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Clinical conference started at 2:30 p.m. It is the nursing
students' first day with me at the hospital. I can feel the tension
in the room. They are nervous. They are wondering what this experience
is going to be like. For them the questions are: Will I make it
through tonight? What is this teacher like? Will she be kind to
us or will she intimidate me? Why cannot I remember the drugs
that I looked up last night? and Will I make a mistake? For me
the questions are: "Will these students conduct safe care
tonight?" "How will they react to my questions and my
advice for improvement?" and "Will they stop to think
before they act?" These are questions unheard by each other
but ever present in the minds of the students and teachers as
they start a clinical experience together.
As the students leave the conference room to start their work,
I am organizing myself for the evening. I have done clinicals
many times, but I wonder how I can do it better. I know I must
incorporate methods that will help the students to solve problems,
think critically, and work with patients and staff in a team effort.
But what strategies are the most effective? What strategies do
other nursing educators use to help their students link theory
to practice? I am using cooperative learning in the classroom
and wonder if it will it work in the clinical setting. I wonder
what others are saying about the clinical experience. The following
is a search of the literature for problem solving using journaling,
reflection, and cooperative learning. In ERIC, there are 2,601
citations for critical thinking, for reflection 1,100, for cooperative
learning 2,182, for problem solving 5,357. To narrow the search
further, I used Cumulative Index to Nursing and Allied Health
Literature (CINAHL). The results are critical thinking and nursing
520, reflection and nursing 455, journaling and nursing 15, cooperative
learning and nursing 30, reflection, nursing, and critical thinking
32, cooperative learning and clinical nursing 2, cooperative learning,
reflection, journaling, and nursing 0. After reviewing the abstracts,
I chose the articles that seemed to be appropriate to the purpose
of the research. I then read the articles and identified the authorities
that were mentioned numerous times. The discussion of the various
dialogues will be primarily from nursing and include clinical
teaching, critical thinking, journal writing, reflection, and
cooperative learning.
Clinical Teaching
Clinical learning activities are the "heart" of nursing
programs. They are what shape the student into the professional
nurse. Students spend two-thirds of their time in nursing in clinical
practice. It is crucial that nursing educators understand this
activity. Yet, according to Infante (1981):
clinical learning is the least studied of all nursing education
activities. Many aspects of clinical learning are taken for granted,
and many are rooted in traditionalism or the way it is always
done'. Thus there is ample room for improvementa variety
of strategies can be tested in attempts to use the clinical laboratory
in nursing education to achieve learning outcomes. (p. 16)
Studies regarding clinical learning are often about the student's
perception of what characteristics make a good clinical teacher
(Benor & Leviyof, 1997; Flager, Loper-Powers, & Spitzer,
1988). Benor and Leviyof (1997) found that the students would
like effective teachers to exhibit the following characteristics:
(1) competency; (2) fair evaluation processes; (3) good instructional
skills; (4) good interpersonal relationship; and (5) good personality.
This list is in order of importance to the student.
The second area of study is the structure of clinical time. Using
an experimental design, Infante, Forbes, Houldin, and Naylor (1989)
studied the effects of synchronization of clinical laboratory
experiences with instruction in nursing theory and science and
collaboration of faculty, students, and nurse practitioners. Findings
indicate that students in the experimental group achieved higher
scores on the Mosby Assess Test (a comprehensive examination for
medical-surgical nursing), college laboratory practicum scores,
and grade point averages.
Graham (1995) studied the relationship between critical thinking
and how
time is structured in the clinical setting. There were three groups:
a control group (sophomore nursing students), a group (junior-level
nursing) who spent 5 hours a day for two days in the clinical
setting, and a group (junior-level nursing) who spent 2 hours
on 1 day and 8 hours the next day in the clinical setting. The
Watson-Glaser Critical Thinking Appraisal (WGCTA) form A and form
B was used to assess critical thinking. WGCTA form A was administered
to all three groups at the beginning of the semester and form
B was administered at the end of the semester. There were significant
differences in the groups with the comparison group scoring the
lowest and the 2-hour/8-hour group scoring the highest. Even though
the conclusion was that structuring time in the clinical setting
makes a difference in critical-thinking scores, it is not clear
as to what was happening in the control group or the effect of
using students at different levelssophomore and junior.
Problem Solving
The student stated, The blood pressure of this patient is 200/150.
I rechecked the blood pressure on the opposite arm and it was
180/150. I checked the medication record and there is no order
for antihypertensive medications and he has no history of hypertension.
I told the nurse and she is calling the doctor.
Problems! Students face them from the time they start their clinical
day to the time they leave. They need to be able to use knowledge
from what they have previously learned with the problem-solving
process to come up with the best solutions. Part of clinical teaching
is to assist students to solve problems safely and effectively.
Problem solving, decision making, and critical thinking are often
used interchangeably. According to Klaassens (1992), "problem
solving is the process used to resolve or answer a proposed question
or achieve an answer to a client need" (p. 29). It involves
defining the problem, gathering information, analyzing the information,
developing solutions, making a decision, implementing the decision,
and evaluating the solutions.
Why do college students have difficulty in problem solving? The
answer may lie in the fact that students are not at a cognitive
functioning level to effectively problem solve. Klaassens (1992)
reports that "in spite of the fact that most college courses
require formal reasoning ability, most students are functioning
at a concrete level based on Piaget's stages of cognitive growth.
Estimates vary from 50-80% that some student populations are functioning
at this lower level" (p. 29). According to Piaget's stages
of cognitive development, the adolescent transitions from concrete
operations to formal operation. In formal operations the adolescent
can think in more abstract terms. He or she solves problems by
making hypotheses, testing the hypotheses, and drawing conclusions
(Wong, 1997).
Taylor (1997) showed the difference between nursing students'
problem-solving abilities and the problem-solving abilities of
a registered nurse (RN). The nursing students had difficulty in
recognizing cues that are needed in caring for the patient and
making sound decisions. The author suggested that
in order to improve novice problem-solving abilities in the clinical
arena, real life situations should be used as the education vehicle.
Problem-based learning as the framework for content delivery in
undergraduate courses would address some of the defects identified
by this study, and students should be introduced to the diagnostic
reasoning process as a component of problem-based learning. (p.
336)
There are many models of problem solving that are discussed in
the literature which are deemed helpful in promoting problem solving
and critical thinking. One model is the Personally Perceived Problem
Technique (PPPT) (Russaw, 1997). It is rooted in the inquiry-learning
philosophy of John Dewey. There are four steps to the process:
(1) exploration, (2) idea generation, (3) solution validation,
and (4) evaluation. The tool is helpful to students crystallizing
questions about a clinical situation. Another model is the Paradigm
of Problem Solving (Klaassens, 1992). There are five steps in
this model: (1) scanning, data gathering, (2) formulating goals,
(3) planning, (4) implementation, and (5) evaluation. This model
allows the student to actively collaborate with the client to
solve the problem. Two others are Hypothetic-Deductive Model (HDM)
and Knowledge-Driven Problem-Solving Models (KDPS) (Cholowski
& Chan, 1995). Cholowski and Chan advocate the use of KDPS
because it allows students to bring old knowledge to new knowledge
in the problem-solving process. Students are encouraged to "think
aloud" and to use interactive dialogue with the expert nurse
to help connect nursing knowledge to in order to problem solve.
All of the above models are types of problem-solving models; the
differences lie in who assists the students to problem solve and
with whom they are problem solving. The PPPT is primarily generated
with the help of the teacher. The process involves the teacher
questioning the student at each of the steps so that students
identify their own learning needs. The Paradigm of Problem Solving
is primarily assisting the student to learn to problem solve with
the patient. The student and patient are collaborating together
to solve the problem. Both HDM and KDPS are to assist the student
in self-directed learning. The difference lies in HDM using a
systematic approach and KDPS using the process of categorization.
Knowledge content is interconnected by rational links, getting
the student to connect hypothesized diagnoses with reorganized
clinical data and rearranged knowledge structures.
Three strategies were mentioned in the literature that may assist
problem-solving ability:
1. Concept mapping is used to assist students in organizing the
data about their patient in preparation for caring for them (All
& Havens, 1997).
2. In Patho-flow Diagraming (Reynolds, 1994), the teacher assists
the student to use the nursing process and pathophysiology to
diagram the concepts in relationship to the problems presented.
3. The use of the Taba teaching model, called concept formation,
assists students to become active participants in the thinking
process and not mere by-products of memorization. The teacher
uses signs and symptoms of the patient for whom the student is
caring. With the use of guided questions, the students categorize
and hypothesize to come up with a solution (Malek, 1986).
All three strategies are taught during pre-conference or post-conference
time. All three strategies involve identifying the concepts and
assisting the students in relating characteristics that define
the concepts. These processes assist the student in storing the
information/knowledge when needed. Both Patho-flow diagraming
and concept mapping provide a clearer understanding of the clinical
situation through the use of visual representation. Patho-flow
diagraming is sequential representation. Concept mapping is like
a road map with connecting pathways. Taba uses dialogue between
the teacher and students in the identification of the concepts.
Decision Making
After the students have spent time in pre-conference, the rest
of the time is spent in actual patient care. Students are expected
to apply knowledge from the classroom to the patient. They are
confronted with decision-making opportunities related to nursing
intervention. The faculty make rounds to assist students in problem
solving as well as assessing their progress. The time the faculty
spend with the student does seem to make a difference in clinical
decision making. According to Wang and Blumber (1983), interaction
between students and teacher falls into three equal levels: (1)
1 minute or less; (2) 1-6 minute; and (3) 20 minutes or less.
The less time the faculty spends with the student, the more lower-level
interactions occur. "The results of this study indicate that
students' thinking abilities may not be encouraged by faculty
due to the preponderance of low-level techniques, or that the
students do not have necessary information for clinical decision
making" (p. 149). The implication is that faculty need to
spend more time with students and use higher-level interaction
techniques. But is that possible with the numbers of students
a clinical instructor usually is supervising?
In nursing, decision making is often interchangeable with problem
solving, but they are different. "Solving a problem may require
making a number of decisions and making a decision may involve
solving a number of problems" (Kozier et al., 1995, p. 190).
There are many definitions of clinical decision making. Shamina
(1991) defines clinical decision making as "command of the
knowledge base related to the decision, and the ability to select
and combine facts appropriately from this knowledge base"
(p. 59). She examined the effects of systematically teaching decision
analysis to students. The results showed the nursing students
were able to prioritize clinical interventions in accordance with
clinical experts. They continued to do so after they had been
taught this method.
Tsychikota (1993) "defined clinical decision making as the
formulation of hypotheses and/or the selection of nursing interventions,
and includes the thoughts that precede choice" (p. 389).
In her study, the group that had internal locus of control verbalized
more decision-making elements than those with external locus of
control. Therefore, "the internal subject used significantly
more of complex decision-making processes than did the external
subjects" (p. 394). The researcher suggested
that learning [decision making] can be facilitated by using guided
discussion and research in case studies that are composed of data
sets of varying complexity and degree of ambiguity. In addition,
nurse educators can help students learn how to make decisions
under circumstances that closely reflect actual practice by sharing
personal experience and expertise with them. (p. 396)
Jenks (1993) recognized that a complex activity like clinical
decision making entails multiple patterns of knowing. She used
a qualitative research methodology to gain a practice-based understanding
of clinical decision making. She reported on personal ways of
"knowing." Personal ways of knowing included the patient,
the doctors, and interpersonal relationship with staff. These
affected nurses' clinical decision making. Jenks concluded that
"creating teaching methodologies that recognize the importance
of the multiple patterns of knowing in clinical decision making
could well result in more effective education for clinical practice"
(p. 405).
Critical Thinking
In post-conference, I usually share the definition of critical
thinking suggested by Paul (1993): "Critical thinking is
thinking about your thinking while you are thinking in order to
make your thinking better" (p. 91). It is the one definition
that students seem to understand. It also corresponds with Rubenfield
and Scheffer's (1995) simple formula which helps student nurses
to understand thinking and doing aspects of nursing so that they
can reach their goal of "being a good nurse." "The
patient + you + thinking skills + content knowledge + nursing
process (problem solving) = good nursing" (p. 39).
There does not seem to be agreement about the definition of critical
thinking, but
Facione (1984) states: "Whatever critical thinking'
means, it simply cannot be
allowed to mean anything a person wants, for at that abysmal level
of individualistic relativism, communication breaks down entirely"
(p. 255). Dewey (1933) describes the process of thinking:
Thinking enables us to direct our activities with foresight and
to plan according to end-in-view, or purposes of which we are
aware. It enables us to act in deliberate and intentional fashion
to attain future objects or to come into command of what is now
distant and lacking. By putting the consequences of different
ways and lines of action before the mind, it enables us to know
what we are about when we act. (p. 17)
The Foundation for Critical Thinking (1997) lists the following
that would be helpful in teaching critical thinking.
1. Help students to better produce and assess intellectual work
as well as act more "reasonably" and "effectively"
in the world affairs and personal life. 2. Help students assess
their work and action using intellectual standards essential to
sound reasoning and personal and professional judgment.
3. Help students exercise more skilled and proficient reasoning
and problem solving in a diversity of fields.
4. Help students think more clearly, more accurately, more precisely,
more relevantly, more deeply, more broadly, and more logically.
5. Help students to become lifelong learners with more of the
capacity to deal effectively with a world of accelerating change.
(p. viii)
Critical Thinking in Nursing
The National League for Nursing (NLN) mandates that nursing programs be accountable in assessing critical thinking in nursing education. "The responsibility that nursing faculty feel for ensuring that entry level professionals can make sound professional judgments is grounded ultimately in a concern for health and welfare of the clients and the communities our graduates will serve" (Facione & Facione, 1996b, p. 42). "Nursing ultimately can enhance the quality of their practice by examining their thinking" (Colucciello, 1997, p. 237). Colucciello (1997) found there was a significant difference in critical thinking skills among students at different academic levels.
Critical Thinking in Clinicals
Critical thinking and professional judgment are often used interchangeably,
and Facione and Facione (1996b) explains how they are related.
The scope of critical thinking in the context of professional
judgment in nursing is remarkably broad. Focusing only on critical
thinking in the context of clinical practice is too restrictive.
It underestimates the rich range of professional responsibilities
expected during management and supervision, peer leadership, public
health education, collective bargaining, policy making or membership
on boards regulating professional practice standards. (p. 42)
Heaslip (1996) advocates the use of reflection of the narrative
notes that are written by students in nursing charts. Students
who have the opportunity to reflect on their thought processes
will become independent critical thinkers.
A process called "Critical Thinking Rounds" is used
to practice dialogue with various levels of nurses and students
to enhance critical thinking, decision making, and clinical judgment
of students. Using 6 to 14 people at a time, these rounds can
be conducted in a conference room or at the bedside of the patient
(Schumacher, 1996). Research results were not available at the
time of writing the article.
Alexander and Giguere (1996) paired undergraduate and graduate
students together to facilitate the development of critical thinking
and holistic-intervention competencies. They used a case study
approach and concluded that it is a good teaching tool. Whiteside
(1997) designed a model based on three dimensions of memorysemantic,
episodic, and productive. Their results suggested that critical-
thinking skills can be improved with the use of the model. Perciful
and Nester (1996) used computer-assisted instruction throughout
the clinical experience. The comparison group scored significantly
higher than the control group on assessing, analyzing, and evaluating.
They suggest that computer-assisted instruction can be used to
promote critical thinking.
Reflection and Connecting Theory to Practice
Reflection is a complex process where feelings and thinking are
closely linked. Broussard and Oberleitner (1997) define reflective
thinking "as careful consideration and concentration regarding
one's own thinking" (p. 335). According to Boud et al. (1985),
reflection is "an important human activity in which people
recapture their experience, think about it, mull it over and evaluate
it" (p. 19). Although experience alone does not always produce
learning, reflection and experience together do seem to transform
the learning into knowledge. "Reflective education aims to
help students take each client encounter as unique and constantly
arrive at a new or revised interpretation of the meaning of an
experience" (Wong, 1997, p. 447).
Schön (1991) argues that a reflective practicum can help
form a bridge between the worlds of theory and practice. Although
he talks mostly about professionals using reflection as a part
of practice, reflection can assist students to learn about their
own reality which would help them to link theory they are learning
to clinical experience.
Journaling as Reflective Practice
I enjoyed my clinical experience. I feel that when I am at my
clinicals that I learn the most about nursing. I did a nursing
care plan the way the RNs do in the hospital. I also really enjoyed
my time with my patient. I was nervous when I first greeted her.
I was afraid I wouldn't be able to communicate well with her because
of her shortness of breath, but it wasn't a problem. She let me
glimpse a small part of her life and it was very pleasant (Journal
110, p. 5).
In the past 15 years, journal writing has become popular in nursing
education. It is a strategy used to develop the practitioner of
nursing. It is also believed that it will help bridge the gap
between theory and practice and assist students to think critically.
Hahnemann (1986) advocates the use of journal writing. "We
believe that journal writing has been a valuable tool that encourages
clearer thinking and better learning. Our students are able to
take theory and apply it in their practice. They have the ability
to express their thoughts and feelings in writing" (p. 215).
Facione and Facione (1996a) recognize that journal writing is
a valuable source to of evidence of critical thinking in students.
Self-reports can be a rich source of information about students'
metacognitive reflection as well as their interpretations, evaluations,
and analysis. Student journals structured around questions that
call for reasons as well as opinions and explanation as well as
description can provide qualitative self-report data. . . . They
[journals] invite students to engage in some metacognitive reflection
about their own thinking and provide some evidence of both their
critical thinking skills, and their habits of mind. (pp. 50, 51)
Degazon and Lunney (1995) discuss the purpose of writing in
relationship to the
metacognitive process.
The ability to recognize, analyze and discuss thinking processes,
i.e., metacognition develops as the writer focuses on thinking
processes. Because metacognition is continuously useful as a tool
for self-modification, development of this skill provides a basis
for growth as a thinking professional. Discussions with, and writing
for others expand the pool of viewpoints from which alternative
decisions can be selected. The journal writer should recall one
or more clinical situations as soon as possible after the clinical
day. . . . Timeliness facilitates accuracy in recognizing, analyzing,
evaluating and validating (or refuting) thinking processes that
occur in relation to the situation (s). (pp. 271, 272)
The clinical setting is rich with thinking and problem-solving
activities. Outside of post-conference there is very little opportunity
for the student to discuss these experiences and try to integrate
the knowledge and ideas into their own reality. "Thus, much
of what occurs in practice remains unspoken and unheard. Journals
are a means through which nurses can speak and listen to the voice
of practice" (Holmes, 1997, p. 491).
There are various ways that journals can be used. According to
Seschachari (1994), "the purpose of the instructor-mediated
journal is threefold: to enable students to (1) overcome the fear
of writing, (2) enhance their critical thinking, and (3) raise
their level of discourse within the discipline, so that they merit
higher scores in college-level examinations" (p. 7). Journals
can be used for comparing (looking for similarities and differences),
summarizing reading or activities just performed, for observation,
interpretation of data, criticizing and looking for assumptions,
applying fact and principles to new situations, and decision making
(Zacharias, 1991). Journal writing can be done as personal journals,
dialogue journals, where the student and the teacher maintain
a written dialogue throughout the course, class journals, and
cooperative learning group journals in which group members share
ideas with each other and the teacher (Jacobson, 1989; Reinertsen
& Well, 1993; Tryssenaar, 1995). Landeen, Byrne, and Brown
(1995) explored the use of journals in identifying important issues
facing nursing students when learning in a psychiatric setting.
Their conclusion was that the journal provided the student with
an opportunity to be more self-reflective in his or her practice.
Journal writing does not come without problems. Paterson (1994)
and Zacharias (1991) suggest that journals should have specific
questions or guidelines for students to follow and a climate of
trust. Abegglen and Conger (1997) used journaling as a tool for
critical thinking in a community-health nursing course. They had
to change their criteria so that students would reflect and apply
community-health nursing concepts and principles to practice.
For them, journaling is not just a mere retelling of the experience.
At the end of the quarter they had the students give a self-assessment
after they reread their journals. The students discovered for
themselves how much learning and thinking had taken place.
Dialogue and Reflective Practice
Students engaged in active learning through dialogue retain information
and develop cognitive skill (Gelula, 1997; Rossignol, 1997). Through
the use of dialogue and reflective practice the essence of nursing
practice is facilitated when students and RNs share "therapeutic"
practice together (Schumacher, 1996). Paul (1993) defines dialogical
thinking:
Thinking that involves a dialogue or extended exchange between
different points of view or frames of reference. Students learn
best in dialogical situations, in circumstances in which they
continually express their views to others and try to fit others'
view into their own. (p. 464)
Sedlak (1997) and Wong et al. (1997) discussed the following regarding their findings on dialogue and journal writing. To the researchers, dialogue is a form of reflective conversation. It was found that journal writing and dialogue complemented each other in facilitating student reflection. In the dialogues, the students could share their ideas among peers and gain further insight during the discourse. It was often observed that ideas discussed in dialogue sessions were incorporated in subsequent journal writing. Students expressed the view that the dialogues were stimulating and that they could be exposed to different dimensions in viewing the world.
Questioning
By using questioning, students learn to justify their position
and to support their arguments through logic. Questioning facilitates
critical thinking. It moves the student from passive learning
to an active form of learning (Lambright, 1995; Schoeman, 1997).
Questioning techniques such as teacher high-level questions and
probing questions, elaboration of students' ideas, and students'
participation may serve to encourage and focus student's thinking
in these critical cognitive activities (Rossignol, 1997). Questions
in written form help link prior knowledge with skill acquisition,
decision making, and the release of feelings (Patton et al., 1997).
Cooperative Learning
Cooperative learning goes far back in history. According to Johnson
et al. (1998), cooperative learning is as old as history. A quotation
from Eccl 4:9-12 is used.
Two are better than one, because they have a good reward for toil.
For if they fall, one will lift up his fellow, but woe to him
who is alone when he falls and has not another to lift him up.
. . . And though a man might prevail against one who is alone,
two will withstand him. A threefold cord is not quickly broken.
(p. 1:14)
Throughout history such people as Quintillion, in the first century,
Seneca, a Roman philosopher, and Johanne Comenius (1592-1679)
believed that students could teach each other and they could learn
from each other. Cooperative learning came to the United States
through the founding of the "Lancastrian school" in
the 1800s. This was a model that dominated American education
through the turn of the 20th century. John Dewey promoted cooperative
learning as a part of instruction (Johnson et al., 1998).
The first research study on cooperative learning occurred in 1889.
Since then there have been more than 600 experimental studies
on cooperative learning that considered the competitive versus
cooperative environment in the classroom (Johnson et al., 1994).
The leading research groups in the field of cooperative learning
in the classroom were led by Roger and David Johnson at the University
of Minnesota and Robert Slavin at Johns Hopkins University. Their
results indicated that cooperative learning increases academic
achievement, critical thinking, self-confidence, and cooperative
spirit (Gabbert, Johnson, & Johnson, 1987; Johnson et al.,
1998; Slavin, 1988a,1988b, 1989). Ellis and Fouts (1997) state:
"Cooperative learning is one of the biggest, if not the biggest
education innovation of our time. It has permeated all levels
of teacher training from preservice to inservice" (p. 165).
There continues to be studies at various levels of education as
to the effect of cooperative learning on the individual student's
achievement, thinking, and interpersonal relationships. Slavin
(1989/1990) challenges educators to research how cooperative learning
advances higher-order conceptual learning.
Cooperative Learning in Higher Education
College teaching has been changing. According to Johnson et al.
(1998), faculty should think about the following principles:
1. Knowledge is constructed, discovered, transformed and extended
by students.
2. Students actively construct their own knowledge.
3. Learning is a social enterprise in which students need to interact
with the instructor and classmates.
4. Faculty effort is aimed at developing students' competencies
and talents.
5. Education is a personal transaction among students and between
the faculty and students as they work together.
6. Education is a personal transaction among students and between
the faculty and students as they work together. (pp.1:9-11)
If faculty believe this, then learning should take place within
a cooperative environment.
In their meta-analysis of the use of cooperative learning in college
or adult settings, Johnson, Johnson, et al. (1998) found over
305 studies conducted since 1960 that compared cooperative learning
with individualistic learning on individual achievement. Benefits
and outcomes of cooperative learning included increase academic
success, increase perception of greater social support and establishing
better relationships, personal adjustment to college, and more
positive attitudes towards the college experience. Springer, Stanne,
and Donovan's (1999) meta-analysis of science, mathematics, engineering,
and technology also demonstrates, greater academic achievement,
more favorable attitudes toward learning, and increased persistence
when cooperative learning is used. In my search of the literature
on cooperative learning in higher education the benefits of cooperative
learning are academic achievement (Daley, Onwuegbuzie, Anthony
& Bailey, 1997; Gooden-Jones, 1996; Kim, Cohen, Booske, &
Derry, 1998; Necessary & Whilhite, 1996; Pezeshki, 1998; Rupnow,
1996), decreased anxiety, increased motivation, change in attitudes
(Fitzgerald, Hardin,& Hollingsead, 1997; Hazelbaker, 1997;
Hill & Ross, 1996; McInerney, 1996; Stern, 1996; Watson, 1996),
and greater amount of time discussing in groups (Doran & Klein,
1996; Wathen & Resnick, 1997).
Cooperative Learning in Nursing
Nursing recognizes the use of cooperative learning in the classroom
as a strategy to promote critical thinking and problem solving.
Students taught using problem solving and decision-making skills
with the use of cooperative learning had a better self-perception
of problem solving and decision making than did the students who
were taught using lecture methods (Baumberger-Henry, 1998).
Abegglen and Conger (1997) write of their experience in a Community
Health course where faculty tried to infuse critical thinking
into the curriculum. The authors believe that nursing requires
active learning. "If faculty expect students to think critically,
then students must practice and faculty must role model, and one
way to model critical thinking is through group discussion and
problem solving" (p. 453). The small-group activities remained
consistent throughout the year.
Beck (1995) reported that a "cooperative learning model can
be an effective means of teaching nursing content" (p. 226).
In Beck's (1995) and Thompson and Sheckley's (1997) study on cooperative
learning in the classroom, the students commented that it was
a positive experience and it increased their thinking.
Cooperative Learning in Clinicals
Cooperative learning as a term does not appear in the literature
on clinical activities, but studies with the use of peer collaboration
do appear. The primary purpose for using peer collaboration was
to increase leadership skills, increase collaboration skills,
and to enhance critical thinking. As the result of these experiences,
students discovered that their peers were a good resource of knowledge
and problem solving as well as enhancing each other's technical
skills (Bos, 1998; Ford-Gilboe, Laschinger, Laforet-Fliesser,
Ward-Griffin, & Foran, 1997; Gerace & Sibilano, 1984).
Summary
I learn a lot from my partner. She and I can talk together regarding
the problems that have arisen. I wish every teacher did this.
Clinical experience presents many challenges to the students and
it is important that clinical instructors understand how learning
take place in the clinical setting. Research on clinical learning
supports that good clinical teachers possess characteristics that
are conducive to students learning, and that structured time in
the clinical setting promotes learning and critical thinking.
In order to assist students in the problem-solving process they
face in the hospital setting, teachers need to be aware of the
cognitive level of students and use a variety of strategies that
specifically assist them to build on their knowledge in the problem
solving process.
My review of the literature shows that methods used to promote
critical thinking and reflection in the clinical setting are dialogue,
pairing students, computer-assisted learning and the use of journaling.
The number studies in these areas, however, are small thus leading
to the reason for studying the clinical setting which will be
discussed in chapter 3.