[dropcap]O[/dropcap]ne of the goals of professional programs is to develop students’ critical thinking and problem-solving abilities, however it’s not always easy to create authentic exercises that enable students to practice the kinds of critical thinking skills required by their profession and then demonstrate competency. This is particularly true for those of us teaching online. In this article, we describe a viable, no-cost, and low-tech approach to meeting this instructional challenge.
Our online nurse practitioner program was looking to teach students how to master the professional thinking process required during a clinical patient visit that would allow them to arrive at a correct diagnosis and determine appropriate treatment. In other words, faculty desired to re-create patient visits online and have students play the provider role. We also wanted to use the tools already available to faculty and students to avoid introducing any technological barriers or additional costs. Our solution consisted of creating a series of exercises based on complex unfolding case studies, which we presented to students through the testing tool in the Blackboard course management system (Ribar & Polyakova-Norwood, 2017).
The nature of the exercises: case studies, quizzes, or simulations?
The exercises, which we called Online Patient Visit Simulations, unfold exactly like a patient visit to a clinic that is prompted by a specific health concern or complaint. Before each exercise, students are presented with a brief overview about the patient: reason for the current visit, demographics, and past medical and social history. In preparation for these exercises, students are instructed to review the patient information, read up on the patient’s chief complaint, and think through all possible clinical scenarios.
Although created with a testing tool, these exercises are neither quizzes nor case studies in the traditional sense, in that they do not test student knowledge of course content nor do they ask students to analyze the entire patient case at once. These are simulated online patient visits because:
- Each one is based on an authentic patient scenario, with students assuming the role of health care provider.
- Each question represents a step in the patient-provider encounter and requires decision-making based on analysis and synthesis of available information: students decide what questions to ask of their patient, what systems to examine, what diagnostic tests to order, and so forth.
- Each step adds more information to the scenario. The new information, which would be obtained through the appropriate action taken on the previous step, appears in the question stem. Questions are written in different formats, including multiple choice, short answer, and essay.
- Throughout the exercises, students are asked to describe their thinking processes and provide rationales for clinical decisions.
- To move students through the exercise, questions are presented one at a time and backtracking is not allowed. And just like in real life, there is a time limit.
Faculty inform students of the unique format of these exercises in advance of the assignment. Students are advised to pay close attention to the information provided in the stem of each question and to take notes along the way to assist with making and reviewing clinical decisions. Finally, instructors ask students to schedule their “patient visits” when they will not be interrupted.
While Online Patient Visit Simulations are sufficiently rigorous, they are not designed to be high-stakes assessments of student knowledge or skills. In keeping with current recommendations in the literature on teaching and learning, these are practice exercises that contribute only a small percentage to the course grade (Dunlosky, Rawson, Marsh, Nathan & Willingham, 2013). Furthermore, the online simulations do not replace on-site simulation with standardized patients (actors trained to portray patients) or working with real patients in clinical settings. They are meant to prepare students for these activities by providing a convenient platform for practicing a new professional critical thinking process.
Technology limitation or learning advantage?
An important feature of these exercises is the built-in feedback and self-correction at each step. As mentioned earlier, students answer one question at a time and are expected to take notes as they proceed through the exercise. As they advance to each new question, the information presented in the stem of that question should flow logically from the decisions made during the previous step. If there is a serious break in logic and information flow from one question to the next, it signals an error in clinical judgment. At this point, the student can review their notes, find an error, and adjust their thinking process. In a sense, this becomes a safety mechanism because it keeps everybody on the same trajectory and allows students to self-correct at any step.
The testing tool in Blackboard also enables instructors to provide individual feedback to students when grading their attempts to progress through the patient scenarios. This works well when working with small groups of students but may not be feasible in large classes. One feedback and discussion strategy we used extensively in large online classes was to address questions on the discussion board and record a video with brief comments on the class performance and an overview of the expert approach. A combination of feedback formats should give students opportunities to compare their performance with that of an expert and measure their progress in skill acquisition.
Recommendations for implementation
Over three semesters, student response to Online Patient Visit Simulations has been overwhelmingly positive. Students expressed appreciation for the authenticity and rigor of the exercises, the variety of patient problems included, as well as structure and format of the exercises. Course instructors, too, have been satisfied with the learning outcomes as they noticed improvement in students’ critical thinking skills.
Although we created these exercises specifically for nurse practitioner students, we believe that this approach can be beneficial to students across a variety of disciplines. Course instructors, who know the specific learning needs of their students, can collaborate with instructional designers to adapt teaching methods to specific learning objectives and find appropriate technologies.
For colleagues interested in creating this type of critical thinking exercises, we offer the following suggestions:
- Begin by identifying a decision-making process that unfolds in several steps or stages.
- Define each step, determining what decisions are made and what information is added.
- Create an engaging narrative based on an authentic scenario that requires students to investigate, analyze, and identify solutions to complex problems.
- When writing questions, place the new information in the question stems and make sure that there is a natural and logical progression from one question to the next.
- To involve students in the action, write questions in the second person (e.g. What questions would you ask of the client about …?). Aim to make the exercise “feel real and personal.”
- Role play the exercise with colleagues or graduate assistants and fine-tune the questions as necessary.
- Think through grading and other issues related to online assessments.
- And, finally, determine how to provide feedback.
As our experience shows, with insight, creativity and inter-professional collaboration, it is possible to create simulation-type critical thinking exercises using the tools already included in the old toolbox.
References
Dunlosksy, J., Rawson, K. A., Marsh, E. J., Nathan, M. J., & Willingham, D. T. (2013). Improving students’ learning with effective learning techniques: Promising directions from cognitive and educational psychology.
Psychological Science in the Public Interest,14(1), 4 – 58.
Ribar, A. K. & Polyakova-Norwood, V. (2017). Developing critical thinking skills through online simulations created with Blackboard’s testing tool. In Chen, B., deNoyelles, A., & Thompson, K. (Eds.),
Teaching Online Pedagogical Repository. Orlando, FL: University of Central Florida Center for Distributed Learning. Retrieved from
https://topr.online.ucf.edu/developing-critical-thinking-skills-online-simulations-created-blackboards-testing-tool/.
Alicia K. Ribar is the assistant dean for graduate studies and a clinical associate professor in the University of South Carolina, College of Nursing. Vera Polyakova-Norwood is the director of online learning in the University of South Carolina, College of Nursing. 
