Wednesday, August 1, 2018

Critical Thinking in Monitoring and Evaluation

Rubenfeld, M. G., & Scheffer, B. K. (2005). Critical Thinking TACTICS for Nurses:
Achieving the IOM Competencies
 (3rd ed.). [Vital Source BookShelf].
Retrieved from

Critical thinking in Monitoring and Evaluation focuses on selecting and using the most appropriate outcomes/indicators.

The following are the types decisions that require critical thinking and an example of each:

Selecting appropriate indicators/outcomes
The Pareto Principle or Pareto's Law may are looking for the critical few indicators that will give you the best picture of whether your intervention has been successful.  You may want to choose process indicators as well as outcome indicators from various places in the cascade of outcomes.  For example with a client receiving Medical Nutrition Therapy (MNT) for Disorders of metabolism indicators could be chosen reflecting knowledge or attitude toward making a change, servings of specific foods, dietary fat intake, and changes in serum LDL cholesterol.  

Using appropriate reference standard for comparison
For example, if you select dietary intake for a specific nutrient you need to decide if you will compare the intake to DRIs for healthy individuals, to targets for therapeutic nutrition interventions, to a nutrition prescription, or to a step-wise reduction or increase toward an optimal nutrition prescription. 

Defining where client is in terms of expected outcomes
If a client who received MNT using the Evidence-Based Nutrition Practice Guidelines for Disorders of Lipid Metabolism has achieved an 8% reduction (compared to an expected reduction of LDL from 7% to 22% reduction after 12 weeks) the conclusion would be that outcomes were within expected range. 

Explaining variance from expected outcomes
However if the client who received MNT for Disorder of Lipid Metabolism only achieved a 4% reduction in LDL cholesterol, the dietitian would explore explanations for not achieving expected outcomes.  For example, did the actual dietary intake meet the targets for dietary fat and food choices,  had client been following the dietary modifications for the full 12 weeks, were there other factors (e.g. medications like prednisone or beta-blockers) that could have affected LDL cholesterol levels.

Determining factors that help or hinder progress
Using that same example, if the dietitian determined that the actual intake had not been modified enough to meet the nutrition prescription; then the dietitian and client might explore factors that impacted ability to make changes in dietary intake (e.g. family support, availability of desirable food choices, importance placed on making changes). 

Deciding between discharge or continued care
The dietitian and client might want to discuss whether scheduling additional follow-up appointments are desirable to make further changes toward an optimal nutrition prescription or maintain current changes.

Bottom Line:  
The critical thinking during the monitoring and evaluating is essential to establishing and using a M&E plan that evaluates the success of the intervention and/or sets the stage for modifying or adding nutrition interventions to achieve greater success.