Article: Debourgh (2008) – Using Clickers to Promote Critical Thinking in Nursing Education

Reference: DeBourgh, G. A. (2008). Use of classroom “clickers” to promote acquisition of advanced reasoning skills. Nurse Education in Practice, 8(2), 76-87.

Summary: Gregory DeBourgh provides a useful introduction to using clickers in nursing education, focusing on pedagogical strategies that use clickers to promote critical thinking.  His exploration of critical thinking in the context of nursing education is particularly interesting.  Here’s a sample:

“Reasoning is about using intellectual power to draw conclusions, form judgments, and make inferences based on evidence, education, and experience… The practical significance of acquiring skill in advanced reasoning is to move to the level of predictive clinical reasoning which enables one to anticipate both ideal and likely outcomes given a set of data.”

DeBourgh argues that using classroom response systems to engage students in high-level questions is an effective strategy for developing their critical thinking skills.  He supports this assertion by drawing on the literature on the roles of feedback and questioning in learning and by sharing concrete examples of clicker uses in nursing education.

Included are three sample questions, including a “one-best-answer” question that asks students to identify the likely cause of a particular symptom shown by a patient in a case study.  DeBourgh endorses the use of such questions since they better represent situations students are likely to encounter in clinical settings where they must deal with ambiguity.  He also suggests asking question sequences based around patient cases that “change the focus to add new variables,” noting that doing so also reduces the cognitive load students experience when familiarizing themselves with a new case.

DeBourgh makes a good argument for using clicker questions to model critical thinking skills for students:

“Anticipate likely incorrect responses and prepare ‘talking points’ for discussion as this facilitates ‘thinking on your feet’ and makes more visible to students how an expert uses heuristics, reasoning, and refined problem-solving skills to gain command of a clinical situation.”

Asking questions designed to provide an opportunity for the instructor to model critical thinking is one instance of many DeBourgh describes of crafting questions to meet particular teaching and learning objectives.  In doing so, DeBourgh draws on articles by Ian Beatty on good question design, transferring Ian’s advice to the context of nursing education.

DeBourgh also points out that clicker questions embedded in PowerPoint can be particularly useful in nursing, a field which frequently uses pictures, diagrams, sound clips, and video–media that can also be embedded in PowerPoint.  He also notes that nursing courses often involve discussion of nursing ethics and student opinions about ethical decisions, topics that lend themselves well to clicker questions.

The article also includes results from a study survey about clicker use.  Student responses to rating questions are summarized, and student responses to open-ended questions are presented, as well.

DeBourgh ends with a few challenges involved in teaching with clickers, two of which are particularly significant.  He notes that since instructors can track student performance in a class on a daily basis, expectations for students are raised, which is not popular with all students.  DeBourgh also speaks to the increased expectations for instructors:

“The greatest challenge is the new role for faculty to plan the curriculum and instruction around ‘deep comprehension’ rather than ‘covering content’ using a traditional lecture format.”

Comments: I read this article in advance of my presentation at the Health Professional Educational Research Symposium earlier in the month, and I was particularly impressed with Gregory DeBourgh’s eloquence in describing critical thinking in the context of nursing education and in describing ways that clicker pedagogies can foster those critical thinking skills.

As I’ve tried to capture above, DeBourgh describes a variety of ways of using clickers in nursing education, and he included one approach that was entirely new to me, one inspired by the 50-50 option in the television game show Who Wants to Be a Millionaire? DeBourgh suggests that before the correct answer to a clicker question is revealed to students, an instructor might ask the students which answer choices should be eliminated.  It’s a little unclear how DeBourgh implements this, but I can even imagine setting up a multiple-mark question with four answer choices, then asking students not to select the one correct answer but to select two incorrect answers.  This would offer a nice change of pace in question format and would help students focus on more than just the correct answer.  It’s often useful for students to consider why some answer choices are plausible on the surface but actually incorrect.

Hopefully it’s also above that DeBourgh puts an emphasis on teaching with case studies (multimedia case studies, at that) in his article.  I understand that case study methods are perhaps more common in nursing than they are in other disciplines, and I appreciated reading this article as a way to better understand why that was the case.  DeBourgh’s comments about using clickers for discussing ethics also helped me better understand the disciplinary context here.

If you’re a nursing educator, please share a thought or two about using clickers in your field in the comments section!

Update: Greg DeBourgh emailed me and clarified his 50-50 technique.  Here’s what he said:

I display the potential four-answers to a given question, then before the students “vote” with their clickers, I ask for a volunteer or select a student at random (my clicker system has this feature) and ask the student to eliminate 2 of the 4 potential answers and to explain why they are eliminating these two. This speaking out loud of their rationale for eliminating two of the potential answers that are not related to the question strengthens the students’ reasoning skills. They actually get quite good at it. If the student I called upon to answer hesitates or is reluctant to speak, I invite them to choose a “consultant” in the room to help them out. I hope this clarifies a bit for you.

I asked Greg what he does if the student eliminates the correct answer.  Here’s his response:

If the student eliminates one of the correct answers, it is still learning, and so I ask “does everyone agree with the 50/50 elimination?” If someone objects, I ask for their rationale. If no one objects, I just let the process go and during the “reveal and rationale” we talk about why each answer is incorrect or correct.

Thanks, Greg, for this clarification, and for this great use of clickers.

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