in business (Langley, Nolan, K. M., Norman, C. L. et al., 1996). It has only recently been modified (evidenced-based improvement-EBI) and applied in the health care arena in improving geriatric, palliative and chronic illness care, as well as symptom management and caring, healing environments in nursing and medicine. For purposes of this course, only the plan, do and study steps are implemented with hopes that the learner intends to act on what they have discovered. Learners are expected to identify from a faculty developed DVD on “Aging Successfully” the problem or issue in their own aging process that they wish to improve.  Examples of evidence (reviews, guidelines, etc.), the work sheet and Fishbone chart for improving physical activity for aging successfully is provided to each learner. 

Rationale for use of the EBI model is three fold. It is universal: everyone has something to improve individually or collectively in groups, organizations, and health care delivery systems.  It is trans-disciplinary meaning that both within the interdisciplinary aspects of health care as well as disciplines outside of health care need improvement. Finally, improvement is a global need within education, health care, communities, politically and individually.

Transformative and Self Regulated Learning Theoretical Basis

The writing and thinking processes involved in the application of the EBI model are under girded by transformative and self-regulated learning theories. Transformative learning is a process for questioning old assumptions, beliefs, values, perspectives and   making sense of one’s experiences. This model is used in health care in survival or healing from health changes. It is characterized by centrality of experiences, critical reflection, and rational discourse (Meizrow, 2000). Learners in this course are directed to examine their own aging process for improvement.

Self-regulated learning is the deliberate planning and monitoring of both cognitive and affective processes for successful completion of the two academic tasks, writing and thinking critically (Corno, 1986). Both theories of transformative and self-regulated learning  developed in the early eighties use the principles of active participation, self awareness, reflection, change, meaningful learning experiences, strategies and motivation. In light of educational reform and today’s electronic age, both theories are  applicable as nurse educators serve as facilitators or consultants of learning to promote life long learning skills of writing and thinking critically.  

After reviewing a faculty made DVD from the National Geographic (2005), featured article, “The secrets of living longer: Those who live the longest,” the learner is asked to engage in a four step writing process.

Step 1- PLAN
On the basis of what the learner has seen on the DVD, they are asked to define “aging successfully” and what it means to them personally. Then, they are asked to describe a friend, relative or someone whom they have read about who is a centenarian or octogenarian. A few of the questions asked to guide the writing process of the learner are: What characteristics does this person possess that may attribute to their aging successfully? What characteristics do you have that match the person you have just described?  Finally, the question is asked of the learner of what is needed for them to improve their own aging processes? In other words, what do you need to change? This activity is an opportunity for the learner to put forth the issues/problems and to provide a solution. Finally, the learner uses the Fishbone chart from the business world to note the driving and resistive forces impacting on the learner, society, health care professionals and their discipline (Nursing) to cause them to want to or not to want to change their behaviors in aging more successfully. The Fishbone chart fosters critical thinking skills and is the most challenging for the learner to critically analyze all the potential forces that push and cause resistive behavior. All of these writing exercises give the facilitator ample opportunities to provide feedback on their writing and thinking skills.

Step 2-DO
Questions that guide the learner’s thinking in this step are: What EVIDENCE do you need to validate that by changing your behavior you would age more successfully? Where can you look for this EVIDENCE?  What professional organizations and foundations would have guidelines and consensus/position statements regarding the change you are hoping to make to change your aging processes? Do you have the latest data? The NLN (2005) publication on “Essential Nursing References” for obtaining evidence is provided to the learner. Having found this data, the learner is expected to compile a one-page, single spaced work sheet of the evidence they have retrieved from the multiple sources. This sheet is particularly beneficial for the construction of the improvement paper or the outcome of this improvement process.

Step 3-STUDY
Having decided where to secure the data and retrieving it, the learner begins the data analysis. Questions to guide their thinking and writing are as follows:  How can you present a synthesis of what you have discovered from the various resources? What are the major findings from the guidelines, reviews, meta-analyses, and consensus/position statements as well as from the experts? What conclusions can you reach? What recommendations can you make for changing your behavior to enhance your aging? What is your goal for change?

Step 4 – ACT
This step is not possible to fully evaluate for it is how the learners change their behavior that is significant. However, it is possible to determine what their intentions are based on their recommendations and goals.

Evaluation of Improvement Approaches

These writing and thinking exercises using the EBI model met with considerable success among twenty-six senior nursing students. The improvement approach provided examples of what they were to construct, provided writing opportunities in short intervals, therefore, constructing a pathway for the improvement paper. Multiple questions guide the learner’s writing and thinking processes as they seek answers at each step of the improvement process. Ample feedback on their writing and thinking at each interval is given by the faculty member. Twenty five of the learners felt it enhanced their critical thinking, inquiry and writing skills. Eighteen of the learners felt it promoted greater resource utilization while approximately half of the learners described it as facilitating self directedness, writing and evidenced based learning. Anecdotal notes from the learner’s perspective are best captured in the following anonymous statement: “It is nice to be exposed to something different.” Another learner noted, “The work sheet fosters improved writing of the paper.”

EBI can be used by all learners in all disciplines and integrated at all levels globally. This approach gives the learner a choice of what to improve as well as serving as a basis for their own inquiry. Furthermore, the EBI captures the principles of transformative and self regulated learning for lifelong learning.


References

Corno, L. (1986). The metacognitive control components of self-regulated learning. Contemporary Educational Psychology, 26, 11, 333-346.

Interagency Council Resources for Nursing Resources. (2005). Essential references in Nursing. Nursing Education Perspectives. 26(5): 300-14.

Langley, G. J., Nolan, Norman, C. L. et al. (1996). The improvement guide: A practical approach to enhancing organizational performance. San Francisco: Jossey Bass.

Meizrow, J. (2000). Learning as transformation: Critical perspectives on a theory in progress. San Francisco: Jossey Bass.


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