Clinical teaching: developing critical thinking in student nurses

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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: potgie@unisa.ac.za

Clinical facilities

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, problem-solving and decision-making, as well as the skills to create a therapeutic and caring environment for patients. 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.

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.

The changing needs of the healthcare environment require a shift from content-based, to concept- based or problem-based, 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

(reflective journals or diaries), and problem-solving, are more effective in stimulating active learning.

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)

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). 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

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construct knowledge, based on existing knowledge. Previous constructs, of knowledge and experience, form the foundation for the learning process.

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, problem-solving, 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.

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.

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.

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

attributes to be developed in students, such as critical thinking, demonstration of a caring attitude, and effective communication with patients.

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.

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.

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

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the information themselves, and through dialogue with fellow students and the clinical instructor. An inquiring mind, critical thinking, and problem-solving skills, are developed.

Lisko and O’Dell advocate that weekly clinical post-conferences 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.

Nursing care plans

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.

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.

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

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.

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.

Dialectical critique

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.

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.

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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competence is not enough. Students must aspire to excellence and knowledge advancement.

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).

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.

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.

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.

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.

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.

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.

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. 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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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.

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.

Assessment and feedback

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.

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).

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. Summary

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,

and encourages them to reflect, and discover the answers for themselves.

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