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Moving from Memorization to Critical Thinking

Created Aug 01 2019, 03:19 PM by LIPPINCOTT NURSING EDUCATION
  • Critical Thinking

Diana Breed
Mesa Community College
Simulation Coordinator | Nursing

Every nursing school struggles with helping students transition from memorizing information to analyzing a situation for priority actions. For students to develop an overall patient care concept with assessments, interventions, and goals requires complex critical thinking.  When adding the higher level of prioritizing that care, many students and faculty wring their hands in frustration.  It can be incredibly frustrating for students when the “right” answer is “wrong” for a certain patient.  

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As a nursing instructor, I first see this struggle in the skills lab.  In the beginning, students are dressed in their crisp new uniforms, eager to show us what they can do.  Even though they are nervous, it is a type of learning they understand.  Every skill comes with a “skill check-off list”, a video, and even the same equipment for each student.  This learning style is similar to the way they grew up.  You do the same steps at the same time in the same way and you PASS!  

Next, their clinical instructor has them practice the skill in clinical.  They use different equipment and demonstrate the skill a little differently.  Questions start exploding in the student’s head.  How can they learn these new steps?  Is my clinical instructor teaching me a wrong way?  Is the patient going to be okay?  Do I have to buy this different equipment?  Who is going to be checking me off?    A good student heads to the practice lab and has the lab faculty help them --- and then “Oh no, she does it differently too!”

As a seasoned nurse, I am comfortable with the idea that the same skill can be done any number of ways and still be correct.  However, students learning something for the first time often struggle with this ambiguity.  The "memorizing student" wants the skill to equal their early step-by-step learning.  How do we turn the "memorizing student" into an “analyzing student"?

Building on Previous Knowledge

One of the ways to help students start analyzing is to build on previous learning.  Using previous knowledge provides the confidence students need to move to the next learning level, analyzation. This movement can be done in small clinical groups or in larger classroom settings.  Faculty can use the teaching of a skill as a learning method that builds up to critical thinking. The step-by-step process of the skill is the first block in learning. The concrete nature of skills allows the student to add the possible alternative steps (the analyzing) slowly before those alternatives become a “struggle”.   

The first step is to learn the skill in the lab.  You can have students prepare prior to lab in a number of ways.  Since there are many different types of learners, it is best to have multiple forms of learning available.  It is a priority to have a step-by-step written form for students to refer to during video, audio, or even in-class demonstrations.  This method provides the concrete information necessary for step one. 

Building on step one, each student must then document the skill performed in the electronic health care chart.  Using documentation provides students with concrete information about a patient and requires them to move from a “task” to a patient care intervention.  They are not performing a skill in a vacuum, there is a patient who needs consideration during the skill.  Documentation allows a student to practice communicating the important information surrounding a concrete skill. 

Some of the important information they need to consider:

  1. Type/size of equipment
  2. Cleaning technique and type
  3. Patient reaction
  4. Patient education
  5. Results
  6. Do results need to be communicated to the provider or are they “expected”?  This question is a rich discussion related to “abnormal” versus “abnormal for this condition”.

“Curve Balls” and Patient Individuality

Another step for moving students towards critical thinking is to introduce patient individuality into the scenario.  This can be added by including “curve balls” often seen in clinical practice.  Organize students around a patient bed for group discussion with the overall goal on how to adjust our “skill” to safely care for this particular patient. 


  • Two students are performing the skill – they are responsible for gathering supplies, explaining to the patient and family, and assisting with holds and equipment. 
  • Two students are watching for safety - this includes bed position, allergies, reviewing documentation of previous issues, and patient identification. 
  • Two students are watching for infection control - this includes both sterile and aseptic techniques.
  • Two students are documenting – they will be the resource for all students to refer to for any later assignment.  They must include the equipment, procedure, and the discussion between nurses, family and patient, if pertinent.
  • Finally, there are two students who are assigned the patient/family roles – these students are given index cards with feelings and questions to ask during the procedure.  The questions are leveled based on the expertise of the students.  A few examples are – Beginning students: “Why do I need to have this procedure?”  Advanced students: “Are there any alternatives?  What are the pros and cons of this procedure?  What could go wrong?” 

We are all working together to problem solve in a safe learning environment.  Any time patient care is at risk, someone has to speak up and offer an idea for how to change it.  Those students performing the skill can ask for help at any time. 

Curve balls may include:

  1. Inserting a urinary catheter – patient is allergic to betadine, patient can’t open legs during the procedure, family member contaminates the kit
  2. Repositioning the patient – patient has a surgical wound R hip, patient complains of pain during movement, patient has blanched skin that doesn’t return to pink when moved
  3. Central Line dressing change – patient develops difficulty breathing, or bleeding at the site, patient starts to move so they can see the dressing
  4. Intravenous catheter placement – patient's skin is diaphoretic; patient complains of pain during saline flush infusion, patient is allergic to transparent adhesive dressing
  5. Suctioning tracheostomy – the patient continues to cough after suctioning, patient cough out tracheostomy tube, suction catheter clogs

Our students enjoy problem solving in a safe, skills lab environment.  As faculty, we spend many hours helping them perfect these skills.  This type of activity does the double-duty of perfecting the skills and role modeling the constant critical thinking nurses do every shift. 

Adding these patient conditions into the skill practice can be done with the instructor or as an assignment for submission.  It can be done in a skills lab or even as part of a discussion board.  This type of student-patient interaction allows the student to develop their own alternative safe practices.  

This strategy helps to decrease the anxiety students associate with skill check-offs and helps to eliminate the concern with different practices.  By this point, students have moved beyond memorizing the steps to understanding the purpose of each step and how it might be altered.