Teaching Methods to Affect Clinical Reasoning

A variety of studies have been undertaken to investigate the effect of particular educational approaches on nursing students’ development of clinical- reasoning skills. Strategies that have been researched commonly include concept mapping, problem-based learning, simulation and active learning.

Studies by Abel and Freeze (2006), Maneval et al. (2011), Nejat, Kouhestani, and Rezaei (2011) and Passmore, Owen and Prabakaran (2011) have investigated concept mapping as a strategy to assist clinical-reasoning skills among nursing students. Abel and Freeze’s work (2006) suggests that concept mapping can enable students to create a hierarchy of concepts and create a scaffold that highlights relationships among concepts and increases the opportunity for analysis, synthesis and clinical-reasoning skills. Measurement methodologies used in these studies included mapping scores, study-process scores, and care-planning scores. However, due to methodological issues such as small sample sizes and lack of control groups to compare outcomes in these studies, the effect of concept mapping on clinical- reasoning outcomes remains unclear.

Some studies have focused on problem-based learning as a means of improving nursing students’ abilities in critical thinking. For example, in the Hong

Kong context, Tiwari, Lai, So and Yuen (2006) conducted a randomised control trial to investigate the effect of problem-based learning (in the form of scenario cases and reflective groups) on the development of critical thinking in nursing students (N= 79) from year one to year four. Data were collected using the CCTDI and perceptions of the learning experience at four time points spanning three years. The study results revealed that intervention-group students had significantly greater development in their overall critical-thinking disposition score (p = 0.0048), analyticity (p = 0.0368), systematicity (p = 0.0440) and critical-thinking self-confidence (p = 0.342). From the qualitative data, students perceived that it was important to learn to think to be competent in making judgements in the clinical setting. Recently, Yuan,

Kunaviktikul, Klunklin and Williams (2008) conducted an experimental study to examine the effect of problem-based learning on the development of critical-thinking skills in second-year undergraduate nursing students (N= 46). Results suggested that the critical-thinking scores of the problem-based learning intervention group were significantly higher (p = 0.040) than the control group’s scores. However, qualitative data revealed that students reported high levels of stress related to the problem- solving tasks, which also raises a question about the focus of the study.

Simulation has also been used as an educational medium for enhancing nursing students’ critical thinking. For example, Linden (2008) conducted a pre-test post-test quasi-experimental design of undergraduate nursing students’ (N = 97) critical-thinking skills by comparing traditional lectures and high-fidelity simulation (HFS). Results demonstrated a significant difference (p < 0.000) in cognitive-

learning outcomes in the group intervention. Nonetheless, the use of a single data source, convenience sampling and a non-standardised instrument are limitations of the study. Similarly, Shinnick and Woo (2012) conducted a quasi-experimental, pre-

test and post-test design using human-patient simulation (HPS). Results provided evidence of Kolb’s Learning Style Inventory (LSI) knowledge improvement (p < 0.001) but there was no statistically significant change in the Health Science

Reasoning Test (HSRT) scores. This study argues that knowledge enhancement with HPS is not associated with critical-thinking development. Accordingly, the authors note the need for an optimal learning design to improve knowledge and critical- thinking skills.

Studies have also been undertaken to examine the effects of interactive- learning approaches such as using case studies, questioning, debate, role play and small-group activities, and journal writing on the development of critical-thinking skills (Burbach, Matkin & Fritz, 2004; Dinç & Görgülü, 2002; Huang, Chen, Yeh & Chung, 2012; Popil, 2011; Simpson & Courtney, 2009). In a professional-

development programme, Simpson and Courtney (2009) investigated the effects of case study, questioning, debate, role play and small-group activities on Middle Eastern nurses’ critical-thinking skills (N = 20). Data collection included direct participation and observation of students’ interactions in discussing thought provoking questions designed to assess students’ understanding of the stimulus material. The researchers also evaluated the critical thinking questions (CTQs) that were generated by students. Findings indicated that students who received the educational intervention developed greater critical-thinking skills. These were followed by focus-group interviews. Findings indicated that students who received the educational intervention developed greater critical-thinking skills. Simpson and Courtney (2009) argue that the programme successfully transformed students’ learning from memorisation to interactive participation. Nonetheless, the use of a single data source, convenience sampling and a non-standardised instrument are

limitations of their study. Similar to Simpson and Courtney (2009), Burbach et al. (2004) conducted a pre-test and post-test quasi-experimental design of undergraduate nursing students’ (N = 80) critical-thinking skills after receiving active-learning strategies, including journal writing, service learning, small group, scenario, case studies and questioning in an introductory leadership course. Data were collected using the Watson–Glaser Critical Thinking Appraisal (WGCTA). Results

demonstrated that the total critical-thinking post-test scores were significantly higher (p < 0.05) than the pre-test scores. The coefficient alpha was 0.81. The study

concluded that the active-learning strategies were able to improve critical-thinking skills. However, Burbach et al. (2004) acknowledge that the inability to control external variables was a limitation of the study. Arguably, the use of a single data source and convenience sampling are further limitations of their study. Several studies using an individual strategy, that is, only case study, have also been found to improve critical-thinking skills significantly (Dinç & Görgülü, 2002; Mayo, 2004; Popil, 2011). Popil (2011) argues that case study is a valuable teaching and learning strategy to promote active learning and assist students to apply their knowledge in the clinical setting and develop clinical-reasoning skills.