Critical Thinking II:Teaching Strategies to Foster Critical Thinking in Undergraduate Nursing Students:A Case Analysis Approach

LEE Shirleatha,ZHAN Lin,FLEMING Belinda

（Loewenberg School of Nursing，University of Memphis,Memphis,TN 38152,USA）

The complex and ever changing health care system has increased the need for nurse educators to prepare students for developing critical thinking skills to support safe,effective,and improved patient care[1].Nurse educators seek learning strategies that foster critical thinking in their students[1-3];however,this can often be challenging.Teaching nursing students based solely on knowledge is no longer acceptable as nursing students need to become lifelong critical thinkers[4]as critical thinking is essential to professional nursing practice[5].However,only 1/3 of graduate nurses in the United States have the critical thinking skills required for entry level practice[5-6]and research indicates that Chinese nursing students also display weaknesses in their overall ability to think critically[7].

The role of the nurse educator is to encourage students to combine theoretical and clinical knowledge and utilize critical thinking to improve patient outcomes[4,6,8].Nursing is an applied discipline and different learning strategies should be used by nurse educators to develop the critical thinking skills of students[9].It is important that students are equipped with the ability to think critically across clinical settings as nurses are faced with more complex issues,challenging and acutely ill patients, advancing technology, and ethical dilemmas[9].

The role of the nurse educator is to utilize effective teaching strategies to foster critical thinking and to make theoretical and clinical teaching seamless.In part one we sought to clarify the term “critical thinking”through historical,philosophical,and conceptual analyses.In this paper-Part two-we will seek to describe the role of the nurse educator in helping nursing stu-dents to think critically.We will examine a case analysis and describe ways that nurse faculty can help undergraduate nursing students develop their critical thinking skills.

In didactic and clinical classes students should obtain knowledge through lecture, but should also learn using strategies that enhance critical thinking such as Socratic questioning,role modeling,debates,case studies,and reflective journaling[10].The following case presentation will be used to guide and explore teaching strategiesthatcan be used by nurse educators to cultivate students to think critically.

1 Case Scenario

Sara,an undergraduate baccalaureate nursing student provided care for Ms.D.on a Medical Surgical Nursing unit in clinical practicum.Ms.D.was an 80-year old African American female,who presented to the emergency department with shortness of breath and fasting blood glucose of 325 mg/dl.Her medical history included many risk factors and morbidities.Her diagnoses included type 2 diabetes mellitus(T2DM),stage five chronic kidney disease although she was not currently on dialysis,congestive heart failure,chronic obstructive pulmonary disease,hypertension,right eye blindness,glaucoma,cataracts,and obesity.In addition,Ms.D.had a right above the knee amputation and a history of stent placements.Because of Ms.D’s obesity,right leg amputation,and shortness of breath,she was very sedentary both at home and in the hospital.She required full assistance with position changes and eating,and was completely non-ambulatory. Although her daughter,who visited frequently,assisted Ms.D.with her meals,position changes required the assistance of several nursing staff.She had multiple previous hospital admissions related to hyperglycemia from poor glucose control.

2 Socratic questioning

The nurse educator wants Sara in the case scenario above to use critical thinking to provide care to Ms.D.One method that can be utilized to help foster critical thinking in the student is Socratic questioning.Scholars contend that thinking is driven by questions;you simply have to ask the right question to stimulate the thought[11].A nurse educator could easily formulate declarative statements to inform the student who is providing care for Ms.D.However,those statements should be transformed into Socratic questions to stimulate the student to think critically.Over the years it has occurred that students can easily provide the instructor facts related to their patients, but when asked the most profound questions such as,“Why?” or “What is your rationale for that?”the student is easily left speechless.This is because higher level phrases include words such as,“explain” “why” “compare” and others that are at the higher level of Blooms Taxonomy[12].The educator needs to stimulate the student to think critically by connecting thoughts,ideas,and knowledge and by asking “why”“explain” “compare”.The following dialogue demonstrates how the nurse educator can utilize Socratic questioning to help Sara to think critically about her patient.

Educator:What do you believe caused Ms.D to exhibit shortness of breath?(explain)

Student:Chronic obstructive pulmonary disease(COPD).

Educator:What lead you to this assumption?(inquiry)

Student:Well,COPD can cause shortness of breath and that is in her history.

Educator:Does Ms.D have any other illnesses that could also lead to this symptom?(compare)

Student:Yes,diabetes,congestive heart failure,and kidney disease

Educator:How can each of the diseases cause shortness of breath?(explain)

Student:Well,they can all be connected.

Educator:What do you know about the relationships between these diseases and how can they contribute to shortness of breath?(connecting)

The goal of the educator is to stimulate student thinking about how to apply concepts they have learned. The educator should reply to the student’s response with a question that requires the student to think more deeply and/or in a different way[11].This rigorous,thoughtful,and disciplined dialogue between educator and student can stimulate critical thinking.

3 Role modeling

Learning by observation and role modeling is an important aspect of teaching students to critically think[13].Often when faculty,preceptors,or clinical nurses are with nursing students they do not think out loud.Therefore,students are unable to get the full grasp of how the nurse/faculty/preceptor goes through the decision making process.Students’ability to hear the nurse who verbalizes his/her thought processes can be an important part of learning how to think critically[13].The nurse educator is the primary role model for students[14].It is beneficial for faculty to share thought processes with students so that students understand how decisions are made in a complex and often vague clinical situation.A thinking loud approach is particularly helpful for preceptors whose behaviors are essential in the process of empowering students to think critically[15].The following demonstrates role modeling.

Student:Professor,I have just taken Ms.D’s vital signs.She has a chest x-ray scheduled this morning and the transporters are here to take her to this procedure.

The nurse educator is aware that this patient has not had their medications and has hypertension.She also knows that time is of the essence and essential priorities must be addressed prior to the patient going off the unit for this procedure.Since there is not much time for the faculty to perform Socratic questioning this is an ideal situation for role modeling.The educator can think out loud to help the student understand the decision making process required.

Educator:“Sara,this is what I’m thinking.Ms.D.has hypertension so it is important as a nurse that we ensure she receives her anti-hypertension medication prior to leaving the unit.What were her vital signs?”

Student:“Blood pressure 186/94,Pulse 88,Respirations 14,and Temperature 98.7 F”

Educator:“Well Sara,usually when the patient leaves the unit for a procedure it can often take a while for them to return.It is really important that Ms.D gets her blood pressure medication before she leaves to decrease her blood pressure and prevent complications” Also,as a nurse in this situation we should look at the previous blood pressure trends,notify the primary nurse,and contact the healthcare provider if required.We will also need to get a followup blood pressure as soon as she returns.So first,let’s get Ms.D’s antihypertensive medication as this is a priority and the transporters are here"

Role modeling how the nurse prioritized the decision to give Ms.D her antihypertensive medication before she left the unit for the procedure and additional steps that must be taken by the nurse is an effective way for the educator to help the student to begin to think critically. This gives the student a clearer understanding of the mental processes of the nurse and educator and demonstrates the steps in clinical decision making.

4 Debates and Classroom Discussion

Discussion and debates in the classroom can create an environment that supports reflection,reasoned judgment,and considers multiple perspectives[12-16].Preparing for a debate can engage students in active learning[16-17].When debates are used as a teaching strategy to promote critical thinking skills the nurse educator that requires evidence rather than mere opinion is preferred[17].Students should be provided criteria for the debate,a time frame,rebuttal time,and a moderator[17].Debates are also useful in addressing ethics[17]and public policy in nursing in which some issues may be controversial.In the case scenario above the nurse educator could pose a public policy question to Sara and her classmates about Ms.D.such as： “Ms.D.has multiple co-morbidities that include obesity.Do you think public policy initiatives(i.e.taxes on sodas,requiring calorie posting at fast food restaurants,etc.)can significantly impact the obesity epidemic? What public policy initiative can nursing take to prevent and reduce the incidence of obesity in our community and support how your recommendation will be effective?”

In a debate, students can be divided into two groups:pro and con.Group one supports public policy to curve the obesity epidemic and group two argues that public policy may have little to no impact on obesity. The students should be allowed to research the topic and identify supporting evidence to support each side.It is acceptable for students to debate on a side that is not consistent with their beliefs. On the day of the debate allow the pro side to speak for a specified time uninterrupted supporting their position,and group two is allowed a rebuttal with a specified time frame.This cycle is repeated as needed.It is also important for the faculty to determine if this will be a graded assignment and if so,a grading rubric must be provided.An evaluation can be made to see how students feel about debate and how debate helps their thinking.

5 Case Studies

The use of an actual description of an actual situation through case studies provokes students to think critically[2-18].Cases can be presented to students in both the classroom and clinical setting and can range from simple to complex[2].The use of case studies can engage the learner and enable students to apply both theoretical and clinical knowledge;they can also be assigned a conceptual or clinical problem individually or in a group and share different ideas and points of view[2].Case studies can help students become active learners,relate topics to real world situations that might be encountered in the clinical setting[2],to encourage students to become more responsible for their own learning,and this learning strategy can be increasingly beneficial when the student transitions into professional practice.Case studies should focus on the most important concepts to be learned and consider alternative responses[18].The following are examples of questions that can be utilized with Ms.D’s case scenario as a teaching tool to stimulate critical thinking in nursing students.

（1）What additional assessment data would the nurse obtain for Ms.D.?

（2）What are three priority nursing diagnoses for Ms.D.?

（3）On auscultating Ms.D.’s lung sounds the nurse hears crackles bilaterally in the base of the lungs.What is the most appropriate follow-up action by the nurse?

（4）The nurse is preparing to administer the morning dose of regular insulin based on the sliding scale, Ms.D.’s morning glucose level is 176mg/dl following the administration of insulin what interventions are a priority for Ms.D.?

（5）Describe the teaching requirements for Ms.D.?

Case studies have also been threaded into clinical simulation scenarios.Recently,the introduction of simulation learning has provided controlled environments where students can learn and think critically in a controlled setting.The use of simulation provides an innovative strategy that uses case studies in nursing education.Kaddoura[1]identified that students reported that simulation greatly assisted them to make sound clinical decisions. Researchers have identified a statistically significant relationship between overall high fidelity human simulation performance and overall critical thinking scores in nursing students[19]. A nurse educator could document the case scenario for Ms.D. This case scenario can then be constructed into a simulated learning activity with students.

6 Reflective Journals

Written assignments allow students to develop critical thinking processes[12].Reflective journaling is one teaching strategy that requires purposeful contemplation of thoughts and feelings that can be used to guide actions[20].Baker’s four step model of reflective writing contains the following elements （1）identification, （2）description,（3）significance,and （4）implications[20].The nurse educator could guide the student presented in the case scenario above to follow these steps in reflective writing.In writing the first step is to identify the clinical practice experience with Ms.D.and next describe the patient care experience. This would be followed by deriving the student’s personal meaning from the clinical experience and lastly,the student should explain how the experience impacted them[20].Reflective journaling can provide students with several benefits. These include insight on how to handle similar situations in the future,awareness of thoughts and feelings,the ability to critically analyze the clinical experience,and new viewpoints[21].

In conclusion,nurses are increasingly expected to demonstrate critical thinking skills for providing safe and quality care for patients. Critical thinking has been considered an essential nursing competency for over 15 years[22].Four factors influence critical thinking in nursing education including the student,educator,education system,and environment[10].The responsibility of the nurse educator to teach critical thinking skills requires the faculty to understand and to be able to think critically[22],and to translate understanding and thinking into effective teaching.The teaching strategies we described earlier can be beneficial to faculty in both the clinical and classroom settings.These strategies capture a glimpse of the array of methods nurse faculty can utilize to foster students’ critical thinking skills. An advantageous learning environment allows faculty and students to think together, solve clinical problems, and make clinical decisions based on evidence. Critical thinking helps students develop sound inquiries as they practice and ultimately improves patient outcomes in our growing and complex healthcare system.

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