NLN Guide to Teaching Thinking
The National League for Nursing will publish a monograph titled The NLN Guide to Teaching Thinking in 2017. The guide is a response to the call to action for nurse educators outlined in the NLN vision statement "Debriefing Across the Curriculum" (written in collaboration with INASCL, International Association for Clinical Simulation and Learning). This vision statement encourages nurse educators to let go of their long-held assumptions and reframe how they see the teaching/learning process and the student-teacher relationship. The challenge is to shift the emphasis from depositing content into passive learners to using content in realistic settings. Here we briefly describe three concepts outlined in the NLN Guide for Teaching Thinking: context, content, and course. Figure 1 outlines these concepts in terms of questions for the learner and directions for the educator or guide.
Recent advances in theory-based debriefing methods used in simulation (Dreifuerst, 2012; Eppich & Cheng, 2015; O'Donnell et al., 2009; Rudolph, Simon, Dufresne, & Raemer, 2006) illustrate the value critical conversations have on the teaching/learning process. The theoretical underpinnings of these debriefing methods have at their core an emphasis on being critical, that is, the ability to examine and share perspectives (Freire, 1970). It is a process of assessing what is relevant and determining the reasons for our actions.
The NLN Guide for Teaching Thinking captures this critical core. The guide provides a structure that educators can use in conversations to guide students to discern what is meaningful and relevant and use their knowledge to work through the problems of nursing practice.
Context
Being critical incorporates the complexities of context (Brookfield, 2000; Mezirow, 2000). Context is defined as the nature of the world in a given moment. Culture, facts, ideals, concepts, rules, principles, and underlying assumptions all shape how we construct knowledge. Argyris and Schon (Argyris, 1992; Argyris & Schon, 1974; Schon, 1983, 1987) suggest that context impacts the knowledge we use and how we interpret our actions and the actions of others. In order to understand the context of a situation, the dialogue must first focus on what is known, seen, and/or heard. Focusing the conversation on objective, observable data gives educators and learners a way to examine any underlying assumptions at play that may color the lens through which data and knowledge are seen and used.
Critical conversations begin with context. This is illustrated in the guide by first having our learners describe the patient care story. Asking "Who is the patient? What are your main concerns?" helps learners uncover their thinking and emotions to highlight important features that make up the context. These contextual elements lay the foundation to further explore the learner's thinking and knowledge (Forneris, 2004).
Content
Having established the important contextual elements, the next phase of the critical conversation focuses on content. In this phase, the teacher and the learner seek to understand each other's perspective. Importantly, the influence of the learner's perspective on decision-making is explored. This exploration seeks to uncover factors that may have influenced decisions, such as past learning, past experiences, knowledge, values, goals, and assumptions. In Kolb's (1984) experiential learning cycle, this phase of the conversation would correlate with "Reflective Observation" and "Abstract Conceptualization." Especially during the conceptualization phase, teachers have the opportunity to assist learners in creating new meaning from the experience. In this way, new knowledge is created that can result in improved practice in the future.
One technique that can be used to begin the exploration of a topic during a critical conversation is pairing advocacy with inquiry. This technique has its roots in the practice of organizational behavior and has been applied to health care simulation debriefing (Cheng et al., 2015; Rudolph et al., 2006; Rudolph, Simon, Raemer, & Eppich 2008). Advocacy includes first stating objective data observed by the teacher (e.g., "Rob, I saw you administer 10 mg of morphine"); the second part of advocacy is stating the thinking the teacher has regarding the action being discussed (e.g., "I am concerned that this is a large dose of morphine, which could have negative hemodynamic or respiratory effects on the patient"). The advocacy is followed by an inquiry into the learner's thought processes (e.g., "I'm wondering, what were your thoughts at the time?").
The advocacy-inquiry questioning technique recognizes that decisions are made for a reason and that understanding the reason is key in understanding why a learner chose a certain course of action (or inaction). It attempts to get at the invisible drivers of actions. It also demonstrates the curiosity of the teacher. Once the conversational door has been opened using advocacy-inquiry, a deeper exploration of the thoughts and actions of the learners can ensue. During this time, the teacher may be able to offer insights into decision-making based on his or her practice.
Course
In closing out the critical conversation, the educator and learner focus on the future. The learning from this experience is applied to future decisions, both short and long term. In an unfolding situation (such as during a class, a clinical day, or in the midst of an ongoing simulation), learners can discuss next immediate steps. For longer-term application, learners are encouraged to discuss how their practice might change going forward as a result of this experience.
A useful cognitive exercise at this point is to have the learner compare this situation to a similar situation - one that presents in the same way on the surface but has different deep structure. This strategy is a valuable constructivist technique that may help learners begin to build cognitive schema for use in subsequent similar situations (Weidman & Baker, 2015). This phase of the critical conversation correlates with Kolb's (1984) "Active Experimentation" phase of the experiential learning cycle, when new learning is applied.
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