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Expressions of critical thinking in role-playingsimulations: comparisons across roles
Peggy A. Ertmer • Johannes Strobel • Xi Cheng •
Xiaojun Chen • Hannah Kim • Larissa Olesova •
Ayesha Sadaf • Annette Tomory
� Springer Science+Business Media, LLC 2010
Abstract The development of critical thinking is crucial in professional edu-
cation to augment the capabilities of pre-professional students. One method for
enhancing critical thinking is participation in role-playing simulation-based sce-
narios where students work together to resolve a potentially real situation. In this
study, undergraduate nursing students were divided into small groups (2–3) to
role-play a medical emergency (stroke) within a high fidelity simulation envi-
ronment. The research team utilized a cross-case comparison design; cases were
defined by the different roles played by the nursing students (e.g., primary nurse,
secondary nurse, and family member). Results indicated that although students in
all three roles displayed instances of reflection, contextual perspective, and logical
reasoning, these were not distributed evenly across roles, with family members
demonstrating fewer instances of reflection and logical reasoning and secondary
nurses demonstrating fewer instances of contextual perspective. However, evi-
dence of students’ abilities to apply clinical standards was observed fairly equally
across all three roles. Implications for the use of role-plays within high-fidelity
simulations are discussed.
Keywords Critical thinking � Simulation � Role playing � Nursing education
Introduction
Educators in professional fields are charged with preparing their students to solve
the kinds of complex problems they will encounter in practice (Stepich et al. 2001).
This is a particularly challenging task due to the lack of fidelity between the
P. A. Ertmer (&) � J. Strobel � X. Cheng � X. Chen � H. Kim � L. Olesova � A. Sadaf � A. Tomory
Purdue University, Beering Hall of Liberal Arts and Education, 100 N. University St.,
West Lafayette, IN 47907-2098, USA
e-mail: [email protected]
123
J Comput High Educ
DOI 10.1007/s12528-010-9030-7
competencies required to be successful in school (e.g., memorizing information) and
those required in the workplace (e.g., solving problems). For example, Dahlgren and
Pramling (1985) described the disconnect that engineers and business administrators
experienced when trying to apply the ‘‘simplistic’’ theories learned in school to the
complex problems encountered in real life. Julian et al. (2000) observed that novice
instructional designers lacked the knowledge needed to apply the systematic design
process learned in their degree programs to solve authentic design problems.
Similarly, in the nursing profession, del Bueno (2005) noted that although new
registered nurses have a vast amount of medical knowledge, they tend to have
difficulty applying it within the clinical environment.
In professional education, critical thinking is considered to be one of the most
important competencies, as it promotes sound judgment (Kulper and Pesut 2004)
and professional accountability (Scheffer and Rubenfeld 2000). According to the
Facione (1990), critical thinking is ‘‘a process of purposeful, self-regulatory
judgment’’ (p. 2). While the general definition of critical thinking is conceptualized
within a cognitive rational model (Hyslop-Marginson and Armstrong 2004),
nursing-specific definitions also contain skills which are affective, emphasizing core
elements of empathy and care such as confidence, intuition, and inquisitiveness, to
name a few (Simpson and Courtney 2002). After conducting a comprehensive
Delphi study, Scheffer and Rubenfeld (2000) proposed a nursing-specific definition
of critical thinking that included seven essential critical thinking ‘‘skills’’
(analyzing, applying standards, discriminating, information seeking, logical
reasoning, predicting, transforming knowledge) and 10 essential ‘‘habits of mind’’
(confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellec-
tual integrity, intuition, open-mindedness, perseverance, reflection). Together, these
skills and habits of mind represent the key competencies expected of today’s
nursing graduates, and moreover, might be considered key competencies of
professionals in other fields (e.g., education, leadership, management) as well.
(Note: see ‘‘Appendix’’ for definitions of each skill and habit.)
To foster critical thinking among nursing students, a comprehensive active
learning approach, involving all of the students’ senses, is suggested (Hoke and
Robbins 2005). As an active learning method, simulations have been heralded as an
effective strategy for facilitating and enhancing critical thinking and subsequently
enabling students to transfer and apply their knowledge in a clinical context
(Bradley 2006; Ruggenberg 2008; Thompson et al. 2006). In general, nursing
simulations tend to revolve around the use of patient simulators, which offer
students the chance to apply their knowledge in real situations without the fear of
hurting patients (Issenberg et al. 2005). According to Bremner et al. (2006), students
using patient simulators improve their self confidence, decision making, and clinical
performance, and become better prepared for their hospital experiences. Simulations
have been shown to enhance communication skills among pre-service nurses
(Nikendei et al. 2005) and to increase students’ motivation and self-regulation
(Jeffries 2007; Mooradian 2008). Additionally, Henneman and Cunningham (2005)
demonstrated that simulations helped students learn from their mistakes while
enabling them to learn from others.
P. A. Ertmer et al.
123
When implementing high-fidelity simulations in nursing education, two key
instructional strategies are recommended in the literature: (a) role play, particularly
with differentiated roles such as primary nurse, secondary nurse, and so on (Jeffries
2005; McNaughton et al. 2008) and (b) debriefings, or guided reflection, about the
simulation process (Bruce et al. 2003).
Role Play. Role play is defined as ‘‘an experiential learning technique with
learners acting out roles in case scenarios to provide targeted practice and feedback
to train skills’’ (Lan et al. 2008, p. 356). In nursing education, roles may include
patient, nurse, family member, other health care professionals, unlicensed assistive
staff members, and/or observer/recorder (Jeffries 2007). The roles are usually
divided into two categories: a response-based role (such as that played by a family
member) with no control over material, and a process-based role (such as that
played by a primary or secondary nurse) with decision-making ability and control
over material. The process-based role requires students to collect and combine
needed information in order to construct conceptual understanding (Jones 2007).
Research supports the idea that using role-play during simulation provides active
learning opportunities that engage both the affective and cognitive processes of the
learner (Jones 2007; Mooradian 2008), however, it remains unclear whether
assuming a process-based role (e.g., primary nurse) leads to better outcomes than a
response-based role (e.g., family member).
Simulation Debriefing. Defined as the purposeful reflection and discussion that
occurs after a simulation (Dreifuerst 2009; Jeffries 2005), debriefings are typically
facilitated by instructors or, less commonly, the students themselves (Switky 2006).
Debriefings, especially when led by instructors, can help students assimilate the
meaning of the learning experience and support the development of critical thinking
by providing insights on students’ interventions, as well as their mistakes.
Moreover, debriefings can promote reflective learning and encourage learners to
discuss how to intervene in complicated situations (Jeffries 2005). Debriefing is also
considered critical to developing students’ abilities to transfer new knowledge to
real-life settings (Childs and Sepples 2006; Dreifuerst 2009; Jeffries 2005).
Purpose
This study was designed to examine how playing a process-versus a response-based
role during high-fidelity nursing simulations influenced students’ expressions of
critical thinking skills and habits of mind. More specifically, the purpose of this
study was to examine how undergraduate nursing students demonstrated critical
thinking during high-fidelity simulations and debriefing sessions, and particularly to
investigate how critical thinking varied across different roles. Our guiding research
questions were:
(1) How are critical thinking skills/habits of mind expressed by undergraduate
nursing students during high-fidelity nursing simulations and debriefings?
(2) How does the expression of these skills and habits of mind compare across
different roles played during the simulation?
Expressions of critical thinking in role-playing simulations
123
Method
We used comparative case study to augment our understanding of critical thinking
during nursing simulations through the development of ‘‘rich contextual evidence’’
(Tsui 2002, p. 742). According to Platt (2007), in comparative case study ‘‘individual’s
characteristics may be used to characterize the group’’ (p. 107). In this study,
comparisons were made across the different roles played in the simulation—primary
nurse (PN), secondary nurse (SN), and family member (FM). Researchers analyzed the
data set for each student, combined instances of critical thinking within roles, and then
compared instances across roles. Qualitative data provided detailed, thick description,
and direct quotations of personal experiences.
Role of researchers
The researchers included two professors and seven PhD students enrolled in an
advanced educational technology research course at a large Mid-western university.
In consultation with two nursing faculty members, the professors and students co-
designed the research questions and procedures and created the debriefing and
interview protocols. Graduate students worked in groups of 2–3 to facilitate two
debriefing sessions each and then each graduate student interviewed two nursing
students the following week. Team members completed an initial analysis of the data
they collected, which was then carefully checked and monitored by their group mates.
Whole-team discussions were held in which emergent themes were presented,
clarified, and revised. For example, specific claims were linked to supporting data,
thus enabling team members to challenge or support initial interpretations and provide
additional or counter evidence.
Participants
There were 164 students enrolled in 23 lab sections of a junior-level Adult NursingCare Clinical course during the 2009 spring semester. Faculty instructors of two lab
sections agreed to allow their students (n = 18) to participate in the simulation
process as a substitute for some of the typical clinical requirements of the course.
However, one student was absent on the day of the simulation. Thus, 17 students
(15 female) voluntarily participated and signed a consent form. Students’ ages ranged
from 20 to 28 years old, with an average age of 22. Of the 17 students, seven had one
previous simulation experience, while one student had two previous experiences.
Participants were randomly divided into six groups. Within each group, students were
assigned the role of a primary nurse, secondary nurse, or family member. The family
member role was missing in one group. Prior to the study, students attended lectures
on content relevant to the simulation (e.g., neuro-vascular systems).
Procedures
The study was embedded within a junior level course in a 4-year nursing
curriculum. Each group of students was assigned a specific time to arrive at the
P. A. Ertmer et al.
123
simulation lab (sim lab). An instructor in the nursing program, responsible for
coordinating sim lab activities, met the students at the appointed time and explained
the procedures. Roles were assigned to group members randomly; primary and
secondary nurses were expected to provide treatment and care to the patient while
family members were expected to accompany the patient and respond from a non-
nursing perspective. Additional roles in the simulation (e.g., physician, pharmacist)
were played by the lab instructor. Students were told that, based on the scenario,
they could contact other professionals (doctors, specialists) to get more patient
information, but they could not ask for additional help from the instructor. The
15-minute simulation was based on a high-fidelity, full-body simulated patient (the
sim-man) suffering from a stroke.
Data collection
The lab instructor followed established video-recording procedures to record each
session. Following a 15-minute role-play simulation, each group was asked to watch
their recorded simulation and to request stops when they wished to record their
thoughts individually. A researcher noted who asked to stop the playback, when the
stop occurred, and what happened at that point. Even if individual group members
had not requested the stop, they were asked to write down their thoughts at each
stop. Collaborative debriefings were conducted after these individual debriefings:
students were invited to openly share their thoughts about the simulation process
using a list of guiding questions. For example, questions related to students’
perceptions of how their actions contributed to the patient’s care, their confidence
playing the various roles, and the extent to which the specific roles influenced their
confidence. An individual interview occurred the following week to clarify
information gained during the individual and collaborative debriefings with a focus
on how the various roles influenced students’ thinking during the process. For
example, students who played a nursing role were asked to describe their decision-
making processes, including the alternatives considered. They were also asked to
describe their interactions with the family member and the extent to which they
included him/her as part of the team. Students who played the family member role
were asked to describe how the nurses involved them in the patient’s care and to
reflect on their own responses to the patient’s distress and their perceptions of the
amount of knowledge gained by playing a non-nursing role. Figure 1 provides an
overview of the data collection procedures.
Data analysis
Interviews (n = 14) and collaborative debriefings (n = 6) were transcribed and
summaries created for each simulation sequence (n = 6). Transcriptions were
examined using a constant comparison method, with specific attention given to
participants’ expressions of the seven critical thinking skills and 10 habits of mind,
outlined by Scheffer and Rubenfeld (2000). Initially, each researcher created a
profile for two participants. Following this, three researchers examined all data
sources to identify and code, deductively, all relevant instances (i.e., a complete
Expressions of critical thinking in role-playing simulations
123
response to an interview or debriefing question) of critical thinking across par-
ticipants, while also linking each instance to the specific nursing role played.
Throughout the coding process, we also employed an inductive approach to identify
emerging categories or themes not included in the original framework. For example,
while Scheffer and Rubenfeld (2000) identified reflection as a habit of mind, we
noted that our participants engaged in a more specific form of reflection—that of
self-evaluation. Thus, self-evaluation was added as a sub-category during our
analysis process.
The use of three researchers to examine the data, first individually and then
collaboratively, helped to establish ‘‘confirmability’’ of our results (Lincoln and
Guba 1985). That is, after each researcher completed individual codings, extensive
discussions were held in order to clarify interpretations and come to consensus.
Patterns were then identified for each critical thinking skill and habit of mind and
comparisons made across nursing roles. A nursing faculty member verified
questionable codes.
Consistency and credibility of research methods
To assure consistency in our research methods, the entire research team participated
in the development of the research instruments; three sub-teams were formed to
draft introductory procedures (including obtaining consent), debriefing guidelines,
and interview protocols. Teams adapted sample questions from the literature
(Rubenfeld and Scheffer 2006). Rough drafts for the debriefing and interview
protocols, emails, and consent forms were then posted and discussed for several
weeks on a threaded discussion board. After reviewing each of these drafts, team
members indicated any needed modifications or corrections. Several revisions to the
texts of the interviews and debriefings were made. Second, a nursing faculty
member provided assistance with the coding process to assure accurate interpre-
tation of students’ comments, relative to specific nursing standards or competencies.
Sequence Step1 Step 2 Step 3 Step 4
Phases
Subject As a group As an individual As a group As an individual
Communication
Method
Writing Talking Talking
Time 15 min 20-25 min 20 min 15-30 min
Data collected Video recordings
Summary
Reflection sheets
Video recordings
Transcripts
Video recordings
Transcripts
Audio recordings
Fig. 1 Data collection procedures
P. A. Ertmer et al.
123
Credibility was gained through triangulation of multiple data sources including
video- and audio-taped recordings of the simulations, debriefings, and interviews.
For each participant, data included (1) the written individual debriefing, (2) the oral
collaborative debriefing, and (3) the interview transcript. Also, the use of multiple
researchers, following a standard protocol, served to eliminate personal bias, thus
ensuring greater credibility. According to Patton (2002), ‘‘the validity, meaning-
fulness, and insights generated from qualitative inquiry have more to do with the
information richness of the cases selected and the observational/analytical
capabilities of the researcher’’ (p. 245). In this study, we employed multiple data
sources and multiple researchers, leading to richer descriptions and thus deeper
understanding.
Results
We examined our data sources for instances of critical thinking skills and habits of
mind. In general, students’ uses of critical thinking clustered around three habits of
mind (reflection, contextual perspective, and confidence) and two skills (e.g.,
applying standards and logical reasoning). While students may have possessed
additional skills and habits, the limited nature of the research task may have
impacted their need to use them. We discuss, in more detail, the nature of the skills
and habits expressed by the students during the simulation, debriefing, and interview
processes.
Critical thinking habits of mind
Reflection. Of the three habits of mind demonstrated by the students, the most
frequently recorded was reflection, which was evidenced by 15 of the 17 students.
Reflection is defined as ‘‘contemplation upon a subject, especially one’s own
assumptions and thinking’’ (Scheffer and Rubenfeld 2000, p. 17). As a habit of
mind, reflection enables students to gain insights into their own thinking for the
purposes of deeper understanding and self-evaluation (Rush et al. 2008).
In this study, reflection was displayed relatively evenly among students in all
three roles. More specifically, every primary nurse (6/6), five of the six secondary
nurses, and four of the five family members showed evidence of reflection. In
general, students reflected on the simulation process as well as the entire learning
experience. For example, in her interview, SN3 (secondary nurse, group 3)
described how the simulation gave her an opportunity to learn by thinking actively
and making decisions about the assessments and treatment. She stated, ‘‘It’s like I
have to actively think about it. Whereas if you are watching it, you aren’t making
decisions so you don’t learn it as well.’’ PN1 reflected on the experience by
considering both his strengths and areas for improvement: ‘‘It definitely showed
where I was lacking and what I need to get better at. It showed … where you will
definitely need to use critical thinking. Everything is not going to be cut and dry.
You actually have to go through the process of thinking what needs to be done,
[and] how it needs to get done.’’
Expressions of critical thinking in role-playing simulations
123
Students in all three roles also engaged in self-evaluation, a form of reflection on-
action (Schon 1983, 1987). Sixty instances of self-evaluation were expressed by 14
of the 17 students and was evenly distributed among the PN (6/6) and SN (5/6)
roles, but with only three instances demonstrated by family members. Because FMs
didn’t actively participate in patient treatment, they tended to evaluate their peers’
actions instead of their own performances. PN2 provides a typical example of self-
evaluation:
… I should have done the assessment very first, you know. I mean, start with
listening to her lungs, getting her vitals done, checking her sensory, checking
her whole body. Instead, I just did a piece … It should have been more fluid.
It’s important to note that students initiated these types of reflective self-
evaluations without any prompting from an instructor. That is, students were able to
make these judgments by reflecting back on what had occurred during the
simulation and comparing that to what they had previously learned, in lecture or
clinical, about how to diagnose and respond to a neuro-vascular emergency.
In general, our findings revealed that both primary and secondary nurses reflected
on the procedures needed to follow up treatment and on their decision-making
processes during the simulation, including when to contact the physician. On the
other hand, FMs reflected on how it felt being family members and what the nurses
could have done to make them feel better.
Contextual perspective. Another frequently observed habit of mind was
contextual perspective, defined as being ‘‘considerate of the whole situation
including relationships, background and environment, relevant to some happening’’
(Rubenfeld and Scheffer 2006, p. 16). In this study, contextual perspective was
observed primarily in the form of perspective-taking. That is, instances of
contextual perspective were noted whenever students were able to either (1) think
like a nurse (or family member) or (2) assume the perspective of more than one
stakeholder in the situation. For example, in our interview with PN1, he assumed
four different perspectives (patient, PN, FM, and SN) to describe how the simulation
unfolded. Furthermore, each perspective (note the bold font within the quote) was
considered in relationship to the entire situation:
Obviously the patient was in distress, and you want to solve the problem as
quickly as possible. And they are complaining about not being able to breathe.
And like in this situation I felt like I (PN) wasn’t going very quickly […]. And
then the family member kind of being worried there […]. And if the othernurse (SN), isn’t, like (trying to think how to word it) if they are not, I guess,
putting input into it, and you feel like you’re kind of controlling everything.
In this study, contextual perspective was demonstrated by 13 of the 17 students
(5/6 PN, 3/6 SN, 5/5 FM). Interestingly, only half of the secondary nurses displayed
this habit of mind, while all five family members did. Differences across roles
suggest that some roles may be more useful in prompting students to consider the
situation from different points of view. For example, only six students (2 PNs, 1 SN,
and 3 FMs) discussed the situation from the patient’s point of view and only seven
of the 12 students who played a nursing role (4 PNs and 3 SNs) considered the
P. A. Ertmer et al.
123
situation from the family member’s point of view. However, all five nursing
students assigned to play the family member discussed the situation from their given
perspective, noting that playing a family member allowed them to ‘‘actually see how
and what actual family members feel’’ (FM3). FM1 stated: ‘‘I learned (about) being
more aware of the family member, realizing that they need to know what is going on
because they don’t understand vital signs. They don’t understand it as well as the
nurses. I think communicating that to the patient or to the family member is
important.’’ In addition, FM6 claimed that playing the family member role helped
her observe the nurse’s role from a different perspective: ‘‘I was able to … look at
things that maybe I’ve been doing, but never noticed until I stepped on the outside
and looked at it from a different perspective.’’
Interestingly, only four students (2 PNs, 1 SN, 1 FM) considered the perspectives
of three or more stakeholders in the situation. Given that contextual perspective is
defined as being considerate of the whole situation, only a small number of students
in this study demonstrated contextual perspective at this level. While this might
have been a function of the role they played in the simulation, it may also have been
a function of the students’ personalities, experience, or maturity. Additional
research, with a larger sample, is needed to examine the relationship between roles
played in a nursing simulation and students’ ability to demonstrate a higher, or more
sophisticated, level of contextual perspective.
Finally, it is important to consider students’ ambivalence, in general, toward the
role of family members in an emergency medical situation. Although six students
described the importance of the family member to the patient’s care (SN2: … ‘‘you
have to remember that you’re not caring for just the patient, but the family member
is kind of your patient too.’’ PN2: ‘‘You treat the patient, you have to treat the
family.’’), others described how family members are likely to get in the way
(n = 3), be hysterical, in shock, and/or ‘‘freak out’’ (n = 1 each). For example,
FM1 noted, ‘‘in a real situation, the family member would be put out of the way.’’
PN3 agreed, ‘‘If it had been a real family member, I would have asked her to wait
outside.’’ PN4 stated that if she were asked to be a family member during a
simulation, it’d be hard to ‘‘act like you don’t know anything.’’ Similarly, FM1
stated, ‘‘Most family members don’t have that insight. They’re pretty much
hysterical and going crazy.’’ In general, the students in this study believed: (1)
family members are not helpful in an emergency situation (they don’t know
anything and can’t do anything to help) and (2) family members are unable to
handle these kinds of situations. The reasons for these perceptions merit further
investigation.
Confidence. During the collaborative debriefing, students were asked to rate, on a
scale from 1 to 100, their levels of confidence. Of the 16 students who responded
with a number, the average rating was 54, with a range from 1 (given by a FM:
I don’t need confidence; I just stood there.) to 90 (also given by a FM: I put 90%because I was a family member … I was pretty comfortable playing that role.). In
general, the PNs rated their confidence at the lowest level (M = 48), while the SNs
and FMs gave fairly equal ratings (M = 58 and 57, respectively). Data from the
interviews and collaborative debriefings suggested fairly equal levels of confidence
among the PNs and SNs, while the FMs provided no additional evidence of
Expressions of critical thinking in role-playing simulations
123
confidence. This suggests that the roles played by nursing students during a nursing
simulation may influence their perceptions of confidence. When asked to play a
secondary role (SN or FM), students tended to feel more confident. However, this
confidence appeared to relate to not having to perform as nurses.
In general, all of the students thought that the role they played influenced their
levels of confidence. Similar to the perception described earlier, students thought
that playing the family member was the easiest because ‘‘you just kind of sit there’’
(PN2). Similarly, playing the secondary nurse was perceived as being less stressful
than the primary role: ‘‘I gave some input on what should be done but I basically let
the primary nurse tell me what I needed to do. Because I was the secondary…I took
advantage of it and let the PN do it’’ (SN1).
The ratings given by the PNs may be a more realistic representation of nursing
students’ confidence at this stage in their careers. Comments made during the
collaborative debriefings and individual interviews support the general conclusion
that the students were not very confident during the simulation, or playing the role
of primary nurses. As SN1 stated, ‘‘We’re definitely not ready for the emergency
room.’’ Given students’ relatively low average ratings of confidence, it is more
accurate to describe students’ expression of this habit of mind in terms of their
confidence playing a specific role, rather than their confidence to perform these
nursing tasks in a real situation. It will be important to examine how students’
confidence grows as they participate in more simulations.
Critical thinking skills
Applying standards. Scheffer and Rubenfeld (2000) defined this skill as making
judgments ‘‘according to established personal, professional, or social rules or
criteria’’ (p. 17). In this study, we counted 45 instances of applying standards,
demonstrated by 11 of the 17 students (4/6 PNs, 4/6 SNs, and 3/5 FMs). More
specifically, students referred to established nursing standards related to diagnosing,
treating, and interacting with the patient. For example, in our interview with SN5,
she described how she applied medical standards related to oxygen saturation levels
to determine how to treat the patient:
… She [the patient] was already on oxygen. She was not breathing correctly,
um, if I remember…she was kind of labored, she was kind of wheezing, like,
she seemed to have difficulty breathing. And like, her SAT [saturation] was
below 90%, and that is not good. They like it to be at least 90, I mean,
obviously the higher the better, but it just wasn’t high enough on a lower
oxygen saturation, so we increased it. I thought it was imperative.
Another common standard that students applied related to their roles as nurses
and what they were allowed to do as nurses. During his interview, PN1 said, ‘‘… in
that situation, I would assume that calling a doctor is the most necessary thing …nothing more could have been accomplished without the doctor’s permission.’’Similarly, PN4 stated, ‘‘I really don’t have any orders. We have to have orders to do
certain things, as a nurse’’.
P. A. Ertmer et al.
123
In general, the primary and secondary nurses applied standards to make clinical
decisions and to treat the patient. PN6 explained how he made his decision to increase
the patient oxygen level: ‘‘… the pulse oximeter shows the oxygen levels in the
patient’s body. So, we know it was at 85 and we thought 91 was good, because 85 wasnot acceptable in the hospital settings.’’ PN2 talked about how she followed a standard
procedure when providing treatment: Question: ‘‘Did you consider any alternatives?’’
Answer: ‘‘With that, not so much. Because it’s been programmed. This is what you do:
this if the [first] step; go to the next one. If it works, you are good [done].’’
In contrast, the family members used standards to judge the situation, their
responsibilities, and the nurses’ performances. For example, during the silent
debriefing, FM6 commented on the nurses’ conduct: ‘‘You can’t get a blood draw
without a doctor’s order. He would need to call the physician.’’ Overall, the students
in all three roles seemed to understand the importance of following a standard
procedure to treat patients and it was clear that the nursing standards influenced the
students’ decisions and performances.
Logical reasoning. Logical reasoning, as defined by Scheffer and Rubenfeld
(2000), refers to the process of ‘‘drawing inferences or conclusions that are
supported or justified by evidence’’ (p. 17). In this study, every student, with the
exception of two family members, demonstrated instances of logical reasoning for a
total of 33 instances: 16 instances by 6 primary nurses, 14 instances by 6 secondary
nurses and 3 instances by 3 family members. The primary and secondary nurses
used logical reasoning skills to judge the situation and make clinical decisions based
on the information they knew. For example, PN1 explained in his interview how he
decided the patient had a stroke:
… the fact that she had the right side of paralysis like this patient did, and the
really high blood pressure and the neuro difficulties, [led] to the decision that
it was a stroke.
SN2 explained how her understanding of the patient’s symptoms led her and the
primary nurse to consider switching their initial treatment approach:
We were talking at one point about giving the patient oxygen because the
patient had presented with stroke symptoms and exacerbation of COPD
[chronic obstructive pulmonary disease] and so the primary nurse and I were
talking about ‘‘Should we increase the oxygen?’’ ‘‘Should we switch from a
nasal cannula to a non-breather mask?’’
Students also used logical reasoning while evaluating their performances. For
example, SN5 said in the collaborative debriefing: ‘‘I think we should have
addressed the family member more. And asked her [the patient] questions, too, and
kept the questions a little bit more simple. Like, since she was having problems with
speech, it should have been more yes/no type of stuff.’’ She also wrote in her silent
debriefing: ‘‘Good move putting client on heart monitor because she has history of
artificial Fib and her blood pressure is high, along with irregular pulse.’’
In general, the students who played primary or secondary nurses demonstrated
more instances of logical reasoning skills than those who played family members.
The family members who displayed this skill noted during the silent debriefing
Expressions of critical thinking in role-playing simulations
123
(n = 2) or an individual interview (n = 2) how the nurses needed to change their
treatment approaches. While this was not something they felt comfortable noting
during the simulation itself, particularly since they were not role-playing a nurse,
they were able to reason through this as they watched the simulation unfold. Thus,
even as nurses playing family members, students were able to gain greater insights
into the specific medical situation—diagnosing the medical condition of the patient
and then reasoning logically to the appropriate medical intervention.
Constraints on the demonstration of critical thinking
Students described constraints that limited the effectiveness of the simulation and
also gave suggestions for improving the experience. Role limitation and lack of
experience with the simulator were two main complaints from the students. For
example, three of the students who played family members described how this role
did not allow them to use their nursing knowledge to actively participate in the
situation, which limited their learning. For example, FM1 said in her interview: ‘‘I
didn’t really get to help provide patient care and what we’ve been working on in our
classes. So, that was kind of frustrating…’’
However, the primary nurses didn’t like having to take the main responsibility for
making life-death decisions during a tense situation. Distinguishing between a
primary and secondary nursing role was perceived as decreasing the potential
collaboration between the two. For example, PN1 stated:
The fact that it was distinguished between a primary and secondary nurse I
think almost may have hindered the team work because the secondary nurse
kind of stayed back and kind of was waiting for what the primary nurse would
tell them to do. If it had just been a nurse and a nurse, both of them would have
been more of a team because neither one of them would have been in complete
control of the situation.
Students in the secondary nursing role also expressed similar sentiments. SN1
stated in her interview: ‘‘The only thing [that would make it better] is taking the
labels off of the nurses. Just have them both be primary nurses.’’ SN2 said in her
interview: ‘‘I felt constrained by the title because I felt like I should be deferring to
the primary nurse. But in a realistic clinical situation it needs to be more of
collaboration.’’
Primary and secondary nurses also mentioned that being unfamiliar with the
simulator restricted their performances. PN4 said in the collaborative debriefing: ‘‘I
think, that if we were able to do this a couple more times that it would have gone a lot
better because we would have just been more familiar with like what was actually
happening, what was going to happen.’’ SN1 expressed similar ideas in her silent
debriefing: ‘‘I would have been better prepared if I knew how all the equipment
worked. I think it may have been better to play around with the Sim man first to know
what to look and listen for.’’ SN2 also mentioned technical difficulties that she had
with the simulation: ‘‘… having things, like our monitors weren’t working properly so
you couldn’t get a blood pressure and just things like that and making sure that every
thing was in perfect working order so that it’s as close to a real situation.’’
P. A. Ertmer et al.
123
In general students identified limitations related to the roles and the simulation
experience and perceived negative effects on their performances and learning.
However, different roles influenced their understanding of the limitations. The
family members focused on the constraint of being unable to actively participate in
the simulation. The primary and secondary nurses paid attention to the unequal
distribution of power and responsibility between the two roles and lack of expe-
rience with the simulator.
Discussion
In this study we examined (1) how critical thinking skills and habits of mind were
expressed by undergraduate nursing students during high-fidelity nursing simula-
tions and debriefings, and (2) how the expression of these skills and habits of mind
compared across different roles played during the simulation. Results suggest that
reflection and contextual perspective, as well as applying standards and logical
reasoning, were displayed more frequently than other habits and skills outlined by
Scheffer and Rubenfeld (2000). Also, playing different roles influenced the
demonstration of these skills and habits.
Critical thinking habits of mind
Reflection. In this study, reflection was observed more frequently among the nursing
students than any other habit of mind or critical thinking skill, and furthermore, was
displayed relatively evenly across roles. While it is not surprising that reflection
occurred during the debriefings, which are designed to be reflective sessions,
reflective moments were also noted during the simulation-action phase itself. Nelson
and Blenkin (2007) noted that role-play simulations engage students in a reflective
and dynamic process that requires them to act, interact, and adjust their actions to
reach their goals. In our study, nursing students tended to break down the procedure
into smaller steps and reflect on the decision-making path during the simulation.
Based on the results of this study, students in all three roles engaged in reflection;
that is, it didn’t seem to matter what role students played, as reflection was
incorporated into each role relatively easily. This result is supported by work of
Nelson and Blenkin (2007) who suggested that role-play enhances student self-
awareness. However, given the small amount of self-evaluation observed among the
students playing family members, it may be important to either give these students
the opportunity to play other roles or to provide specific prompts during the
debriefings that facilitate self-evaluation. Additionally, it may be beneficial to
engage all students in discussions, prior to role-playing, that explicate the specific
responsibilities of each role. This, then, would provide a reference point for
students’ self-evaluations.
Contextual perspective. The majority of students in this study (13/17) demon-
strated contextual perspective, although only a few students (n = 5) were able to
consider three or more perspectives simultaneously. Furthermore, students playing
the primary and secondary roles were less likely to consider the patient’s or family
Expressions of critical thinking in role-playing simulations
123
member’s perspectives during the simulation. That is, only six students considered the
patient’s point of view; three of these six were playing the role of family member.
Perhaps this is not too surprising; for nurses in an emergency situation, the focus is
more immediately on trying to save the patient as opposed to considering how the
patient might be feeling in response to their actions. On the other hand, it might be
expected that a family member would more readily assume the role of patient
advocate during a medical emergency (Soderstrom et al. 2003). The students in this
role appeared to be comfortable discussing how the patient felt in addition to how
they, as family members, felt. As noted earlier, these differences across roles suggest
that a response-based role may be more useful in prompting students to consider the
situation from a non-nursing point of view. This has implications for nursing
educators: asking nursing students to role-play a family member may be one way to
jump-start nursing students’ ability to assume the perspectives of others in an
emergency situation.
By their very nature, simulations enable students to obtain a ‘‘big picture’’ view of a
complex situation (Bremner et al. 2006; Medley and Horne 2004). In contrast, role
plays enable students to delve deeper into a particular perspective, that is, to consider
how the big picture impacts a specific stakeholder (Leininger 1994; Sogunro 2004).
Thus, one of the limitations of a role play is that it may cause students to focus too
heavily on their assigned perspective and miss the opportunity to understand other
perspectives within the situation. In general, the nursing students in this study who
played primary and secondary nursing roles focused the majority of their attention on
their own roles, while students in the family member role typically considered the
perspectives of both themselves and the patient. This is similar to the results of a study
by Leininger (1994) who demonstrated that playing a non-nursing role helped
broaden participants’ insights into other’s perspectives and expectations.
However, this tendency to ignore or discount the family member may not be
unique to nursing students. Based on interviews with nurses in intensive care units
(ICUs), Chesla and Stannard) described a general failure of the nurses to reflect on
the medical situation for the family as a whole (as cited in Soderstrom et al. 2003).
According to Astedt-Kurki et al. (2001), ‘‘interaction between nursing staff, patient,
and significant others is one of the cornerstones of nursing’’ (p. 142). However,
ambivalence regarding the role of family members has been documented during
trauma situations. While the literature suggests that significant others can play an
important role in the patient’s well-being, approximately two-thirds of nurses
surveyed by Astedt-Kurki et al. (n = 51/85) thought that family members, at least to
some extent, complicated their work. Soderstrom et al. (2003) characterized these
two approaches as ‘‘inviting’’ and ‘‘uninviting’’ and provided guidance to enable
nurses in intensive care units to interact in more inviting ways. Some discussion
about these different views and approaches may help students understand how and
when to incorporate family members into a patient’s care.
Confidence. In general, the students in this study were not confident playing the
role of primary nurses during the high-fidelity simulation. Rather, students
expressed fear and a lack of confidence for making clinical decisions; they
described themselves as ‘‘feeling panicked’’ and ‘‘not knowing what to do.’’ In their
study, Haffer and Raingruber (1998) also found that students, who had little to no
P. A. Ertmer et al.
123
experience, expressed fear during clinical reasoning efforts. Similar to the findings
of Nelson and Blenkin (2007), the primary nurses in this study were the most
stressed, due to the responsibilities of their role, which resulted in low self-
confidence. As noted by PN2, ‘‘The simulation makes me more nervous because it
makes me think that I am not a good nurse because I didn’t do well. I think if we had
more (of these), it would be so much better because you can build on that
confidence.’’ Although simulations are designed to increase students’ confidence
(Bremner et al. 2006), this early or first experience was not powerful enough to
make a strong positive impact on students’ initial levels of confidence. Additional
opportunities for students to engage in these kinds of experiences are warranted.
Critical thinking skills
Applying standards. The majority of students in this study (11/17) explicitly referred
to established nursing standards when interacting with the patient and evaluating
their own performances during the simulation. Students seemed to have a fairly
strong understanding of what was required when treating a COPD patient and the
extent to which they could or could not act without a doctor’s orders. Jeffries (2007)
indicated that assigning students different roles during simulations results in
collaboration among participants in order to jointly confirm assessments, make
decisions about interventions, and evaluate outcomes. This was evident in our study
as the primary and secondary nurses recorded vital signs of the patient and
interpreted their assessments based on standardized criteria.
Students in all three roles demonstrated the ability to apply standards. Even
students who played family members had the opportunity to observe and judge their
peers’ actions, based on established criteria. Alinier et al. (2006) noted that
observation is vital for preparing students for emergency situations on the ward or in
recovery. Results of this study confirm that observation of a simulated emergency
situation can positively influence students’ ability to apply standards.
Logical reasoning. Clinical judgment is a complex process, as it is ‘‘an inter-
pretation or conclusion about a patient’s needs, concerns or health problems, and/or
the decision to take action (or not)’’ (Tanner 2006, p. 204). In this study, the students
who played primary or secondary nurses demonstrated more instances of logical
reasoning than those who played family members. This may be attributed to the
expectations and requirements of each role; family members didn’t have as many
opportunities to make decisions and so the potential to observe them reason
logically was limited.
Research results obtained by Cato et al. (2009) suggest that the majority of students
who participate in simulations show an ability to think deeply about the situations they
encounter and are able to assimilate these experiences into their ‘‘broader knowledge
of nursing and the clinical judgment required to practice safely and effectively.’’
(p. 108). According to Bambini et al. (2009), students who participated in simulations
also learned (1) the importance of prioritizing assessment skills, (2) when and how to
intervene, and (3) how to better identify abnormal physical assessment findings. Thus,
by creating scenarios in which students interact as though they are in real medical
environments, students have the opportunity to simultaneously learn valuable lessons
Expressions of critical thinking in role-playing simulations
123
and demonstrate knowledge gained (Fanning and Gaba 2008; Good 2003). This
appears to extend to their ability to apply logical reasoning skills.
In summary, this study confirms and extends prior research on the role of
simulations in professional education, particularly extending our understanding of
how students playing different roles engage in critical thinking during simulations, as
well as during follow-up debriefings. In this study, students demonstrated reflection in
the debriefings, as well as reflective behavior within the simulation. While reflection
was part of all roles, the family member role might have benefited from more guidance.
Similarly, participants in family roles, while applying standards at comparable levels
to their colleagues in primary and secondary nursing roles, demonstrated less logical
reasoning. However, on a positive note, due to the nature of the family role, students
playing this role appeared primed to assume a ‘‘big picture’’ view, thus displaying a
stronger understanding of multiple perspectives than their peers. This suggests that not
all roles contribute equally to the development of an understanding of a complex
situation. As previously reported, high-fidelity simulations are realistic enough to
invoke similar feelings (such as fear and low confidence) as real-life situations, yet are
perceived by students to build confidence with repeated use. Based on the results of
this study, the expression of critical thinking during follow-up debriefings appeared to
be influenced, at least to some extent, by the structure of those debriefings. Educators
might consider using more explicit prompts and scaffolding activities to increase the
likelihood that students will employ additional skills and habits than the relatively few
expressed by the students in this study.
Implications
The results of this research have implications for nursing educators. First, playing a
specific role during the simulation experience allowed students to think and act
accordingly, with different roles, seemingly, calling for the use of different skills
and habits of mind. Allowing students to switch roles may provide important
opportunities for them to assume different perspectives as well as utilize additional
kinds of critical thinking skills. Furthermore, using multiple simulations may help
students become more confident and comfortable working in a variety of emergency
situations.
Second, students were observed to employ critical thinking across the three roles,
including a non-nursing role. Cautiously, this means that employing different roles
during simulations does not necessarily lead to disadvantages for students playing
non-nursing roles. Furthermore, benefits for students may be improved if additional
prompts or guidelines were provided. For example, PNs might be reminded that
other staff (e.g., SNs) and stakeholders (FMs) are a valuable part of the nursing
team; this might remove some of the pressure the students experienced as PNs and
increase their confidence. SNs, too, might benefit from prompts to remind them to
provide support to both the PN and FM. Finally, FMs should be reminded of the
critical role they play in the care of loved ones; they should be reminded that they
are expected to play an active role during these types of simulations.
P. A. Ertmer et al.
123
Students in this study provided important suggestions for improving the
effectiveness of their simulation experiences. At the very least, students suggested
that they be given opportunities to become familiar with the simulation equipment
prior to engaging in emergency scenarios that required them to diagnose and treat a
simulated patient. Alternatively, students might benefit from using a checklist, prior
to engaging with the simulation, to determine if all of the equipment is working
properly. An additional recommendation relates to whether students should be
assigned a specific nursing role (e.g., primary nurse, secondary nurse) to play during
the simulation; students in this study did not feel this was beneficial and suggested
that those in a nursing role not be further categorized as primary or secondary
nurses. This recommendation requires further investigation, as it is not clear if this
poses a real limitation or was just perceived as such by a specific group of students
who were not yet comfortable taking full responsibility for a patient’s care.
Limitations and suggestions for future research
Generalizability of our results is limited, first of all, by a relatively small sample size.
Comparisons among more students playing similar roles or the same student playing
all three roles might help address this. Second, this study examined the expression of
nursing students’ critical thinking during a single 15-minute simulation. Additional
studies involving different types of problems and different contexts might increase
our understanding of the use of critical thinking across a variety of situations. Third,
because the researchers were not nurses or nursing faculty, we were not always
effective when probing for additional information to validate the actions and
responses of the students. Finally, critical thinking is not readily observable. Thus,
the results of this study are based on observing students in a limited action setting
augmented by students’ recall of the thoughts and perceptions they had during the
simulation. Although video recordings of the simulation are useful in stimulating that
recall, it is quite possible that other skills and habits of mind may have been applied
during the simulation but not recalled or described to the researchers. Think-alouds
during the simulation may be one strategy for circumventing this problem, although
the conditions under which the students are responding (an emergency) may make
this a challenging task.
For the most part, students in this study thought that distinguishing between the
two nursing roles was not productive and that the family member was not able to
benefit as readily from the simulation. Future research should examine the benefits
of conducting simulations in which the students all play nursing roles. In addition,
the family member role might be investigated more thoroughly in order to reveal
additional advantages and disadvantages to the development of nursing students’
critical thinking skills and habits of mind.
Conclusion
Learning in school is often criticized as being a low-fidelity representation of the
competencies required by work and daily life (Bransford 1993). That is, students
Expressions of critical thinking in role-playing simulations
123
gain the knowledge needed to answer items on a test but cannot apply that
knowledge to solve relevant problems. This phenomenon, commonly referred to as
‘‘inert knowledge’’ (Whitehead 1929), has often been observed among novice
practitioners. High-fidelity simulations offer a potentially effective tool for engag-
ing critical thinking skills of pre-professional nursing students, prompting them to
think more like seasoned practitioners. As noted by Comer (2005) and Nikendei
et al. (2005), and confirmed by the results of this study, even though the students
play different roles during the simulation and their behavior patterns are very
different, each student still perceives the situation as a nursing student and engages
in critical thinking as afforded by the specific role played. Still, in our research
setting, only a small subset of critical thinking habits of mind (reflection and
contextual perspective) and skills (applying standards and logical reasoning) were
observed during the simulation and follow-up debriefings, suggesting the need for
additional scaffolding. Furthermore, depending on the role, the habits of mind and
skills were employed differently.
While critical thinking is not measurable by observations alone, our research
would indicate that there is a need for simulation scenarios that are developed to
demonstrate other skills and habits of critical thinking, whether through additional
scaffolding or embedded guidance. Additional research is necessary on the use and
design of roles in simulation-based instruction, particularly if playing a response-
based role leads to equal gains in skills and refinement of habits of mind among
participating students.
Acknowledgment The researchers express their sincere gratitude to Dr. Maria Young and Ms. Lyn Nuti
for their guidance in designing and implementing the study, and to the 17 nursing students who willingly
participated. We dedicate this work to our dear friend, Xi. We continue to be inspired by memories of her
great dedication and passion.
Appendix
See Table 1.
Table 1 Definitions of habits of mind and skills of critical thinking in nursing
Habits of mind Skills
Confidence: Assurance of one’s abilities Analyzing: Separating or breaking a whole into
parts to discover their nature, function and
relationships
Contextual perspective: Considerate of the whole
situation, including relationships, background and
environment, relevant to some happening
Applying standards: Judging according to
established personal, professional, or social rules
or criteria
Creativity: Intellectual inventiveness used to
generate, discover, or restructure ideas; imagining
alternatives
Discriminating: Recognizing differences and
similarities among things or situations and
distinguishing carefully as to categorize or rank
Flexibility: Capacity to adapt, accommodate,
modify or change thoughts, ideas, and behaviors
Information seeking: Searching for evidence, facts
or knowledge by identifying relevant sources and
gathering objective, subjective, historical, and
current data from those sources
P. A. Ertmer et al.
123
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Author Biographies
Peggy A. Ertmer is a Professor of Educational Technology at Purdue University and is the co-founder and
current editor of the Interdisciplinary Journal of Problem-based Learning. After graduating with a B.A. in
elementary education and a M.A. in special education-learning disabilities, she received her Ph.D. in 1995
from Purdue University in Instructional Research and Design. Dr. Ertmer’s scholarship focuses on the
impact that student-centered instructional approaches and strategies have on learning. She is particularly
interested in the impact of case- and problem-based instruction on higher-order thinking skill; the
effectiveness of student-centered, problem-based learning approaches on technology integration; and
strategies for facilitating higher-order thinking and self-regulated learning in online learning environments.
Johannes Strobel is Director of INSPIRE, Institute for P-12 Engineering Research and Learning and
Assistant Professor of Engineering Education & Educational Technology at Purdue University. After
studying philosophy, religious studies and information science at three universities in Germany, he
received his M.Ed. and Ph.D. in Learning Technologies from the University of Missouri-Columbia, USA.
He worked at Concordia University, Montreal before joining Purdue University in 2007. NSF and several
private foundations fund his research. His research and teaching focuses on the intersection between
learning, engineering, the social sciences, and technology, particularly sustainability, designing open-
ended problem/project-based learning environments, social computing/gaming applications for education,
and problem solving in ill-structured/complex domains.
Xi Cheng (1982–2010) was a doctoral student in the Educational Technology program at Purdue
University from 2007 to 2010. She obtained her master’s degree in China, specializing in second
language acquisition. Her research interests included distance learning and online learning for language
and literacy.
Xiaojun Chen is a doctoral student in Educational Technology at Purdue University. Prior to her study at
Purdue, she obtained a Masters of Education in Communication Education and Technology from the
University of Manchester, UK. She worked in higher education and the TV industry after her study in
UK. Her current research interests are technology integration in both formal and informal learning
environments, team learning in undergraduate education, and international development of virtual
collaboration and virtual universities.
Expressions of critical thinking in role-playing simulations
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Hannah Kim is a doctoral student of Educational Technology at Purdue University. Her research
interests include lifelong learning, distance learning, performance support, and adaptive instruction.
Larissa Olesova graduated in English and Literature from Yakutsk State University, Russia, in 1989. In
1994, she joined the General Pedagogy Program at the same university, as a Ph.D. student. She received
the Ph.D. degree in general pedagogy from Yakutsk State University in 1999. From 1989 until now, she is
an Associate Professor in the Department of Foreign Languages in Technical and Natural Sciences at the
same university. Since 2006, she has been a Ph.D. student in Educational Technology at Purdue
University, US. Her research interests are focused on distance education, computer assisted language
learning, and EFL teacher training.
Ayesha Sadaf is a doctoral student in educational technology at Purdue University. She received her
M.Sc. degree in computer graphics technology from Purdue in 2005. Her research interests are focused on
online education, role of emerging technologies in teaching and learning, and instructional design and
development.
Annette Tomory graduated in chemistry education from Purdue University in 2000. She taught high
school chemistry for the next eight years in Indiana while earning her Master’s of Science in Secondary
Education from Purdue University Calumet, awarded in 2006. Currently, she is a graduate student at
Purdue University in West Lafayette in Instructional Design and Educational Technology while
instructing chemistry at Purdue University North Central. Her research interests include international
collaboration and the incorporation of technology into k-12 classrooms.
P. A. Ertmer et al.
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