Findings

At the beginning of her first year of study, Amelia experienced a lack of confidence in academic work. She had not completed A-Level study at school and felt unprepared for study at university. She said that she “felt confident in her previous job but felt completely out of my

depth with academic study.” However, she recognised she had to work on her academic skills.

Coming to university following paid employment was a big step for her. Her decision to attend a full-time degree programme, therefore, was based on her motivation to train to practice as a qualified radiographer. Amelia stated the following:

…employers are looking for people who are more educated…I didn’t want to get left behind…stuck in a particular job earning a certain kind of money…

In making her decision, she said she weighed the influencing factors of getting a university degree against the conflicting option of continuing with the paid employment she had at the time. She felt she used sound reasons in her decision-making process and considered her decision as, “honestly… the best decision I have ever made.”

In relation to handling information on a daily basis, Amelia would rely on both her experience and that of other people. However, she felt that if information “didn’t quite add up”, she would

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look up the information. She did not take things at face value. She felt that some people working within the healthcare professions did not give accurate information about patients. She therefore, did not want to exact inaccurate information. This made her perhaps very critical and wary of her decisions. However, she said that she was indecisive and needed to see the full picture before going ahead and making a decision. I doubt very much that it was indecision here given her understandable reluctance not to make a decision before she got the full picture. This demonstrates the making of a good decision-maker, not an indecisive one. If she made the wrong decision, she would reflect on what she thought went wrong, review her thinking and consider what she could do better in future. She felt she was beginning to develop the thinking skills that enabled her to reflect on her decisions. She felt critical thinking skills were important to develop as a student radiographer and provided the following reason:

…everything is not always clear-cut as you anticipate it being. You have to think. If a patient is not ambulant you have to think, “how will I get those images?”

Here she reasoned that one would sometimes encounter situations, which are not straightforward (clear cut), and one had to think deeper to bring about a clearer picture in relation to how to proceed. By referring to an ambulant patient above, she usefully exemplified her understanding by linking her explanation to an example from her clinical experience. She explained that critical thinking to her, in year one, meant “looking at both sides of things.” She felt critical thinking could develop through clinical practice but appeared confused about how to apply critical thinking to undertaking an essay assignment, at the university.

In her second year of study, in response to the question, ‘what do you understand critical thinking to mean?’, her reply was the following:

I think critical thinking is taking a problem and breaking it down and finding the best way to solve whatever the problem is.

She did not perceive a change in her understanding of the meaning of the critical thinking from her first year of study, yet the assertiveness with which she responded to the question told me her confidence had grown and she was sure of her response. She linked her understanding of what critical thinking meant to problem-solving. She stated, “I am quite logical in how I

approach a problem.” There was an inherent understanding underpinning her confident

response; she appeared more comfortable speaking about critical thinking in her second rather than in her first year. Experience gained from writing university assignments helped develop her confidence, yet interestingly, she did not perceive her confidence to have grown from year one. Despite this her thought processes had begun to change. Experience gained from clinical placement helped solidify knowledge and understanding of performing routine

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examinations, and she felt her thought process and actions, in these situations, become habitual. She felt new situations required more than just the routine application of thinking, where she had to think, “…a bit more.” This could be perceived as having to think more deeply.

During the second interview, a critical thinking exercise was conducted involving a critical incident from Amelia’s experience. The purpose of this exercise was to explore her ability to think critically and act accordingly. From the literature review, it is evident that critical thinking involves demonstration of higher order thinking skills and the disposition to use those skills, and these were the criteria that were explored during the exercise. The verbatim extracts from this exercise, conducted with Amelia, are presented below:

AR: So now we go onto the second part of the interview involving a real scenario from your experience. Can you think of and speak about a scenario where there were conflicting views?

Yes

AR: Describe the scenario and how you managed the situation.

The scenario is a patient who needs a PA (posteroanterior projection, see p. x) chest X-ray and they (the referring doctor) wants the PA to measure the mediastinum. She (the patient) has already had an AP (anteroposterior

projection, see p. x) which was done. The patient comes down and the patient

is not well enough to stand for the PA chest, so the radiographers reluctantly do another AP film, but you are still not getting very good resolution in order to see the bases of the lungs and the heart.

AR: What was your point of view in this scenario?

I looked at the clinical history which said that the doctor wanted a PA chest X- ray. The radiographers were the ones in charge and they decided that they will do an AP chest instead because the patient could not stand.

So from their point of view, the patient could not stand so they decided to do another AP chest.

AR: Describe how you felt about what happened.

I thought that it has given the patient an additional radiation dose which she did not need. She already had an AP chest a day ago. So, it seemed like a pointless thing to do from my perspective, as they will not have gained any additional information from doing the radiograph in the same way again.

You know the doctor asked for a specific projection to look at a specific thing so doing what was done before was not going to give them that information. It was not going to help give them more information.

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I suppose there were no pros only cons. The patient did not need the extra radiation dose and the image was not giving them (the radiographers) any more information. So, if she (the patient) cannot stand you have to figure another way of doing it or not do it at all.

AR: You have described your point of view and you gave a rationale for it, so tell me what happened thereafter.

They did the AP chest and still didn't get good resolution, so I turned around and said to them instead of standing her, can't we put the arm of chair down, swing her legs around and get her to lean against the bucky (See Glossary, p.

xi) so that you can get a PA chest. The detector is a digital detector which can

be positioned just above her knees and she can just lean against it and we can get the PA chest that we needed.

AR: What was your reason for suggesting that?

I don't know I just thought you still have the chair - it was about using my judgment, my powers of reason and I was having a look at what I can do and what I can't do, and the best possible solution within what I had within my control. And then we got the PA chest done and got good resolution where you could see the base of the lungs and heart shadow clearly.

AR: So are you able to make an appraisal of the whole event. What was learned in this event?

Even if you got the roadblocks or whatever where the patient cannot stand, there are ways you can get around it.

AR: Explain your reasoning process in reaching your conclusion.

I suppose I was thinking of a way to get the image that a doctor needed. I was looking at the whole situation rather than just the end result of it. I always think I have a more practical way of thinking compared to other people. Whereby you all want the result but not everyone looks at the whole situation in front of you. Some just look at the end result. For me, it's more systematic, more structured and I look at what I got at hand and that will give me the outcome I wanted. I saw what the radiographers did and worked on that. I learned from that and thought well, “how can we get that PA chest.” I looked at the chair and things that we had in the room. The arm of the chair comes down and if the patient was stable enough to swing round in the chair and face a different way, then we would be able to get the view of the chest that we needed.

AR: So you worked out that if you did this, this and this, then this will be the outcome?

Yes

AR: Why didn't you tell the radiographers this the first time when they were attempting to do the AP?

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I'm just a student and did not feel I was senior enough to tell them about my point of view.

AR: Okay, so what have you learned from this experience?

That you have to look at your surroundings, the situation first before forging ahead and doing the normal or routine thing. You treat every situation differently, and every patient and X-ray differently. Next time I will build on that experience and if I had a similar situation, I would try the other method. I would feel more confident to speak to radiographers about my point of view because I feel that I have that much more experience now than I did at that time, so I would speak to them and feel confident about it.

AR: Are there any consequences of your action in relation to the incident?

The patient got more radiation but that was not through my action, that was through the radiographers’ actions.

AR: What might the implications for clinical practice be then?

We should be analysing the situation first before going ahead and doing what we think is the easiest way forward. Try a bit harder and sometimes what appears to be obvious is not helpful at all?

AR: How would you describe the thinking that was used in this incident?

It was routine, habitual thinking which did not have a good outcome at first.

AR: Did you feel that your critical thinking has developed from last year?

I suppose it has a grown a little as experiences like this have taught me not to be complacent and don't just go with what the radiographers would do, and not rely on what appears easier to do. You have to think a bit harder when the obvious does not work.

The AP versus PA dilemma alluded to within this example relates to how a patient is positioned during a chest X-ray examination in order to get a good quality diagnostic image. AP refers to a radiographic position where the X-ray beam passed through a patient’s body from the anterior (front) aspect to the posterior (back) aspect, hence AP means anteroposterior. The PA projection is the opposite where the X-ray beam passes through a patient’s body from the posterior (back) aspect through to the anterior (front), hence PA means posteroanterior. The PA projection is best practice when imaging the chest as it yields the recommended diagnostic information to aid accurate diagnosis and minimises radiation dose to a patient’s eyes, thyroid and gonads. Amelia demonstrated sound reasoning skills in relation to the position of the

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patient regarding the requested information and makes a point about thinking beyond what was perceived to be the easiest option. Amelia demonstrated the application of skills of critical thinking in her quick and methodical decision-making process.

In this critical incident, Amelia was able to analyse and evaluate the situation considering the patient’s individual circumstances and provide a clear and justifiable rationale for her point of view. The radiographer in the scenario chose to go ahead with another routine AP chest examination, due to the patient’s condition, despite the doctor specifically requesting a PA chest examination. Due to Amelia’s critical thought process, she was able to suggest an alternate radiographic imaging technique which enabled the patient to receive the requested examination. This examination yielded better outcomes for the patient as compared with repeating the radiographic technique that had already been undertaken. Her learning and development clearly demonstrated that critical thinking is thinking that goes beyond the surface of habitual thinking; it is a deep thought process, which, in this case occurred in-action and on-action.

Working with different radiographers at placement influenced her learning and understanding in a mainly positive way. However, at certain times she disagreed with radiographers’ decisions, but felt intimidated by their seniority as she stated above. This represented a challenge she faced in her learning. Nonetheless, she demonstrated aloud her critical thought process thus confirming her critical thinking ability in the above-written scenario. In addition, she demonstrated her willingness to engage in and persist at a complex task, the avoidance of acting impulsively, and, being open-minded. These, according to Halpern (1989) and Facione (1990) are dispositions of a critical thinker.

In Amelia’s third year of study, when asked about her understanding of critical thinking, she stated the following:

I honestly, don’t get what critical thinking means...I think it is a deeper form of thinking, but I am not sure.

Here despite stating that she did not ‘get’ what critical thinking meant, she was able to relate her understating to a ‘deeper form of thinking.’ When explored further she explained that she saw it in terms of being asked to “...critically discuss and critically analyse…” at Level six (See SEEC Descriptors in APPENDIX 2). The most significant influential factor in the development of her understanding was seen to be clinical placement. Below is what she stated:

It was a placement that helped a lot because you do a lot of decision making and the decision making is quite rapid due to patient safety issues (because of

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cannot just jump in and make decisions because you are just starting and don’t have enough knowledge. Now I feel more comfortable making decisions.

She felt she had more knowledge than in her previous year and has had the opportunity of making decisions at placement. The decisions must have had a positive outcome as that appeared to have boosted her confidence. She developed greater knowledge and understanding of diagnostic radiography by the third year of study and felt comfortable making decisions. This is a crucial step in the development towards autonomous practice.

When asked for her definition of critical thinking, Amelia offered the following definition:

Detailed, in-depth thinking, a different level of generally thinking. You have thought and then you have critical thinking. It is generally thinking but on a deeper level.

Despite initially stating that she still did not understand the meaning of critical thinking, she was able to capitalise on her experience of learning to provide her definition of critical thinking, clearly making the distinction between critical and non-critical thinking. Throughout Amelia’s three-year study she continued to consider herself as indecisive and lacking in confidence, yet underlying her perception of herself, was a deeper level of understanding about the meaning of critical thinking as seen through her responses to interview questions and prompts. Her understanding of a ‘deeper level of thinking’ indicates metacognition.