DOI: https://doi.org/10.21203/rs.2.10772/v1
In the context of modern biopsychology, changing the care model from disease-centered to health-centered holistic care requires nurses the ability to think, judge, and make decisions independently. Therefore, rigorous clinical thinking is especially important. Excellent clinical thinking of nursing not only needs to understand the patient's clinical manifestations and pathophysiology and diagnosis of the disease, but also needs to understand the disease experience of patients and their families and their physical, social, emotional advantages and coping resources, which is one of the main core competencies of nurses [1, 2]. Nowadays, the cultivation of clinical thinking has always been a difficult problem in medical education. The acquisition of clinical thinking is gradually established in the dynamic process of long-term repeated observation, thinking and verification, which is a huge challenge for both students and teachers. In the past, the process of thinking guidance often stems from the cause, and the dominant method of teaching is “infusion” and “stuffing”. In addition, differentiation of textbooks weakens the connection between various disciplines. Moreover, after three years of undergraduate study, the nursing students have acquired a large number of fragmented knowledge and lack the ability to integrate knowledge, so the theory is out of touch with clinical practice. However, with the continuous deepening of teaching reform, various heuristic teaching methods have been applied to nursing teaching, such as project-based learning, case-based teaching, situational teaching, and virtual simulation teaching [3-6]. By optimizing the curriculum, reforming traditional methods and cultivating students' clinical thinking. Cultivate students’ clinical thinking by optimizing curriculum and reforming traditional methods.
With the “flattening” of the global economy in 21st century, reforms in education of STEM (science, technology, engineering, and mathematics) have been particular critical for the economic competitiveness [7]. STEM education has evolved into a meta-discipline, an integrated effort that removes traditional barriers between these subjects, instead focus on innovation and the applied process of designing solutions to complex contextual problems using current tools and technologies [8]. Research indicates using an interdisciplinary or integrated curriculum provides opportunities for more relevant, less fragment, and more stimulating experiences for learners [9]. Now more than ever, students of STEM need to develop for real-world problem [10]. These include leadership, collaboration, and communication and interdisciplinary thinking [11]. Students are encouraged to become active problem solver, display more advanced thinking, and enhance self–awareness and social skills [12]. This coincides with the ideal of cultivation clinical thinking in nursing students. It reported that the application of STEM education concept in European medical education, providing a realistic evidence to carry out STEM education in medical students [13]. Therefore, it is urgent to apply the STEM education concept into the course of nursing clinical thinking training and integrate related disciplines. In addition, nursing undergraduates should master the specialist knowledge of a course combining with multidiscipline knowledge and skills, and improve clinical thinking.
Based on the understanding of the connotation of STEM education and related teaching researches, four important elements were identified that characterize the nature and scope of integrated STEM education: (1) Disciplinary integration, a new vision calls for STEM to be learned and taught in integrated ways with interdisciplinary methods [14]. Integrated STEM education is one way to make learning more connected and relevant for students. Nowadays, the multidisciplinary collaboration model of patient-centered precision medicine has become one of the most operational platforms for integrating medical resources [15, 16]. (2) Interdisciplinary, authentic and contextualized problems. Integrated STEM is bound by STEM practices with an authentic context [17]. Integrated STEM education is an effort to combine interdisciplinary courses into one class that is based on connections between the subjects and real world problem. Clinical cases could be authentic problems that integrate clinical core disciplines. (3) Problem solver and student-centered learning. Students-centered instruction demonstrably improves student learning, attitudes, and retention in many STEM disciplines [18]. Students receiving education in STEM are thought to be capable of thinking logically and utilizing technology independently to solve problems, collaboration and communication skills [14]. (4) Scientific inquiry, prepares students to think and act like real scientists, ask questions, hypothesize, and conduct investigations using standard science practices [17].
2.1 Guidance of Nursing Clinical Thinking Training Curriculum
The guidance or theoretical foundation is the cornerstone of instructional design. This curriculum design is based on the STEM education concept. The STEM education concept advocate placing the core content into interdisciplinary, authentic and contextualized problems (clinical cases), utilizing problem-driven, student-centered teaching methods to support students to acquire clinical practice skills and learn core curriculum, such as Internal Medicine Nursing, Surgical Nursing, Obstetrics and Gynecology Nursing, Pediatric Nursing and so on. By emphasizing the multidisciplinary integrated in the problem-solving process, the STEM education could help students understand the connection between core courses, improve their ability to analyze, judge, make decision, communicate, in order to shorten the distance between nursing education and clinical practice.
2.2 Three Dimensional Objective of Teaching
Teaching objectives are guidance for instructional design. Instruction should have clear objectives that are separate from the means for completing the task, and these objectives also should be thoroughly understood by the teacher and clearly communicated to students. Based on the teaching objective of Nursing Clinical Thinking Training and STEM education, three dimensional objectives of teaching are presupposed that are expected to be achieved.
2.2.1 Pay attention to the cultivation of students’ knowledge and skills
(1) Case-based. Analyzing case and formulating the nursing plan, so as to cultivate students’ critical thinking and improve the ability of clinical nursing problem solving. (2) Nursing procedure as the framework and focusing on human health and humanistic care, we provide patients with high-quality, full-time, and individualized holistic nursing. Apply the prior knowledge and skills to authentic and contextualized problems to ameliorate patients’ health.
2.2.2 Pay attention to the cultivation of students’ process and steps
To satisfy the needs of patients, the main subjects-related cases selected for lectures, task-driven as teaching content, case analysis to develop learning scenarios, so as to inspire students to design nursing interventions via nursing procedures, and strengthen nursing skills based on holistic nursing according to the patients’ condition and needs. Students could be more proficient in nursing skills and comprehensive application and pay attention to health education accompanying penetrating humanistic spirit.
2.2.3 Pay attention to the cultivation of emotional attitude and values
In the STEM education, students must be inspired so that all are motivated to learn STEM subjects so that many of them will be excited to enter STEM fields [19]. Meanwhile, the transtheoretical model indicate students’ attitudes influence “behavioral effects” through “cognition” and “behavioral intentions”[20].
A relatively stable set of operating procedures is at the heart of mature instructional design. The procedures guide the tasks of teacher and student, as well as the items to be completed in each step, which have potential for engaging students. The curriculum design of nursing clinical thinking training based on STEM education concept, which includes six teaching links: writing teaching cases, group discussion, teacher comments, student mutual evaluation, heuristic guidance, and case scenario simulation.
3.1 Written cases
The STEM education advocate placing the core content into interdisciplinary, authentic and contextualized problems [17]. An authentic and interdisciplinary of case scenario, which fully mobilizes the students’ enthusiasm, is the heart of STEM education. Case-based teaching and learning strategies can be utilized to undergraduate nursing students in both obtaining requisite knowledge and enhancing clinical reasoning skills [21].Case-based learning provides for structuring of knowledge in a context-specific ways. The principle of teaching cases preparation is created by the core curriculum teachers based on the curriculum standards, teaching objectives, and students’ prior knowledge level, needs and interests. The preparation of the case includes the following steps. (1) Initial creation of cases. Learning is best accomplished by repeated, deliberate exposures to real cases, that case examples should be selected for their reflection of multiple aspects of clinical reasoning [22]. Written cases can range from a short sketch used to illustrate a theoretical point to elaborate cases, presented in sections, posing questions to help students develop clinical thinking and integrate the theoretical content. (2) Group discussion. The students are particular concerned to practice relevant clinical skills interview simulated patients, follow a logical problem-solving process and have their performed evaluated [23]. Groups discuss and revise on the content logic of the cases, the professionalism of the symptom description, relevant of corresponding knowledge and appropriate of task setting. (3) Cases show. Each group conducts case presentation. Teachers conduct testing on students responses and teaching effects. (4) Case improvement. Make necessary improvements of cases on the feedback from both the teachers and students.
3.2 Group discussion
Formal cooperation learning groups is the main learning strategies in STEM education [24]. Five essential elements to successful implementation of formal cooperation learning group are identified: positive interdependence, face-to-face promotive interaction, individual accountability and personal responsibility, teamwork skills, and group processing [24]. In this session, firstly, students are divided into groups of 6~8 people, then discussing cases in groups with face-to-face promotive interaction, held individually accountable to do their share of the work, and identifying nursing problems of patients in the cases. Furthermore, the main nursing problems could be listed according to the priority of disease, and no less than four nursing interventions for the top nursing problem in the cases on the basis of the preliminary group discussion and guidance of teachers. After a period of critical thinking training, the cases are displayed in the form of clinical nursing rounds (disease introduction, patient condition report, holistic nursing and health education, etc.). In this part, teachers not only need to ensure members of each cooperative learning group discuss whether or to what extent they have met learning goals and maintaining effective working relationship, but also provide them learning support and summarizing students’ obstacles.
3.3 Teacher comments
The importance of focusing on what teachers need to effectively teach STEM education was noted by the National Science Board [25]. Understanding student misconceptions is effective in implementing the integrated STEM education [25]. The preparation of teaching cases requires the highlighting of the core ideal of clinical critical thinking training. Teachers also need to intentionally guide the direction of students’ thinking in the part of group discussion. However, in the practice of teaching, it is essential to set up a special part to clarify obscure knowledge and misconceptions, and bring out accurate nursing diagnosis. For example, if most students choose the correct nursing diagnosis to a case, the faculty member may ask students to reflect on the underlying evidences for their answer and turn to their neighbor group to discuss it. In addition, although students have been exposed to the interdisciplinary connection in the group discussion, teachers are still asked to illustrate the integration of disciplinary of the cases so that students could be aware of fragmentation knowledge integrated. In the future, when they encounter similar cases in clinical practice, they could consciously integrate previous knowledge. Finally, collaborative teaching should be infiltrated into the teaching activities on the basis of the STEM education concept. Courses are taught by more than two teachers with different expertise. Implementation of the teaching is carried out separately. The teaching team could share the teaching plan, but each one is responsible for their respective areas of expertise or skills. The teaching team develops and designs teaching materials and resources for students. Since teachers may have different licensures and backgrounds, it is important for school provide support and time for collaboration.
3.4 Student mutual evaluation
To be successful during STEM learning experiences, students need to be able to move beyond low level cognitive tasks (e.g., recalling facts in isolation) and gain a foundational understanding of the content, which enables high-order thinking skills [26]. Therefore, it is imperative that STEM teachers design engaging curricular materials that offer a wide range of metacognitive and content-specific instructional supports [26]. The nursing clinical thinking is gained by repeated training, which students enable to experience the characteristics of clinical work and complexity of disease. Furthermore, students are able to present nursing diagnosis accurately, gain clinical thinking and deepen understanding prior knowledge from continuous training. In addition, at the whole learning community of the group, the learner is not only the executor of problem solving, but also the observer. During the process of problem solving, they reflect on their understanding of the problem through observing others’ thinking. Each group has sufficient time to show their nursing diagnosis and measures in this session. After the demonstration, students comments on advantages and disadvantages of nursing diagnosis and measures of other groups, and put forward their opinions. The purpose of repeated training clinical thinking is able to be achieved via this process. Teachers observe the students’ ability of understanding and application of prior knowledge, and point out misconceptions in time at this session.
3.5 Heuristic guidance
Katehi and colleagues’ report call for school to adopt engineering “habits of mind” that entail “(a) systems thinking; (b) creativity; (c) optimism; (d) collaboration; (e) communication; and attention to (f) ethical consideration” [27]. This mindset can be incorporated the day to day classroom environment and instructional activities. This session is knowledge-centered which is designed based on an analysis of what we want students to know and be able to do as a result of the learning experience and helps students develop the foundational and enduring knowledge, skills, and attitudes needed for successful transfer of this knowledge [24]. At this part, the lecturer brings out questions and tasks to inspire students to think in order to expand knowledge. The proposed part is on the basis of the clinical nursing knowledge network system and the consideration of knowledge transfer in case study. Students only review several segments of core curriculum through case study, which is not enough to support the understanding the nursing clinical work as a whole. Therefore, teachers need to set up heuristic tasks in the cases to guide students to think and take the initiative to consult relevant information after class. An important issue in case-based learning is that students may not be able to transfer knowledge in a particular context to other cases, unless knowledge from the case are sublimated into abstract principle and guide them to apply flexibly to other cases. Otherwise, knowledge transfer is difficult to occur outside the classroom. In general, this session include the application of knowledge in this case to other case, expanding knowledge and integrating fragmented knowledge.
3.6 Case scenario simulation
The complexity of competencies expected of undergraduate nursing students is continually increasing. Knowledge is central in building these competencies, but knowledge alone is not enough. Knowledge must be organized and utilized in systematic ways and applied to actual clinical situations. Medical simulation has been used to teach critical illness in a variety of settings. Human patient simulation offers a practical assessment method that addresses many evaluation problems [28]. Simulation-based learning can be the way to develop health professionals’ knowledge, skills, and attitudes, whilst protecting patients from unnecessary risks [29]. Simulation are used in five or more courses indicating a trend toward integrating simulation throughout the curriculum [30]. The skills requirement which can be enhanced with the use of simulation include: (1) technical and functional expertise training, (2) problem-solving and decision-making skills, (3) interpersonal and communication skills or team-based competencies [29]. Multidisciplinary teams are the key factor for implementing case scenario simulation. Effective multidisciplinary teams must always have good communications and leadership sharing behavior. At this stage, environmental preparation include simulated ward, bed unit layout, equipment required in the case, role assignment and tasks of students in each scene. Meanwhile, students are asked to be familiar with nursing skills before class. Give a certain period of time for each group to conduct and record of the nursing measures for the top nursing problem in the case, and organize discussion and evaluation timely. Videotaping the role-playing is useful as it can be played back and the highlights shared with the team as part of their learning process. Teachers can point out both the negative and positive practices and behaviors to the participant.
The evaluation of teaching effect adopts the form of formative evaluation, including process evaluation and end-stage evaluation. The process evaluation utilizes multiple evaluation methods, including conduct questionnaire survey before the beginning of the course, one month later and at the end of course to assess students’ the fundamental condition, self-learning and critical thinking. Additionally, the students and instructors are interviewed respectively to master their opinions and suggestions on the instructional design, process and effectiveness. Assessing students in groups creates additional opportunities and challenges for assessing students learning. There are recommendation for faculty who use cooperative learning groups is to design, encourage, and support students’ learning in groups but assess individual learning and performance [24]. The final evaluation is carried out at the end of the course. The groups are required to conduct scenario simulation and shoot video based on cases. The score of test account for 70% of the total score. The rest is formative evaluation, which mainly includes classroom report, scenario simulation and clinical nursing rounds.
We designed the nursing clinical thinking training course for nursing undergraduate nursing, and applied the STEM education concept into the course and integrated the related disciplines. Clinical thinking training teaching model based on STEM education concept may be able to cultivate critical thinking ability of nursing undergraduate students.
Nowadays, there is growing concern that China is not preparing a sufficient number of students, teachers and practitioners in the areas of STEM. Many schools have not established a sound curriculum system. Their STEM courses either launch technological innovations activities or directly copy foreign courses. Improved STEM education is presented as a way forward, and the supply of well qualified teachers is perceived as integral to achieving this vision. However, teachers are only good at their own disciplines, and training is absent. Teachers involve in STEM must take the challenge of learning more about the STEM areas and begin showing students how they are connected. STEM education practice activities mainly integrate nursing skills and core disciplines via solving real-world problems. Disciplinary integration is not simple putting together the core curriculum content. In fact, the knowledge and skills required to solve nursing problem in different cases do not cover all core disciplines. Furthermore, although case scenario simulation could introduce students to integrated learning in the STEM field, the complexities of a practice that run through different STEM objects often bring a huge challenge for students. Therefore, difficulty of cases, knowledge integrated, and nursing skill should be matched with the level of students’ cognitive and psychological acceptance. Meanwhile, the preparation of teaching cases should be on the basis of objective of teaching in nursing undergraduates, combining with prior knowledge and skills, to train their critical thinking. Additionally, the instructors’ strong insight, keen observation and feedback play an important role in the teaching process.
In summary, we attempts to construct nursing clinical thinking training teaching model based on STEM education concept, in order to cultivate critical thinking ability and realize knowledge transfer through STEM curriculum education. In addition, the practice teaching applied by case scenario simulation achieves the connection between STEM education concept and nursing clinical thinking training.
STEM: science, technology, engineering, and mathematics.
Acknowledgments
Not applicable.
Funding
This work was supported by Hubei Education Science Planning Project (2018GA035). The funders did not participant in the study.
Availability of data and material
The raw dataset used in this paper is available on request from the correspond author at [email protected].
Authors’ contributions
FY conceived and designed the experiments. FY and XHZ contributed to the writing of the manuscript. All authors read and approved the final manuscript.
Ethics approval and consent to participate
All individuals provided written consent to participate in this study, which was approved by the Hubei University of Chinese Medicine Research Ethics Committee (2018-IEC-012).
Consent for publication
Not applicable.
Competing interests
The authors declare that there are no conflicts of interests.