Should the life of a person in an irreversible coma be supported by artificial means? How should we deal with people who have acquired immune deficiency syndrome (AIDS)? Do people who have a painful, terminal illness have a right to end their lives? These questions highlight some of the controversial issues in our society that affect people's health and the role of health care providers. Within these controversial issues one could identify opposing positions, each of which is based on facts. At times, high-quality patient care and equitable health care deh' very may require synthesis of the strong points from opposing positions. Because nursing students may encounter controversial issues during their student clinical experiences as well as in their future professional practice, they need to learn how to deal effectively with controversial issues.
Competence in discussing controversial issues requires skills in discussing opposing viewpoints and ability to reach agreement with people who hold different points of view. This leads educators to search for a teaching strategy that would help students to develop these skills as they learn about controversial issues. Although debate has been used as a teaching strategy when addressing controversial issues, it has some disadvantages. In a debate, students are required to defend opposing positions on an issue but are not required to synthesize the strongest points of both positions. Debating an issue may harden students in their own perspective on the issue and promote a defensive posture that does not facilitate an open-minded approach to an issue, but instead leads to closed-minded adherence to their own point of view and rejection of their opponents' information and reasoning (Johnson & Johnson, 1985, 1989).
Given the importance of developing skills to deal with controversial issues in nursing, it is worthwhile to measure the effectiveness of a teaching strategy designed to develop these skills. This article considers one interactive teaching strategy, namely, structured controversy (Johnson & Johnson, 1979), which may be used to address controversial issues in nursing education. This strategy requires students to argue within small groups both for and against a specific position on a controversial issue and then to identify points of agreement among group members.
Structured controversy is derived conceptually from literature on conflict. Lewin (1948) used the term conflict to indicate mutual hostility. He held that conflict in a group depends largely on contradictory goals of group members, readiness to consider others' points of view, the tension from personal needs, too small a space for movement, and lack of freedom to leave a situation (Lewin, 1948).
Recognizing that he was building on Lewin's work, Deutsch (1973) stated that conflict exists whenever incompatible activities occur. An activity is incompatible with another when it prevents, blocks, interferes with, injures, or in some way makes the second activity less likely to occur. Incompatible activities may originate in one person, between two or more people, or between two or more groups. The greater the cooperative elements within a conflict procedure, the more constructive the conflict (Deutsch, 1973).
This article focuses on structured controversy. According to Johnson and Johnson (1988), structured controversy is a type of academic conflict that exists when one student's ideas, information, conclusions, theories, and opinions are incompatible with those of another and the two seek to reach an agreement. The conflict resides in the attempt of two people to resolve their disagreement (Johnson & Johnson, 1979).
Structured controversy stimulates student involvement in controversial issues. It attempts to develop (a) collaborative skills through working in small groups, (b) constructive conflict management skills through structured controversy discussions, and (c) perspective-taking skills through presentation and discussion of differing perspectives on an issue (Smith, 1984). Structured controversy promotes a high degree of emotional involvement in and commitment to solving the problems on which a group is working (Johnson, Johnson, & Smith, 1986).
A number of research studies conducted in science, engineering, and social studies classes used dependent variables related to the three skills that were dependent variables in the study described in this article. Results of previous research studies indicate that when compared with a no-controversy condition, in which consensus was encouraged and disagreement was discouraged, structured controversy had a positive influence on students' accuracy in perspective-taking (Tjosvold & Johnson, 1977, 1978).
When other studies compared students in nocontroversy conditions with students using structured controversy, students using structured controversy more frequently asked for rationale for arguments, criticized ideas of others, paraphrased others, integrated ideas, and contributed information (Lowry & Johnson, 1981), and more frequently presented rationale for arguments (Smith, Johnson, & Johnson, 1981).
When students engaged in concurrence-seeking (disagreements are avoided and students seek quick consensus in decision-making) were compared with students in individualistic study (work is done independently with no interaction with other students), the students engaging in structured controversy expressed greater interest in learning more about the subject studied (Johnson, Brooker, Stutzman, Hultman, & Johnson, 1985), more frequently presented ideas, presented rationale, paraphrased or summarized, and demonstrated greater perspectivetaking ability (Smith, Johnson, & Johnson, 1981).
When compared with students in a concurrence-seeking condition, students in a structured controversy condition produced higher-quality decisions, judged on complexity of students' analysis of information, synthesis of information, and application of information (Smith, Petersen, Johnson, & Johnson, 1986).
In summary, results of previous research studies indicate that structured controversy is effective in promoting students' perspective-taking skills. Findings of a number of studies indicate that structured controversy promotes skills related to logical arguing and reaching consensus.
The independent variable in this study was structured controversy. The hypothesized process by which structured controversy promotes learning begins when students organize their information and experiences and arrive at a conclusion. Later, during discussions, students realize that their conclusions are being contested by other students who hold different views. They then become uncertain about the correctness of their own ideas, and an internal state of conceptual conflict, or uncertainty, is aroused.
In order to resolve their uncertainty, students search for additional information, unproved reasoning, and a more adequate cognitive perspective. They try to understand their opponents' conclusions and rationale. The cognitive rehearsal of their own position and their attempts to understand their opponents' position result in a reconceptualization of their position. This new level of comprehension is characterized by understanding the opposing perspective, incorporating the opponents* information and reasoning, and changing their own attitude and position if warranted, using higher-level reasoning strategies. This process may be repeated until the differences in students' conclusions have been resolved, a synthesis has been achieved, and an agreement has been reached (Johnson & Johnson, 1988).
When organizing structured controversy, the instructor chooses an issue on which two well-documented opposing positions can be taken. Instructional materials are prepared, including a clear description of the group tasks, the phases of the structured controversy procedure, collaborative skills to be used, the position to be advocated with a summary of key arguments supporting that position, and resource materials. The instructor also structures the controversy with a cooperative context (e.g., group members formulate a final group decision on which they will all receive the same grade) and forms heterogeneous groups of four students to broaden resources and perspectives within groups.
The instructor teaches procedures used in rational argument and monitors students' use of them during the procedure. These procedures include encouraging students to generate ideas, collect and organize relevant information, reason logically, express the perspective of their opponents, and make tentative conclusions based on their current understanding. Then, after opposing teams present their perspectives with rationale and their conclusions, students should ask opponents for proof that their analysis and conclusions are accurate (Johnson & Johnson, 1988).
The instructor conducts the structured controversy procedure, giving students the following instructions:
* Partners plan how to argue effectively for their position, learning as much as possible about that position.
* Each pair of students presents its position forcefully and persuasively to the other pair.
* All four students openly discuss the issue, arguing forcefully and persuasively, mentioning as many facts as possible to support their perspective. Participants are to listen critically to the opposing pair's position, asking them for facts to support their points of view. Then, counterarguments are introduced.
* Pairs reverse perspectives so that the pair who had argued for a position now argues against it. Again, students should argue as persuasively and forcefully as possible, introducing new facts not mentioned by the opposing pair, and elaborating on their previous position, if possible.
* All four group members reach a decision that is supported by facts. The best arguments from both points of view are summarized and rationale is provided. Smallgroup decisions, with rationale, are shared verbally with the entire class and/or are submitted to faculty for a grade that is shared by all group members (Smith, 1984; Johnson & Johnson, 1988). Many of these instructions require students to practice the skills that were the dependent variables in this study.
The three dependent variables in this study were student perceptions of their skills in perspective-taking, logical arguing, and reaching consensus. Perspectivetaking was defined as the ability to understand how a problem or situation appears cognitively and affectively to another person (Johnson & Johnson, 1979). Aspects of structured controversy that are intended to promote students' perspective-taking skills include heterogeneity of the small groups, the instructions given to students to practice perspective-taking skills, and the counterargument of their original position.
Logical arguing was defined as the ability to state facts and relationships when supporting or opposing a position and to identify inaccuracies in opponents' statements. The procedure of structured controversy repeatedly asks that students support or criticize a position with rationale based on facts. During a structured controversy procedure, students' statements and rationale need to be well reasoned and factual in order to be persuasive and to withstand opponents' arguments.
Reaching consensus was defined as the ability to identify points of agreement among small-group members and to formulate a position on which all group members agree. Structured controversy requires students to recognize similarities between positions as well as differences (Johnson & Johnson, 1979). This occurs as students argue and counterargue, and especially as they write a group position with rationale.
These three skills are interrelated, in that both perspective-taking and logical arguing promote reaching consensus among small-group members. Cognitive perspectivetaking ability is central to processes such as communication, problem-solving, and conflict resolution (Johnson & Johnson, 1989). Logical arguing exposes students to their opponents' information and reasoning process, thus identifying strong points and rationale that may influence students when group members reach consensus.
On the basis of results of previous research studies and instructions requiring students to practice skills in perspective-taking, logical arguing, and reaching agreement during structured controversy, it seemed reasonable to expect that structured controversy would promote an increase in these skills. Accordingly, the effects of structured controversy on students' perceptions of these skills were measured within a nursing course in which controversial issues were addressed.
Although the skill in perspective-taking has been measured in previous research studies, the study described in this article expands knowledge about the effects of structured controversy by using logical arguing and reaching consensus as dependent variables. Whereas previous studies using structured controversy addressed environmental, conservation, or engineering issues, this study expands the issues to include health care concerns.
The three controversial issues selected for this study were (a) whether a patient in an irreversible coma should be given nutrition and hydration by artificial means, (b) whether all nurses who provide patient care should be expected to provide care for people with AIDS, and (c) whether a patient in an extremely painful, terminal stage of a disease should be allowed to end his or her Ufe. These issues were chosen because they were considered to be important current issues in professional nursing practice. Also, students' knowledge about considerations (e.g., the Code for Nurses, legal and financial constraints, autonomy, social stigma, and communicability) relevant to decision-making on these issues may be relevant to discussions of other controversial issues that emerge in nursing practice.
The study described below was part of a larger investigation of the effectiveness of structured controversy on knowledge, attitude, and skills used in discussing controversial issues (Pederson, 1990). This study attempted to answer the research question: What is the effect of structured controversy on students' evaluation of their skills in perspective-taking, logical arguing, and reaching consensus with people who hold views different from theirs on controversial issues?
This study used a pretest-posttest design to measure the effectiveness of structured controversy on three skills. Study participants were 51 senior baccalaureate students enrolled in a required nursing course in a midwestern university. This study was conducted within weekly 90-minute class sessions. The subjects' ages ranged from 20 to 48 years, with a mean of 26.5 years. Students' GPA ranged from 2.5 to 4.0 with a mean of 3.02. Forty were basic students; 11 were RNs. This intact class of students was a convenience sample within a course whose content routinely included controversial issues.
Written survey items were used to measure students' perception of their skills in perspective-taking, logical arguing, and reaching consensus. Three items, one measuring each skill, were included in the survey entitled "Controversial Issues in Health Care." This survey also contained 15 items addressing specific controversial issues. Postsurveys following students' second use of structured controversy contained these identical three items. As an example, the item attempting to measure perception of skill in arguing logically was: "When I try to persuade other people about the value of my ideas on an issue, I am able to present logical arguments based on facts." All items used a seven-point Likert-type scale, with responses ranging from not at all to completely.
During the first class session of the course in which this study was conducted, students heard an explanation of the study, signed written consents, and completed the "Con- * troversial Issues in Health Care* survey.
During a class in the fourth week of the quarter, all students enrolled in this course participated in structured controversy on the issue of giving or withholding nutrition and hydration to a described patient. This class was a required ethics component of this course, and, because it used structured controversy as a teaching strategy, it was incorporated into this study.
Another portion of the larger investigation in which this study occurred required random assignment of students to two groups, Group A and Group B, as preparation for a crossover design in which variables of attitude and knowledge would be measured. Results of analyses of variance indicated that these groups were equivalent on variables of age and GPA.
Structured controversy was used by one of these groups on the issue of AIDS, and by the other group on the issue of rational suicide. Thus, all students used structured controversy on the issue of nutrition and hydration. Then, one half of the class used structured controversy on the issue of AIDS, and the other half used structured controversy on the issue of rational suicide. Content on AIDS and rational suicide was alternatively presented by lecture to students not using structured controversy on those topics. All of the structured controversy procedures were implemented as described in a previous article (Pederson, Duckett, Maruyama, & Ryden, 1990).
Students' use of skills in perspective-taking, logical arguing, and reaching consensus was observed and recorded by faculty during all structured controversy procedures. This was done as a condition check, to ensure that students were implementing the structured controversy procedure in a manner consistent with previous research studies. Faculty also evaluated students' written smallgroup reports in which small groups stated the final position on which they had reached consensus, with their rationale.
During the first class session of the course in which this study was conducted, students received both verbal and written information about the general purpose of the investigation in which this study was conducted, surveys involved, the absence of penalties for not participating or dropping out, and benefits of participating. All data were kept confidential and general results of this study were made available to students. This study was approved by the University Committee on the Use of Human Subjects in Research.
A .05 level of significance was used in statistical analysis. Before conducting statistical analysis of data, each respondent was given an identification number. All survey responses were coded according to the respondent's identification number. The numerical value of each response on Likert-type scales was used in data analysis. On each skill item, a higher number indicated a more positive response.
In order to answer the research question of this study, two-factor analyses of variance were done by group on the first and the second measurements on each of the skills in perspective-taking, logical arguing, and reaching consensus. Since students in both groups participated in structured controversy twice, an increase in these skill scores was anticipated for all students.
All 51 students enrolled in this course chose to participate in this study and completed the "Controversial Issues in Health Care* survey that contained the three skills items used as pretest items. Although no student expressed a desire to drop out of this study, due to absenteeism from some class sessions, 48 students completed the posttest skills items. Thus complete sets of pretest and posttest skills scores were obtained from 48 students.
In response to the research question, the Table shows results of two-factor analyses of variance done by group on each of the three skills, pretest and posttest means for the entire class, and group means for each skill. There was a significant positive change in students' perception of their ability on each of the three skills. Interaction was significant only on the skill in reaching consensus. On that skill, posttest responses from Group B students who used structured controversy on the issues of AIDS and nutrition and hydration were more positive about their ability to reach consensus than Group A students who used structured controversy on the issues of rational suicide and nutrition and hydration. The reverse pattern was seen on pretest measures, on which responses from Group A students were more positive about their ability to reach consensus than were responses from Group B students.
Results of Two-Factor Analyses of Variance on Responses to Pretest and Posttest Skills Items
Although these skills were observed to a greater degree in some small groups than in others, all students used phrases indicating their use of these skills. Examples of these phrases were "Is it right that you think that . . . ," "Am I understanding you correctly about . . . ," Tm basing my argument on ... ," "What makes you think that's true?* "So what are we really saying?" and "Can we all agree that ..."
Small-group verbal and written reports stated their group position on which the four members had agreed, with their rationale. Although there was diversity among small-group decisions on each controversial issue, rationale were based on the resources provided.
Students' responses on the first measurement of skills at the beginning of the course were moderately positive, reflecting their perceptions of skills gained prior to their participation in structured controversy. Comparison of responses on the first measurement with responses on the second measurement indicate that participating in two structured controversy sessions had a strong, positive influence on students' skills in perspective-taking, logical arguing, and reaching consensus. This is consistent with findings of previous research studies cited above.
Although students' participation in structured controversy may have increased both their skills in discussing controversy and their perceptions of those skills, it is possible that factors other than structured controversy may have enhanced the change from the first to the second measurement. Students may have had the potential to develop these skills but had not been required to practice them in learning strategies they had used previously. Students may have been motivated to develop these skills by their realization that these skills will be valuable assets when discussing controversial issues they encounter in their professional practice. Also, the second measurement of skills immediately followed their second experience with structured controversy, a time when their awareness of these skills may have been high.
Based on faculty observations during structured controversy procedures, the implementation of structured controversy in this study was judged to be similar to that in previously reported research studies. Confidence in actual change in students' skills is limited by the fact that systematic measurements of these skills were by students' self-report, which may contain error.
It is interesting that interaction was significant on the skill in reaching consensus. The reason that greater change in perception of this skill was seen in students who used structured controversy on the issues of AIDS and nutrition than in students who used structured controversy on the issues of rational suicide and nutrition and hydration may lie in the basic differences between the issues of AIDS and rational suicide. AIDS involves social stigma, cornmunicability, and death, all of which are common to other diseases (e.g., tuberculosis, cancer, and hepatitis), and values concerning these factors have been well integrated into nursing education and socialization.
On the other hand, rational suicide raised the issue of nurses' response to a described patient's autonomy when carrying out the decision to end his or her life. The response of nurses is heavily laden with personal values as well as ethical considerations and professional and legal constraints. There is not unanimous support within nursing for one position on rational suicide, and this issue has traditionally been given little consideration in nursing education. Also, the finality of the effects of a nurse's decision to respect the described person's right to end his life may have contributed to students' difficulty in reaching consensus on that issue.
Participation in this study offered students several benefits. They were given the opportunity to develop and practice their skills in perspective-taking, logical arguing, and reaching consensus. Using structured controversy acquainted students with a model for handling controversy that they can use when dealing with controversial issues in the future. Within their nursing practice, these benefits may enable them to promote high-quality decisionmaking based on facts and synthesis of the strong points from opposing perspectives, thereby improving patient care.
Implications of study results are that future students would benefit in similar ways from using structured controversy and, therefore, this teaching strategy should be included in nursing courses in the future. Because use of this strategy requires considerable preparation time on the part of both students and faculty, it may be wise to use this strategy on only one issue in each of several courses rather than using it on several issues within one course.
Knowledge developed in this study could be used in the future with either students or faculty on controversial issues addressed in this study, as well as other issues such as dealing with nursing students who are HIV-positive, determining the conditions in which a patient should be resuscitated, and allocating nursing resources during a shortage of nurses. It is likely that new controversial issues will arise as technological advances increase the treatment options available to patients and as costcontainment continues to be a pressing concern in health care.
Results of this study indicate a significant positive change in students' perception of their skills in perspectivetaking, logical arguing, and reaching consensus after using structured controversy twice. These findings support expanded use of structured controversy as a teaching strategy in nursing education. Controversial issues that affect the health of the general public and the practice of nursing need to be included in nursing education. Structured controversy is one teaching strategy that educators can use to prepare students to address these controversies effectively. Empowering nursing students to deal constructively with controversial issues can enhance the quality of their nursing care and their contribution to the profession and the community, and may lead to the resolution of conflicts that permeate our society.
- Deutsch, M. (1973). The resolution of conflict. New Haven: Yale University Press.
- Johnson, D.W., & Johnson, R.T. (1979). Conflict in the classroom: Controversy and learning. Review of Educational Research, 49, 51-70.
- Johnson, D.W., & Johnson, R.T. (1985). Classroom conflict: Controversy versus debate in learning groups. American Educational Research Journal, 22, 237-256.
- Johnson, D.W., & Johnson, R.T. (1988). Critical thinking through structured controversy. Educational Leadership, 45(8), 58-63.
- Johnson, D.W., & Johnson, K-T. (1989). Cooperation and competition: Theory and research. Edina, MN: Interaction Book Company.
- Johnson, D.W., Johnson, R.T., & Smith, K. (1986). Academic conflict among students: Controversy and learning. In R. Feldman (Ed.), The social psychology of education. Cambridge, MA: Cambridge University Press.
- Johnson, R.T., Brooker, C-, Stutzman, J., Hultman, D., & Johnson, D.W. (1985). The effects of controversy, concurrence seeking, and individualistic learning on achievement and attitude change. Journal of Research in Science Teaching, 22, 197-205.
- Lewin, K. (1948). Resolving social conflicts. New !fork: Harper and Brothers.
- Lowry, N., & Johnson, D.W. (1981). Effects of controversy on epistemic curiosity, achievement, and attitudes. The Journal of Social Psychology, 115, 31-43.
- Pederson, C. (1990). Comparison of structured controversy with lecture in nursing education. Dissertation Abstracts International, 51, 2289B (University Microfilms No. 90-27, 358).
- Pederson, C., Duckett, L., Maruyama, G., & Ryden, M. (1990). Using structured controversy to promote ethical decision making. Journal of Nursing Education, 29, 150-157.
- Smith, K. (1984) Structured controversy. Engineering Education, 2, 306-309.
- Smith, K-, Johnson, D.W., & Johnson, R. (1981). Can conflict be constructive? Controversy vs. concurrence-seeking in learning groups. Journal of Educational Psychology, 73, 651-663.
- Smith, K, Petersen, R., Johnson, D.W., & Johnson, R. (1986). The effects of controversy and concurrence seeking on effective decision making. Journal of Social Psychology, 126, 237-248.
- Tjosvold, D., & Johnson, D.W. (1977). Effects of controversy on cognitive perspective-taking. Journal of Educational Psychology, 69, 679-685.
- Tjosvold, D-, & Johnson, D.W. (1978). Controversy within a cooperative or competitive context and cognitive perspectivetaking. Contemporary Educational Psychology, 3, 376-386.
Results of Two-Factor Analyses of Variance on Responses to Pretest and Posttest Skills Items