The most valued accomplishment of a well-educated mind is the ability to discern what questions should be asked (Bryant, 1999). This ability to ask (and subsequently answer) significant clinical questions is a learned skill that is developed through instruction and mentoring. According to Rowles and Russo (2009), questioning is a strategy that can be used to promote critical thinking and active learning. Advantages associated with engaging students through use of a questioning strategy include promotion of higher-level problem solving, transfer of learning from the classroom to the clinical setting, increased use of evidence for solving problems, disclosure of underlying assumptions, and enhanced student– faculty interactions (Rowles & Russo, 2009, p. 253).
This strategy also provides students with models for formulating their own subsequent questions. According to Benner, Sutphen, Leonard, and Day (2010), schools of nursing do not adequately use pedagogies of inquiry. The resulting outcome is that beginning-level practitioners demonstrate weak questioning skills, “a situation which hampers their learning over the course of their careers” (Benner et al., 2010, p. 31). The Critical Questions Strategy was developed to provide students with mentored and systematic experiences in answering and asking complex clinical questions.
This instructional strategy was initially implemented with two sections of baccalaureate students enrolled in a senior-level, 15-week clinical nursing course. Each course section met 1 day per week for 7.5 hours. The clinical setting for both sections was a progressive neurological services unit in an acute care facility. The Critical Questions Strategy was introduced to the students during the introductory course meeting. The introduction included review of journal-writing guidelines and the 11 question sets. Rationale for each question set was discussed.
Each week, students responded to three question sets provided by the instructor (Table). All students answered question set 1 each week. After reviewing the patient’s medical record and completing an initial assessment, students selected two additional question sets. Students were encouraged to use multiple sources of evidence to construct their answers. Sources of evidence included information from the literature and data obtained from the medical record and patient assessment. Students were encouraged to discuss question themes and collaborate with members of the health care team, peers, and faculty. Ideally, the goal was to select question sets with relevance to the patient’s situation. Because students were required to respond to question sets 2 through 11 at least one time during the semester, selections toward the end of the semester occasionally focused on secondary client issues. Specific questions from the list were often the focus of individual, group, and clinical conference discussions.
Table: Question Sets from the Critical Questions Strategy in Nursing Education
Question set 1 was assigned every week to help students understand the relationship between professional nursing and desirable patient outcomes. Initially, student responses to question set 1 were superficial. Early in the semester, one student noted that the patient was hospitalized because he had surgery. When asked why the client was receiving 24-hour nursing services in an acute care facility, the student responded, “This was a serious surgery.” When asked to differentiate between serious surgery (resulting in hospitalization) and not so serious surgery (resulting in same-day discharge to home), the student became frustrated and said, “No other instructor asks me questions like this.”
Another common response pattern to question set 1 was a list of client care tasks (dressing changes, administration of intravenous antibiotics, tracheal suctioning, and urinary catheter care). When the student response was limited to tasks, the faculty member explained that nurses, nonprofessional staff, and lay caregivers in other settings are sometimes able to perform these functions. The following question was then asked: “Why does your patient need to be hospitalized in an acute care facility to receive these services?” The faculty member explained that expenses derived from hospitalization and professional nursing care must be justifiable. If the same outcomes can be achieved in a less expensive setting or through services provided by less expensive personnel, then the provision of professional nursing care in an acute care setting is not warranted. As the semester progressed, students caring for a postoperative neurosurgery patient answered this question set by describing the strategies used by professional nurses to minimize or eliminate the incidence of potentially devastating and costly surgical complications.
Although the Critical Questions Strategy challenged students at all levels of ability, the inquiry skills exhibited by students were highly variable. The difference between responses provided by high-performing and low-performing students was considerable. Two question sets posed the most difficulty. Most students were not prepared to complete a nutritional assessment and identify appropriate dietary recommendations (question set 8). Multiple postconferences included topics related to nutritional assessment and interventions. In addition, students had difficulty identifying unique nursing contributions (question set 11). In their search for unique professional contributions, some students redefined for themselves what it means to be a professional nurse.
The Critical Questions Strategy was developed as an instructional tool for a senior-level progressive neurological service experience. Although the question themes are appropriate for many clinical courses, faculty should develop critical questions that best fit specific settings and student learning situations.
Donna B. Konradi, PhD, RN, CNE
University of Indianapolis School of Nursing
- Benner, P., Sutphen, M., Leonard, V. & Day, L. (2010). Educating nurses: A call for radical transformation. Stanford, CT: Jossey-Bass.
- Bryant, D. (1999). Asking the right questions. Ambulatory Child Health, 5, 1.
- Rowles, C. & Russo, B. (2009). Strategies to promote critical thinking and active learning. In Billings, D. & Halstead, J. (Eds.), Teaching in nursing: A guide for faculty (pp. 238–261). St. Louis, MO: Elsevier.
Question Sets from the Critical Questions Strategy in Nursing Education
|Journaling instructions: The following is a list of question sets the instructor may ask during the clinical day. Thorough preparation, reasoning, and judgment will be needed to develop your responses. Formulate a response to question set 1 every week. Next, select two additional question sets that are specifically relevant to your assigned patient’s situation. Record responses to all three question sets in your journal. Your instructor will review journal entries at the end of each weekly clinical experience and provide feedback.
Why is this patient currently hospitalized in an acute care facility? Why is a third-party payor reimbursing for the cost of care in an acute care facility versus home health, outpatient care, or family supervision? What are the two most significant nursing diagnoses for this patient (interventions for these two problems must warrant acute care hospitalization)?
What does the patient and his or her family know about the medical condition? Are their perceptions accurate?
How does the patient and his or her family manage health care at home? Are current health problems related to deficient self-care practices?
What health care problems has this patient previously experienced? Are the current problems related to previous problems (if so, how)?
What is the patient-specific rationale for each medication prescribed? Based on information published in drug references, is the dose a little or a lot? How long has the patient been taking this medication? What does the patient know about this medication? Could this patient safely self-administer (or receive) this medication at home? Is the medication effective? (How do you know—labs? physical assessment data? patient perception?)
Is the patient getting better or getting worse? How do you know (clues include lab profiles, physical assessment changes, or diagnostic study results)? Based on the data, what are the likely 3-month, 6-month, or 1-year outcomes for this patient?
What is the patient-specific rationale for treatment (e.g., tube feedings, catheterization, dressing change, continuous ambulatory peritoneal dialysis)? Could this patient perform the treatment independently at home? If not, what kind of assistance would be needed?
Are the patient’s nutritional needs being met? How is this determined? If the patient’s nutritional needs are not being met, what therapeutic changes might be recommended?
What criteria must be met before the patient can be discharged (to home, rehabilitation, intermediate care facility, hospice, or home health)? When is it likely that the patient may be discharged? Do you think the patient will follow the medical regimen at home (provide rationale for your response)?
Why did you select this patient? What did you do to prepare for this experience (be specific—what references did you read or review)? What did you hope to learn as a result of this experience? Describe the extent to which your learning needs were met.
What unique nursing contribution to patient care did you make or observe? A unique nursing contribution is defined as a contribution that could not have been done by a technician or caring significant other (i.e., requires the knowledge and experience that is acquired through a formal nursing education program).