Download Clinical teaching: developing critical thinking in student nurses

Education: Clinical teaching: developing critical thinking in student nurses
Clinical teaching:
developing critical thinking in student nurses
Potgieter E
Department of Health Studies, University of South Africa
Correspondence to: Eugené Potgieter, e-mail: [email protected]
Clinical facilities
(reflective journals or diaries), and problem-solving, are
more effective in stimulating active learning.
Today’s healthcare system is more complex than ever
before. As a rapidly advancing profession, nursing
demands higher-order cognitive skills from nurses, such
as critical, creative and reflective thinking, problemsolving and decision-making, as well as the skills to create
a therapeutic and caring environment for patients.
As the content of nursing science continues to change and
expand, nurses who can think critically are more effective
than those who can only memorise information. If
educators fail to stimulate critical thinking, they produce
habits, rather than skill. Educators and clinical instructors
have to ask questions and then become quiet and
listen, because they should not give answers to students
(McAllister, Tower and Walker). “If you talk all the time
there is no time for students to think”.(Facione)
In the clinical setting, nurses learn to apply theory that
was learned in the classroom, to real life situations.
Clinical settings present problems that are novel, complex,
specialised, and unpredictable. Nurses have to learn how
to practise safely, within the time-constrained periods
that are allocated to the clinical settings. The knowledge,
skills and attitudes necessary for delivering quality of
care, demand that clinical instructors adapt their teaching
to a diverse student population, and a variety of patient
scenarios. Various factors, including a shortage of nurse
educators, limited clinical facilities, decreased acute care
admissions, shorter lengths of stay in hospitals, and a
shortage of nursing personnel in the clinic facilities, pose
challenges to clinical teaching.
Critical thinking
Critical thinking is well documented in nursing literature.
If clinical instructors want to stimulate critical thinking in
students, they have to model creative and critical thinking
skills, and encourage students to be excited by the new
method of scrutinising issues, and asking questions.
A Delphi study by Facione et al explored critical thinking
in depth, and summarised the following attributes of
a critical thinker: an individual, also referred to as a
nurse, who has ideal clinical judgement. Critical thinking
includes analysis (examining ideas, and identifying and
analysing arguments); inference (to query evidence
and draw conclusions); and interpretation (to clarify
meaning, decode significance, and categorise). It also
includes explanation (to present arguments and justify
procedures); evaluation (bassess arguments); synthesis
(create new combinations); and self-regulation (to be able
to self-examine and self-correct) (Billings and Halstead).
Clinical teaching
Nurse educators must move away from traditional
approaches to nursing education, where didactic lectures,
memorisation, and return laboratory demonstrations, are
emphasised. These may lead to technical mastery, but they
do not stimulate the development of critical thinking skills.
Some educators emphasise the development of technical
skills, while overlooking the learning of humanities and
ethical care. Nursing is not only a science. It is both science
and art.
How do students learn?
The traditional approach to learning, in which educators
continually provided students with information that had
to be memorised, is outdated. Information is changing
rapidly as new knowledge is discovered, and students have
to function effectively within a dynamic and global world.
According to constructivism theory (Brandon et al),
learning is an active process, during which students
The changing needs of the healthcare environment require
a shift from content-based, to concept- based or problembased, curricula. Nurses need to reflect, think critically,
self-critique, synthesise information, link concepts, and
become self-directed, lifelong learners. Teaching learning
strategies, such as case studies, concept-mapping, group
discussions, clinical conferences, reflective exercises
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Education: Clinical teaching: developing critical thinking in student nurses
construct knowledge, based on existing knowledge.
Previous constructs, of knowledge and experience, form
the foundation for the learning process.
attributes to be developed in students, such as critical
thinking, demonstration of a caring attitude, and effective
communication with patients.
Learning is a process of discovery, and through
assimilation and accommodation, new constructs are
formed. This type of learning is more meaningful than
merely memorising facts. Constructivism advocates the
principles of active learning, and combines cognitive and
adult learning theories (Piaget and Knowles). Learners
must be the creators of their own education through
dialogue, discovering of principles, experiments, problemsolving, and collaborative learning. A fundamental
challenge when implementing a constructivist education
model is to change the locus of control from educator to
student, and transform passive learners into independent,
active learners in a collaborative educational environment.
The educator becomes a coach and facilitator.
Dialogue is very important. The clinical instructor needs
to talk less, and listen more, to students, to discover what
students think, and what holds meaning for them. Dialogue
facilitates the building of connections. It opens up ideas
to scrutiny, creates a way for thoughts and reflections to
be made public, and enables the dissemination of insight.
Educators should not provide students with answers. They
must encourage them to keep on questioning. In this
way, students develop interpretive, analytical, evaluative,
inferential, and explanatory skills.
Strategies to develop critical thinking
Strategies that stimulate the development of critical
thinking skills are problem based in nature, and require
active involvement in the learning experience, as well as
an inquiring mind.
As students learn through experience, knowledge is
created through the transformation of experience.
McAllister, Tower and Walker view active experiential
learning as transformative learning, in which the
individual experiences a deep, structured shift in the basic
premises of thought, feelings and actions. Transformative
learning alters the individual’s “being” in the world. This
concept was first described by Mezirow, and later extended
by Freire, Greene, Grabov, and Giroux.
The following strategies can be used, when approaching
education from a constructivism theory or transformative
education theory position.
Case study
Using cases studies is one way of implementing
constructivism in nursing education. Referring to a case
study can be a rewarding exercise, in which students gain
insight into patient problems, and develop critical thinking
and problem solving skills. The clinical instructor shares a
specific patient-related scenario, containing a challenge or
problem, with a group of students, during which students
are coached while they are engaged in active learning; to
anticipate patient needs, think critically, apply current
knowledge, and solve the problem. As the students work
through case studies, they gain an understanding of the
difficulties in caring for a diverse population of patients
suffering from different conditions. They demonstrate
an increase in knowledge and clinical skills, and gain
confidence in caring for patients.
It occurs when students consciously use strategies to
rethink phenomena, and define their worlds differently.
This requires them to think critically, creatively and
reflectively, using dialogue, and becoming sensitive to
differences, as well as compassionate.
The educator-student relationship
The relationship between the educator and student, and
the quality of their interaction, is extremely important
for the successful achievement of learning outcomes.
Students prefer different learning styles, and originate
from different educational, cultural, social, and geographic
backgrounds. Students need support, especially when
they are introduced to the clinical setting, when they often
experience high anxiety levels. The educator should be
both nurturing and critical.
Clinical post-conference
A clinical post-conference provides an opportunity for
students and the clinical instructor to discuss clinical
experiences or a case study, share information, analyse
clinical problems, clarify relationships, vent feelings, and
identify further problems. Students engage in active and
collaborative learning. Alternately, the clinical instructor
can request students to take the lead in sharing case studies
with the group. Through preparation for the presentation,
the student takes ownership of the learning process and
knowledge of best practices. Students have to use theory
to make decisions related to complex practice problems,
featuring many variables. Students learn by searching for
The educator has to be a change agent, coach, facilitator,
and role model. Each student must be accepted
unconditionally for his or her individuality, and the clinical
instructor needs to be open, flexible, accommodating,
while challenging and motivating students to develop
inquiring minds. Mutual respect and trust have to be
established, and judgement must be deferred, to allow
students to explore, discover, feel free to ask questions,
and offer their own opinions, in a psychologically safe
learning environment. The clinical instructor must set an
example in the clinical setting, and role model the desired
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Education: Clinical teaching: developing critical thinking in student nurses
the information themselves, and through dialogue with
fellow students and the clinical instructor. An inquiring
mind, critical thinking, and problem-solving skills, are
developed.
potential problems. This reflected a deeper understanding
of the total patient scenario, through deeper exploration.
Educators experienced more satisfaction reviewing
the students’ work, and were able to assess growth in
critical thinking through significant links and increased
interconnections in the students’ concept maps.
Lisko and O’Dell advocate that weekly clinical postconferences can be of great benefit in facilitating reflection
on encountered patient scenarios. These conferences may
include discussions of laboratory results, a change in
health-illness status of patient medications, and changes
in nursing care.
The strengths and weaknesses of each approach
(traditional nursing care plans vs. concept maps), depend
on the expertise of the educators. The way in which these
learning experiences are constructed, and the nature of
the guidance that is given to the students, influences the
quality of student learning.
Nursing care plans
Dialectical critique
Critical thinking is fundamental to the nursing process,
as it requires the ability to seek information, which
includes the collection, interpretation, analysis, synthesis
and evaluation of data. Nurses have to know how to
discriminate, predict and use logical reasoning, as well as
transform and construct knowledge.
Dialectical critique is an application of transformative
education or learning. It is a process in which clinical
routines and habits are interrogated. It challenges
dichotomous thinking. The students are encouraged
to view both sides of a phenomenon or scenario,
examining it from many sides. They have to peruse
both the thesis and anti-thesis, as this process helps to
deepen inquiry.
Constructivism theory and transformative learning
requires that students identify their learning needs, and
formulate their own learning outcomes. Therefore, the
clinical instructor should ask students to select the most
significant patient problems as a focus for their nursing
care plans. Each student should be asked to present a
nursing diagnosis, patient outcome statement, and nursing
intervention, for each problem. The educator can then
correct the nursing care plan, based upon expert knowledge,
and provide extensive feedback to the students. This is a
very time-consuming exercise, for both the students and
the educator. It takes hours to complete patient work sheets.
Regardless, nursing care plans do stimulate students’ critical
thinking and problem-solving abilities.
For example, a student may ask: “In what ways will a
selected treatment be beneficial to a specific patient in a
particular context, and in what ways might it be harmful?”
If a student measures the blood oxygen saturation of a
patient who has been diagnosed with chronic obstructive
pulmonary disease, and find it to be low, a natural reaction
might be to immediately administer oxygen per nasal
cannula to the patient. However, if the patient’s disease
condition and history is taken into consideration, a
lower blood oxygen level may be the norm for him, and
rechecking his file records would indicate a stable lowered
blood oxygen level. Therefore, in this case, the student
should reflect on the positive and negative effects of the
dosage, and methods of oxygen administration. When
using this example, an expert clinical instructor should
steer the student towards dialectical critique by asking
the right questions. Through exploration of different
observations and ideas, inquiry into specific phenomena
is deepened, and the student will learn to appreciate how
inherently complex some phenomena or patient scenarios
may be.
Concept mapping
By drawing concept maps, students express concepts and
their inter-relationships in a visual format. It provides
students with the opportunity to organise information,
understand complex relationships, demonstrate their
ability to think critically and creatively, and integrate
theoretical knowledge into practice.
Maneval, Filburn, Derringer and Lum compared the
strategies of traditional nursing care plans, with concept
mapping of nursing care plans, and found that both
methods stimulate the development of students’ critical
thinking abilities. However, concept mapping was found
to be more enjoyable and exciting for students and
educators, and less time consuming. Concept mapping
stimulated whole brain thinking through the combination
of the written word and visualisation, by drawing a picture.
Students demonstrated creativity and grasped nursing
process concepts more quickly. They learned to think in
a more global and holistic manner, and aside from the
given problems and interventions, identified additional
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Interruption
In practice, in disciplines such as nursing, tension is
created between theory and practice. Sometimes, students
may realise that what’s done in practice may not be the
optimal method, but they tend to conform to group
opinion, rather than what they know to be best practice,
according to the latest research. Theory is necessary
to advance the discipline, and develop evidence-based
practice. Therefore, students should not retain accepted
truths unquestioningly, simply to conform. Performance
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Education: Clinical teaching: developing critical thinking in student nurses
competence is not enough. Students must aspire to
excellence and knowledge advancement.
When clinical instructors use senior students to coach
juniors, they have to prepare the seniors for their task.
Senior students can be shown a video on coaching,
followed by role plays and group discussions, to clarify
concepts that require clarity, and behaviour that relates
to coaching. Seniors students may coach juniors on
initiating patient contact; completing vital sign and
physical assessments; recording treatment on patient files;
communicating with patients, relatives and health care
staff; and implementing the nursing process, with specific
emphasis on the planning and assessment phases.
Interruption is not new in education (Vygotsky), and
it is particularly relevant in transformative education
or learning. Interruption is used to prevent students
from continuing with harmful or self-defeating practice.
According to critical theorists, Apple, Freire, and Greene,
it is crucial to interrupt students when they express beliefs
and values that perpetuate stereotypes, and dichotomise
theory and practice that could cause tensions and
problems. Teaching must take a stand. It should be either
for or against, and must account for the specific within
the universal. Interrupting conversations is generally
regarded to be rude, but it might be worse to allow a
student to continue with harmful and self-defeating
practices. The educator needs to take a dialectical stance.
Clinical instructors must be aware that students are unique
individuals, and at the same time, take into consideration
current healthcare delivery requirements (McAllister,
Tower and Walker).
For junior students, the benefit of peer coaching is
decreased anxiety when they enter the clinical setting for
the first time. They realise the need to develop assessment
and organising skills for the administration of patient
care. They learn to identify their own learning needs, and
gain confidence because they have a “buddy”. The juniors
learn technical skills, and their critical thinking skills are
also developed. The advantages for senior students are
that they learn leadership skills, increase their sense of
responsibility, gain confidence in practice, and enhance
their interpersonal and organisational skills.
Interruption has to be used gently and effectively, to show
students alternative actions, and stimulate new ways of
thinking. Interruption must be undertaken judiciously
to avoid the creation of divisiveness or the stifling of
diversity. The educator’s approach should be gentle, and
he or she must gain the students’ consent to interrupt
them. Students should be asked if they would like the
educator to interrupt them to provide honest feedback,
and in which instances the student would prefer not to
be interrupted.
Teaching caring through the implementation of a
caring code
The need for caring nurses and a caring ethic has never
been more prominent. How can a caring attitude in
student nurses be cultivated? It is believed that caring can
be taught, but the conceptual complexity of caring creates
difficulties in developing effective strategies to teach
students how to be caring. According to Leininger, caring
is the essence of nursing, whereas Watson regards nursing
as the science of caring. Caring is viewed as a human trait, a
moral imperative, an affect, interpersonal interaction, and
therapeutic intervention. It includes presence, empathy,
physical touch, reciprocation, compassion, conscience,
commitment, professional experience, and technical and
scientific competence.
By the day end, the clinical instructor may ask questions
on what techniques or skills the students observed in
the wards, who practiced these, what were the positive
and negative aspects of such techniques or skills, what
messages were conveyed to patients about health care,
and which techniques or skills the students would
choose to perform, and why. These types of questions are
intended to interrupt students’ thinking, and tendency
to automatically follow routine without questioning. It
motivates students to deliberate mindfully.
A caring code, developed in Taiwan, was widely tested in
an experimental longitudinal study, in five nursing schools
and 30 different hospitals, and the outcome showed a
significant positive effect on student caring behaviour
(Lee-Hsieh, Chien-Lin and Hung-Fu). The caring code
was developed in a previous study, in which patients were
asked to describe caring behaviours from nurses. The
caring behaviours described by the patients were then
categorised into six themes: assistance during admission,
professional behaviour, communication, empathy, sincerity,
and respect, each with a number of specific items. They
were printed on both sides of a laminated 17 cm x 9 cm
card, to enable students to refer to the card while working.
Peer coaching
Coaching involves analysing and communicating,
motivating, and assessing others, and guiding others to
think critically, in order to discover, and make decisions.
Coaching is not telling others what to do. Peer coaching
in the clinical setting has been found by Broscious and
Saunders to be beneficial, to both senior and junior
students. Peer coaching could assist clinical instructors
with their teaching load, especially in the light of
current shortages of educators and preceptors in clinical
sectors, and can be very effective in reducing the anxiety
experienced by students during their first exposure to the
clinical setting.
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The students in the experimental group reported positive
experiences on having the card to refer back to, each time
when they were unsure in a situation. They learned how to
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and encourages them to reflect, and discover the answers
for themselves.
provide care and to better understand the needs of patients.
The experience enabled them to develop empathy and
to approach patients holistically. They understood how
a caring and responsible nurse should practice, and put
themselves in the shoes of the patients. They developed
empathy.
Bibliography
1. Apple MW. Pedagogy, patriotism and democracy: on the educational
meanings of 11 September 2001. Discourse: Studies in the Cultural
Politics of Education. 2002;23:299-308.
The pre- tests for both the experimental and control groups
of students were carried out after three days of contact
with patients, and the post-test after the fourth week of
practice. The results showed a significant difference in
the development of students’ caring behaviour, with the
experimental group recording the highest scores for
caring behaviour.
2. Billings DM, Halstead JA. Teaching in Nursing: a guide for faculty. St
Louis: Saunders Elsevier; 2009.
3. Brandon AF, All AC. Constructivism theory analysis and application
to curricula. Nurs Educ Perspect. 2010;31(2):89-92.
4. Broscious SK, Saunders DJ. Clinical teaching strategies: peer
coaching. Nurse Educator. 2001;26(5):212-214.
5. Carrega J, Byrne M. Problem-based scenarios to learn clinical
teaching skills. Nurse Educator. 2010; 35(5):208-212.
Assessment and feedback
6. Facione P. Critical thinking: what it is and why it counts. , Singapore:
2nd Ministry of Health International Nursing Conference and 10th
Joint Singapore-Malaysia Nursing Conference; 2005.
Assessment should be ongoing, and integrated during
clinical teaching. Students will always be anxious about
feedback from the educator. They expect to be judged
for inadequate performance, and may work hard at
creating defences to criticism, instead of being open to
helpful coaching. Therefore, feedback should always be
constructive. The educator must indicate to students how
they can improve their practice, rather than telling them
how bad their performances were.
7. Fink LD. Creating significant learning experiences. San Fransisco:
Jossey-Bass; 2003.
8. Freire P. Pedagogy of hope: reliving pedagogy of the oppressed. New
York: Continuum; 1995.
9. Giroux H. Impure acts: the practical politics of cultural studies. New
York: Routledge; 2000.
10. Grabov V. The many facets of transformative learning theory
and practice. In: Cranton P, editor. New directions for adult and
continuing education: No. 74 transformative learning in action:
insights from practice. San Fransisco: Jossey-Bass, 1997; p. 89-96.
11. Greene M. Releasing the imagination: essay on education, the arts
and social change. San Fransisco: Jossey-Bass; 1995.
Best practices in providing feedback can be summarised
by the following acronym by Fink, from literature in
psychology: : FiDeLity (F = frequent; i = immediate; d =
discriminating and distinguishing features of poor and
good performances; L = lovingly delivered, with personal
understanding and empathy (Tanner).
12. Lee-Hsieh J, Chien-Lin K, Hung-Fu T. Application and evaluation
of a caring code in clinical nursing education. J Nurs Educ.
2005;44(4):177-184.
13. Leininger M. Leininger’s theory of nursing:cultural care diversity
and universality. Nursing Science Quarterly. 1988;1:152-160.
14. Lisko SA, O’Dell V. Integration of theory and practice: experiential
learning theory and nursing education. Nurs Perspect.
2010;32(4):106-108.
Educators should offer performer-friendly feedback,
and not set the expectancy too high in the beginning,
as students will not do well initially. They need to be
guided and encouraged towards improving performance,
and developing professionally. They should be involved
in their assessment. It is through self-assessment and
peer assessment that they will be able to learn to give
constructive criticism and positive feedback to others.
15. Maneval RE, Filburn MJ, Derringer SO, Lum GD. Concept mapping:
does it improve critical thinking ability in practical nursing students?
Nurs Educ Perspect. 2010. 32(4):229-233.
16. McAllister M, Tower M, Walker R. Gentle interruptions:
transformative approaches to clinical teaching. J Nurs Educ.
2007;46(7):304-312.
17. Mezirow J. Perspective
1978;28:100-110.
Summary
transformation.
Adult
Education.
18. Piaget J. The psychology of the child. New York: Basic Books; 1972.
19. Ruth-Sahd LA, Beck J, McCall C. Transformative learning during
a nursing externship program: the reflections of senior nursing
students. Nurs Educ Perspect. 2010;31(2):78-83.
Clinical nursing can only be learned with time and
experience. Expert practice consists of many nuances.
Students should be guided towards the most relevant of
these. To enable students to develop critical thinking, they
have to actively participate in learning. The expert educator
enters into dialogue with students, listening more than
talking, never stops asking questions, challenges students,
Prof Nurs Today
20. Tanner CA. Editorial: The art and science of clinical teaching. J Nurs
Educ. 2005;44(4):151-152.
21. Vygotsky LS. Mind in society: the development of higher
psychological processes. London: Harvard University Press; 1978.
22. Watson J. Nursing: the philosophy and science of caring. 2nd ed.
Boulder, CO: Associated University Press; 1985.
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