This section focuses on participants’ responses to how they perceived the development of increasingly complex knowledge and understanding through the radiography programme.
120
There were no responses from the first-year interviews that contributed to this theme. A likely explanation for this is that students had limited experience of learning at university and had not attended a clinical placement at the time the interviews were conducted. This theme emerged during the analysis of the second-year student interviews and consolidated following the third-year interviews. The student responses are presented followed by the tutor interviews.
5.3.1. Responses from the second phase student interviews
In response to the question, “do you think your critical thinking skills have developed from last year” seven out of thirteen students indicated that they did not feel their critical thinking skills had changed. However, the remaining six expressed a change. Two examples are given below:
Definitely. I had quite a few little glimpses in various departments when after something had happened, I would think well actually… you can actually do this. I am more self-confident than last year. Now I am more likely inclined to compare what other people say and trust my own thinking. (Olivia-IV2)
It has…you are questioned (by radiographers) on the spot regarding justifying requests. Justification is a big thing and that makes you think. You get better and quicker at it the more you do it. (Harry-IV2)
Olivia spoke of confidence and assertiveness to think independently, both of which are dispositions of critical thinking. These changes in her experience indicated that critical thinking had developed from her previous year (year one). Similarly, in Harry’s example, analysing and evaluating patient information on the X-ray request cards led to faster, justifiable decision- making. He demonstrated, through his articulation above, that his critical thinking skills had developed from the previous year. The students felt adept at trusting own judgment and had the realisation that they were thinking more deeply and broadly.
Interestingly, Charlie (IV2) already considered he is a critical thinker as stated below:
I would say, the knowledge I’ve gained on clinical, has definitely helped apply my critical thinking in a radiography context. As for actually developing my critical thinking, I’m pretty sure the mechanisms were already there, and I’m just filling in the blanks of my knowledge, and then using the critical thinking that I already had.
Charlie, therefore, asserts that he already possessed the skills of critical thinking and that the clinical placement environment allowed the opportunity to gain knowledge and apply those skills. Charlie already has a first degree and it is possible that he developed critical thinking skills as a transferable skill, stemming from his previous degree.
121
Six students were able to clearly articulate examples from practice where they demonstrated their critical thinking development from their previous year. Olivia (IV2) describes her experience below:
I was working in A&E and a patient in Resus needed a chest X-ray. If I sat her up completely she wouldn't be able to breathe and if she lay down completely she wouldn't be able to breathe either. And she was getting very upset and flustered. So, I had calmed her down and worked out what the best method for doing the X-ray was; then the radiographer had come in and he just like took the back of the trolley and just sat her up. She started crying and was very upset. She didn't want the radiographer anywhere near her because of that. She said that she would only agree to the X-ray if ‘Olivia’ is the one that does it. No one else. So, it is having those patients, even though you have only been with them for about 15 minutes. It's those moments when you feel that I can do this, and it works. (Oliva-IV2)
In addition, Olivia (IV2) elaborated further as presented below:
…she (the patient) already told us that she was unable to breathe in these two positions and we know that from the start. We just needed to slowly move the back of the trolley, backward and forward to a position which she felt comfortable in. So, it was important to take that into account when positioning her. She was lying on her side on the trolley when she came in and when we spoke to her about how we would like to position her to get a good image, she straightaway said that she couldn't sit up like that. So, we had to use her as the guide to help us position her in such a way that she felt able to sit for the X-ray and to be able to breathe… You have to think a bit harder when the obvious does not work.
Olivia, in her description of her application of critical thinking skills, relates to a more complex patient scenario compared to examples given by students in year one. In year one, students will have gained experience in examining patients who were ambulant, and the examinations would have been routine examinations. Here during her second year, she is undertaking more complex radiographic examinations on more complex patients, indicating a progression in her knowledge and understanding as a student radiographer from the first year to the second year. Her reasoning skills are clearly articulated as is the ability to consider options regarding the comfort and safety of the patient. There is, therefore, a clear application of Olivia’s cognitive skills and affective dispositions of critical thinking. Managing a more complex patient than she did in her first year of study and managing the additional difficulties that arise during the examination, as in Olivia’s case, indicates growth and development from a naïve understanding in year one to a more complex understanding in year two.
122
5.3.2. Responses from the third phase student interviews
Findings from this interview set revealed that although four students perceived their development of critical thinking to have remained the same from the previous year, the rest perceived their development of critical thinking to have changed in their third year of study. Two examples are given below:
I think it is a lot better than it was. I found year two harder than year one. There was more responsibility, especially for placement. I feel that my thinking is more structured than in year one, especially in terms of image evaluation. I do still link together information and break down information so that I can understand what I am doing. (Lola-IV3)
Yes, it definitely has. Before I would take other peoples’ opinions. Now I think through things myself. I will evaluate things myself first and then check with others if that will work and then I will go with that. Moving from consensus thinking to independent thinking. University has helped a lot as we are required to think about things in different contexts. (Sophie-IV3)
Lola acknowledged that her thought process had become ‘more structured’ compared to years one and two, and relates her view to image evaluation, which is a key competency in the practice of diagnostic imaging. Image evaluation requires the methodical, visual processing of an image in relation to several criteria, e.g. image quality, accuracy in positioning of a patient, inclusion of the entire area of interest, radiation safety measures and so on. Sophie perceived her development as a change, from previous consensus seeking to one of independent thought and decision-making. This is an important step in the development of autonomy and using her judgment. Decision-making and trusting one’s own judgment are dispositions of critical thinking. Students have demonstrated that they are developing the skills and dispositions of critical thinking as described by Bloom (1956), Halpern (1989), and Facione (1990).
Four students spoke of the learning gained from the task of prioritising patient examinations. Two examples are given below:
…that was hard for me. This forced me to think deeper and make the connection and be able to justify why I am doing things in a certain way especially in organising patient lists. Confidence is important to be able to stand up to being interrogated or questioned in that way. As a student, you have to be open to this kind of challenge as it has been a really good learning experience. (Jacob–IV3)
…I evaluate things for myself first, then check with the radiographers if it will
work, and then I will go with that. This helped me enormously in prioritising patient lists as I will have to do this by myself as a qualified (radiographer)…
123
Here is the demonstration of thinking to justify X-ray examination requests, by Jacob, where he was required to justify the order of priority in which he would examine the patients. Each patient request needs reasoning to justify its need in relation to the examination. Similarly, Sophie explained that she became increasingly independent in her decision-making. However, she conferred with radiographers to act as a sounding board to her decisions, acknowledging that this part of her development was crucial to autonomous decision-making in the future. Sophie, therefore, identified that as graduate practitioners, they will have to do this autonomously. It is evident that radiographers contributed to their development of critical thinking abilities required in the prioritising of examination lists. Prioritisation of patient examinations is a Level six competency and this task requires the use of higher order thinking skills of analysis, evaluation, and synthesis, in justifying the order in which patients are examined. This extract demonstrated their development from year one (novice) to year three (expert student radiographers).
Eleven students spoke of a growth in relation to the level of thinking required in undertaking a simple task or routine examination, compared with a complex task or new situation. Two examples are given below:
I use an order in which I think through certain things like reading an X-ray requests. Some are quite simple, and I find that my order of considering the key components works well. For complex tasks, I will break down the components into smaller chunks and consider them in a more focused way.
(Lola-IV3)
Similarly, Harry (IV3) stated the following:
Simple tasks will bypass a lot of critical thinking. You would do a lot of thinking of simple tasks on a daily basis. With more complex tasks, like a complex procedure in theatre, for example, positioning the machine (C-arm fluoroscopy
unit, see Glossary, p. xi) in the theatre would require more critical thinking to
ensure I am positioning the tube in the right place. I would slow down a bit and think through what I am doing and what the consequences are. For example, in the case of the tube, if I place the tube incorrectly then the surgeon would not be able to see the images on the screen.
In these examples, both Lola and Harry explained that during simple situations, they resorted to methods used in the past which were informed by their actions and experience, i.e. they would be working at a more routine or automatic level. However, in complex situations, both students acknowledged that they returned to a structured way of thinking where they considered all available information, processed the information using their critical thinking abilities and made decisions based on their evaluation of information. Lola said that her ‘order of considering key components works well’ for simple tasks, however for complex tasks she had to consider the components in a ‘more focused way’. The words ‘more focused’ could be
124
perceived as a deeper thought process. She makes the distinction between ‘simple thinking’ and thinking in a ‘more focused way,’ which she understands to be different to ‘simple thinking.’
Similarly, Harry states that complex tasks would ‘require more critical thinking.’ He related his understanding to the positioning of the fluoroscopic imaging equipment being used in the operating theatre. During this procedure, the student needs to consider multiple factors, such as the sterile nature of the environment, the position of the imaging equipment, radiation protection for staff and the patient, and the range of movement required for the imaging in relation to other equipment present in the theatre at the time. Careful thinking and planning of these multiple facets are required in this situation to successfully carry out the examination. Harry demonstrated his critical thinking ability within the complexity that this procedure demanded.
5.3.3. Responses from the tutor interviews
Findings from interviews with tutors revealed that they perceived the growth of critical thinking skills to take place gradually from year one to year three. Three examples are given below:
In year one, we do very little in critical thinking. They are overwhelmed with getting to University and learning the basics to go to placement. I think at the very beginning we give them the tools for critical thinking to e.g. evaluate their images against set criteria and decide whether to accept or repeat their image and get them to think about applying their knowledge at that stage. It is low level at this stage, but I think it is a critical thinking skill. I don't think they will get the notion of critical thinking in year one but certainly, they do start thinking and applying their knowledge. (Grace)
Students need to get from novice to expert. We aim to develop their reasoning abilities and decision-making processes in relation to clinical situations. (They) need to learn about and understand consequences, how we can benefit the patient. Students need to continually assess the validity of what they do to solve clinical problems by seeing situations, both positive and negative, unfold on placement. They must learn (knowledge), think and be aware of their thinking.
(They) must learn to question, probe, give careful thought to clinical practice. (Mia)
...midway through year two they then start to get in a jumble because they are flooded with information and they are then starting to find their own patterns, systems of work, own expectations, and that's when you get a classic
comment of questioning their own learning and doing things differently. They start to challenge the practice they see in placement although this is seen more in year three as they learn more. Remember we are also encouraging them to ask questions and challenge what they see. Questioning is a sign that their critical thinking skills are developing but this depends on their motivation. They go through a steep learning curve in their final year. It’s about what makes them motivated. (Ruby)
125
Grace relates her explanation to the criteria given to students to teach them how to structure their evaluation of an X-ray image. She calls it “low level” critical thinking at Level four and although she feels that students do start thinking and applying their knowledge, she believes that students will not fully grasp critical thinking at this stage of their learning journey. Demonstration of critical thought is an assessment criterion at both Level five and six. Grace is therefore correct in her understanding of critical thinking development at Level four. Similarly, Mia feels that students must progress from a novice in year one, to expert students in year three. In addition, she feels that situations in clinical placement can be positive and negative; ‘assessing the validity’ of information therefore requires the application of critical thinking skills. Ruby explains that students begin to develop their own way of adapting radiographic procedures and begin to question and challenge poor practice as they reach the point of qualification, in their third year. Critical thinking can be developed by training the mind to think in a disciplined way (Paul, 1990): this is the goal of critical thinking. A disciplined way of thinking uses a system of thinking that includes asking oneself a number of pertinent questions. This can be likened to the Socratic philosophy whereby the goal of Socratic questioning was to question your thinking in a certain context or situation (Paul & Elder, 2007), such as diagnostic radiography. Adapting their radiographic technique and having the confidence and assertiveness to challenge poor practice requires critical thinking skills. However, Ruby elaborates that the application of students’ critical thinking skills depended on their motivation and the factors which influenced their motivation. As previously mentioned, confidence, assertiveness, and motivation are dispositions of a critical thinker. However, it is possible that a student radiographer would possess the dispositions of a critical thinker but choose not to think critically, as discussed in Chapter Two. Ruby, therefore, makes the justifiable point that critical thinking skills development is dependent to some extent on student motivation.
5.3.4. Summary in relation to development of knowledge and understanding from naïve to
complex understanding
In the first year of the students’ journey, they were new to university study with no clinical placement experience. When they attended clinical placement, they were directly supervised by clinical mentors in accordance with the clinical placement regulations. During their second year of study, students grew in confidence and developed a broader sense of thinking. They understood the consequences of their thought processes and subsequent decisions regarding the welfare of the patient. They gained more knowledge and experience and were able to perform more complex examinations with less direct supervision as compared with the year before, leading to an increased level of confidence. They perceived that when something had
126
worked well in the past, they could repeat the action without the need to think critically about it. This demonstrated their learning from novices in year one to building knowledge in year two. Most perceived their development of critical thinking from year one to year two to take the form of being more decisive and self-reliant leading to independent decisions. During placement learning, the complexity of tasks helped to develop critical thinking further. Progress was observed by participants regarding the level of thinking required for conducting simple tasks as compared with complex tasks. Some students said their ability to make decisions became quicker from the experience gained working with patients. Students found that thinking through situations in clinical placement was not straightforward as there were many facets to consider during the thinking process. They demonstrated the development of skills and dispositions of critical thinking from year one to year two.
In their third year of study, their confidence continued to grow, and students undertook more challenging procedures having gained more knowledge and clinical experience, with less supervision as compared with their second year. They were also challenged in their learning by working as ‘semi-qualified’ radiographers where work patterns were matched with those of radiographers to prepare them for graduate autonomous practice. They were clearly able to distinguish between the levels of thinking required in undertaking simple tasks compared with more complex tasks. They understood the moral consequences of their decisions and demonstrated changes in their attitude towards decision-making. The findings from the third- year interviews revealed that the skills and dispositions of critical thinking were consolidating.
Tutors felt that the tools for critical thinking development are provided to students from Level