Critical Thinking Scenarios For Nursing Students

*Note: This post is the third in a series.

In the second post in this series on active learning strategies in nursing, I shared one nursing instructor’s way to set realistic expectations of her students beginning with the first time they step into the classroom. Now in this third post, let’s look at the ultimate question I hear everywhere I go: “How do I get my students to think critically?”

I attended an all-day conference by a nationally known speaker on this very topic. It was called, “How To Get Students to Think Critically.” I was pretty excited and looking forward to the day. It became pretty clear within the first hour of the day what the answer was. It was this: Involve your students. The speaker lectured to us for eight hours about how important it was to involve learners actively in the process. I found this amazing. We were not ourselves involved as learners once in that day. We were lectured to. We were lectured at, but we were never involved. I wanted to know how to involve my learners. That day ended without me gaining that knowledge.

I don’t blame the speaker. Her content was good. After all, she was doing what so many who teach nursing do - she was lecturing. To many people who teach, that’s all they have seen modeled. They are familiar with it. They can come in and do a “content dump” and feel they have done their job well. But who knows the content at the end of that lecture? The educator who give it knows it. The bad news is, he/she may be the only person retaining and understands that knowledge. Many educators have discovered that if they want to teach their students to think critically, they must create opportunities for their students to think critically. It’s like putting in a catheter. Can a student catheterize someone by hearing a lecture on it? No, one masters it by gathering the knowledge, watching a demo, getting the right supplies, and practicing on a manikin until feeling competent enough to get checked off by the teacher. The same is true for critical thinking.

So, how do you do that? I like to start off the thinking at the very beginning of class with something that looks fun or simple to start the brain thinking. Many of these activities can be found by putting these words into a search engine, “Brain puzzle of thinking puzzle.”  Here is one example I put on a PowerPoint slide and ask the students: “Based on the pattern established below, where do the 0, 7, and 9 go?”

Complete the series:

8, 5, 4, __, 1, __, 6, 10, 3, 2, __.

Where do 0, 7 and 9 go?

See if you can figure this problem out without reading further yourself. Have you solved it?

After two minutes I poll the group and ask why people made the selections. I then show them the completed list so they can check whether or not they were right. Also, check yourself:

Complete the series:

8, 5, 4, 9, 1, 7, 6, 10, 3, 2, 0.

Did you solve the pattern this way? You may be asking why is this the right answer. Well, if you write the numbers out, you can see the list is an alphabetical one. Eight, Five, Four, Nine, One, Seven, Six, Ten, Three, Two, Zero. What point does this make? Nursing is all about recognizing patterns. What do we expect to see in a patient with CHF? What would be normal and what would not? What are the expected effects of a diuretic? What is an alarming effect? One must know the patterns to problem solve and act appropriately for the patient.

One could also use a short patient scenario or NCLEX-style question at the beginning of class as the “problem of the day.” Present this and ask each learner to record what he or she thinks the answer to the question before you lecture. Then stop every 20 minutes or so and ask your learners to individually think and write down if they have changed their initial choice. If so, write down why. What principles or information have you learned that has changed your answer or caused you to know your choice is correct? In the last segment of the class, have the learners share and discuss the answers they have and the correct answer with rationales. This makes it safe to make mistakes of judgment on paper, not on people. The only way one learns is to be involved in making situational choices. The number pattern and/or the patient scenario offer learner practice in critical thinking.

Might you use one or both of these ideas? What do you think of these teaching strategies? Are they useful to you? Which strategies do you currently use that gives you great learner results?

Michele Deck presents nationally and internationally on innovative teaching methods in the field of health care education and training. She is co-founder and chief executive officer of G.A.M.E.S., a company that specializes in seminars on adult learning and interactive training methods, and Tool Thyme for Trainers, a company which supplies innovative and creative presentation tools for educators worldwide. Honors include ANPD’s prestigious Belinda E. Puetz Award, election to Sigma Theta Tau National Nursing Honor Society, Business Woman of the Year by the National Business Council, and Best Over All Trainer by Creative Training Techniques Companies. She serves on ANPD’s Education committee and was a member of the Editorial board of the Journal for 8 years.

When I taught novice nursing students in fundamentals, in order to become proficient with every clinical skill I taught, students were expected to practice, practice, practice!

This included the basics of obtaining a manual blood pressure, heart rate, respiratory rate and temperature.

Once vital signs were taught and students were confident because of repeated practice, physical assessment was taught.

Theory content on each body system was reviewed, and how to properly use a stethescope to listen to the different types of breath sounds as well as heart sounds was introduced.

Students then repeatedly practiced assessment skills on each other until needed proficiency was obtained.

What does the practice of these nursing skills have to do with Socratic questioning?

Thinking like a nurse is also a skill that requires repeated practice in order for novice nursing students to become proficient.

It is also the most important skill that students must develop and become proficient in order to become a professional nurse.

Why Practice Nurse Thinking?

Last week’s blog on using Socratic questions in the clinicalsetting begs a point.

Would you expect your students to be safe and proficient in the clinical setting inserting a Foley catheter if they had no preparation or practice of this skill?

Absolutely not!

In the same way, how can you expect your students to develop proficiency with Socratic questions to develop nurse thinking if they have not been given opportunities to practice?

Socratic Questions vs Clinical Reasoning

Socratic questioning is similar but different than clinical reasoning.

Clinical reasoning is the essence of nurse thinking and is a construct unique to practice based professions such as nursing (see prior blog Why Clinical Reasoning is Foundational to Practice).

Once RELEVANT clinical data is identified by a student (key consctruct of clinical reasoning), use Socratic questions to assess and probe student thinking further, to determine the extent of student knowledge related to patient care or to analyze understanding of an essential concept or line of reasoning.

Socratic questions provide a practical tool for educators to assess and evaluate the critical thinking of students (Oermann, 1997).

How to Contextualize Socratic Questions to Practice

In order to transform nursing education, everything that is taught needs to be contextualized to the bedside (Benner, Sutphen, Leonard, & Day, 2010). This includes teaching a new thinking skill such as Socratic questioning to students.

Just as I use a salient clinical scenario to contextualize clinical reasoning with my clinical reasoning case studies, you can do the same with Socratic questions.

First, start with a salient scenario depending on the classroom topic or clinical setting.

Here is my scenario:

Faduma Ali is a 21 y.o. female with a history of type 1 diabetes mellitus since the age of 12, who presents to the ED with  a 12 hour history of vomiting. She states this began two days prior to admission after she began having frequency and painful urination. She feels dizzy when she stands up. She does not consistently check her blood glucose and has not checked her glucose or taken insulin since she began feeling poorly two days ago. Faduma is thirsty but feels nauseated. 

Faduma immigrates to Minnesota from Somalia with her parents at the age of 12. She speaks and understands English, but is not fluent.

But in order for the nurse to use Socratic questions, clinical reasoning must FIRST be utilized to identify what clinical data is RELEVANT.

RELEVANT data includes the following:

  • History of type 1 diabetes mellitus since the age of 12
  • 12 hour history of vomiting
  • frequency and painful urination
  • feels dizzy when she stands up.
  • does not consistently check her blood glucose and has not checked her glucose or taken insulin since she began feeling poorly two days ago.
  • thirsty but feels nauseated.
  • immigrated to Minnesota from Somalia with her parents at the age of 12. She speaks and understands English, but is not fluent.

Then this relevant data must be correctly interpreted aided by Socratic type questions to make a correct clinical judgment.

The data in this scenario appears to point towards diabetic ketoacidosis. But there are no current labs or other clinical data available to support this assumption except a student’s DEEP understanding of pathophysiology and diabetes!

Socratic Questions to Ask

Here are the Socratic questions for this scenario that must be asked to probe and analyze the thinking of the student in order to make a correct clinical judgment (Oermann, 1997):

Clarification Questions

  • What clinical data from this scenario is MOST important? Why?

Questions to Probe Assumptions

  • Are you assuming that your client’s responses are due to DKA?  Tell me more about your thinking here.
  • What (relevant) data  have you interpreted to determine your problem is DKA? What will be your nursing priority?  Why?

Questions to Probe Reasons

  • What are other possible reasons for this clinical presentation?
  • What would do if the patient became nauseated and had a large emesis?  Why?

Questions on Differing Perspectives

  • How might the client/family may view this situation because of their psychosocial history?

Questions on Consequences

  • If Faduma becomes lightheaded and tachycardic, what would you expect to happen next?  Why?

Prevent Failure to Rescue

I am not insisting that students become clinicians/practioners and diagnose diabetic ketoacidosis in this scenario.

Instead, students must develop a knowledge base that can apply essential content to the bedside so that they recognize relevant clinical data and a potential problem even if they are unable to specifically identify what it may be and communicate the concern to the primary care provider.

Students must develop a sense of salience each time they come in contact with their patient because the status could change anytime. Nurses will not always have the luxury of a clinical diagnosis and labs to support identification of the primary medical problem.

This is the level of thinking that new nurses are expected to have acquired in school in order to be safe in practice.

Now is the time to prepare your students to rescue so they do not “fail to rescue” when a change in patient status goes unrecognized until it is too late (Clarke & Aiken, 2013).

In Closing

The most important skill that your students must be proficient in before they graduate is the ability to think like a nurse.

Socratic questions can be used to evaluate critical thinking and deepen and strengthen the reasoning and assumptions a student may have to identify if they are on the right or wrong clinical path.

Just like in simulation when a student makes an incorrect assumption and the patient will deteriorate and may even code, by integrating Socratic questions through the use of simple clinical scenarios, students can obtain the practice needed to become proficient with this essential nurse thinking skill.

If this is a weakness in your program, make it a strength by simply changing the way you teach by utilizing Socratic questions in the class and clinical settings.

By evaluating critical thinking, you can be confident that after graduation your students can think like a nurse and be well prepared for professional practice!

What do you think?
How do you use questions to develop the thinking of nursing students in your class or clinical settings?
Comment below and let the conversation begin!

References

  • Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass.
  • Clarke, S.P. & Aiken, L.H. (2003). Failure to rescue. American Journal of Nursing, 103, 42-47.
  • Oermann, M. (1997). Evaluating critical thinking in clinical practice. Nurse Educator, 22(5), 25-28.

Want More?

Today’s blog was derived from my upcoming book for nurse educators TRANSFORMING Nursing Education: Practical Strategies to Prepare Students for Professional Practice.

My manuscript is being finalized and will be published in 2017.

Download my table of contents, and introduction and stay in the loop with updates and pre-publication $$$ discounts!

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