On the basis of Alfaro Le-Fevre theory, critical thinking has to be a key ingredient in the professional training and part of the job of educators is to work to create openness in a culture where critical thinking has to be an integral part of the workshop [15, 16, 22]. The reality is the moment when the student arrives in a professional situation and faces intense life experience, related to disease, pain, suffering and death of patients and their relatives. In addition, students must react to requirements coming from the institutional environment and a high number of patients and the complexity of critical services. These negative and positive experiences Bonfill et al show the impact in their personality .
The practical training resembles very much, a work environment. Therefore, the implementation of educational strategies searching for critical thinking is highly recommended so as to make a good transition from the academic to the professional world .
The students have been thinking over nursing as a therapeutic relation, a skill that sometimes has not been associated with practice. They debate about critical service humanization, observing deficiencies in emergencies, and contrasting them with the ones in intensive care units, where it seems that humanization has been incorporated . They describe emergencies as a space shared by professionals and patients, with trolleys from patients piling up everywhere in the corridors, depersonalized places without privacy conditions, where patients often stay twenty-four hours. In that context, the respect for intimacy, people’s autonomy, the gestions of emotions, the spirituality and the importance of a proper communication in between patient and professional, are very difficult to apply, due to the physical conditions, the rapid interventions and the urgency of the situation [26–28].
In the context of emergency services, the relation with the family appears as an aspect to be improved. Cohesion and communication from the health team are determining, and it’s stated that to help with patient’s autonomy, it is necessary to work with communications skills, such as empathy, therapeutic relation, and active listening. There are studies [29, 30] that show greater communication skills, and less emotional exhaustion and depersonalization in the professionals of the intensive medicine units, compared to the emergency services. Communication experiences experienced by the students, show the difficulties in applying those skills. For them, that emotional complexity and the gestion of bad news, appear as an important communication barrier in their professional future.
Our results show the risk of an incorrect patient identification, the lack of procedural understanding and the deficiency of resources in certain moments, in personnel and in infrastructure. They are aspects related to the ones that Moure mentions in his study, where he was showing the emotional impact of the professionals when they make a mistake . What is of concern to the students, that impact has been identified with the worry for the mistakes and bad practice, where the complexity of the services (decision making, actuation speed, priority, and prevention) appears as another difficulty in their practice.
Learning, professional knowledge and complexity
The students debate the importance to apply a critical thinking in front of a service that has been defined as complex. Knowledge, nursing competences, techniques, professional experience, actuation efficiency and mainly teamwork, have been presented in the forum, as the necessary factors to carry on with the care of the critical patient in complex units. Jiménez and Montero state that knowledge in critical patient care demands a specific training, effective and efficient competences. They define the emergency care system as complex, due to the fact that it is multidisciplinary, it has hierarchical dependency, their patients are acute, it demands continuous availability, it concerns the whole population and its care is transversal .
Students recognize a set of procedures, in the actuations of the unit professionals: Theorical, practical and experience. They realize about the need of a theorical and specific training base, they show a lack of knowledge although they are satisfied with the level of learning that has been reached. Basically, they are afraid to confront practice with the reality of their knowledge. Zuriguel was also showing in his thesis, that intensive care nurses have a higher level of critical thinking, confirming that this skill is contextual .
On the other hand, Uriarte, Ponce & Bernal stress that knowledge that the student acquires in clinical spaces, reflects a repetitive, mechanical, and cyclic practice. This doesn’t allow that students to reflect about a change in the practice, so that limits their professional development, precisely when the students need greater help and assessment. They say that reflexion and critical thinking are not innate, but they are skills gained by specific learning, ability to adapt and practice . The forum appears as this necessary space for the students, where they can think about their experiences.
Forums with small groups have become a place to share and debate experiences in between colleagues. It is a space to contribute, with a deep reflexion, about the experiences, as the described categories show, allowing that university education to train competent, critical, creative, and thoughtful students.
The general results of the questionnaire give evidence that there is a tendency to a high level of satisfaction in the forum. In agreement with the results from other studies , forum and virtual space have been satisfactorily valued by the students. One can point out that there are some points of disagreement in between groups, concerning the tutor and the perception of the debate contents. These differences lead to thinking that the students’ motivation is crucial for the tool to be correctly used, and to achieve the goal. Buil et al. say that social motivations like the wish to share knowledge and altruism, personal motivations like the recognition of colleagues and teacher, and technological motivations like the use and facility of the platform, develop a key role for the success of the discussion forums .
Regarding the tutor, there are some points that could be improved: To help with a collaboration learning, to contribute with more reference sources, to make individual feedback and to synthesize the contents. Literature  has already put in evidence that one of the greater challenges for teachers proposing a forum, is to encourage the participants and to keep them motivated, giving importance to create ambiences where students can be stimulated.
This motivation comes when what is wanted to debate becomes relevant, proposing friendly and challenging spaces, that create conceptual discussions or cognitive imbalances, so the participant looks for knowledge . So, it is important to highlight the tutor’s role as a person that encourages the platform and creates a secure space. Therefore, the forum becomes a professional and personal grow factor. The fact that it is organized in small groups, helps with the encouragement and motivation of the students to share their experiences.
So, we observe that the implementation of a virtual space with easy access and without timing restrictions, in small groups, where one can share and expose situations associated to the debate, impacts in the accompaniment, and personalizes the supervision of the nursing students in their clinical training. Chang’s study, in between other revised strategies to work in critical thinking, concludes that the forum is a space that allows to interact with a professional. The tutor, that is constantly with them in this learning process, gives security, encouraging reflexion and growing the student . Here is a space to recognize and learn from previous experiences, being a call to the practice which, makes you believe and think about the situations.
Finally, the combination of the dynamized forum with the last seminar, becomes a virtual assistance model, an ICT resource for the interchange of knowledge in between the participants, an educational strategy to incentivise critical thinking in the world of clinical practices which occupies an important part of the academical curriculum, where students often feel alone and do not perceive belonging to a group. The model has helped the student to reach three of the six axis that incorporate the learning results in the clinical training: Axis 1 – Professional values, attitudes, behaviours, and caring ethics; axis 3 – critical, social, logical, and creative thinking; and axis 4 – information and knowledge management. The model has some points to be improved in the role of the motivational tutor, to reach the enthusiasm of the group, facilitating cooperation and collaboration in the learning process. Here we have a tool with great potential, in front of scenarios arising with lock down situations, that will provoke a change in the universal teaching model.
The study is aimed at senior nursing students, which may limit the transfer of results. Although both men and women have been included, the female sex predominates, an aspect that may have influenced the characteristics of interventions. Finally, future studies are needed that can apply the same method in other practice subjects, to be able to compare the level of depth and management of b-learning and to study the impact of the accompanying model in the reduction of secondary stress in clinical practice.