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ENHANCING HIGHER ORDER THINKING
SKILLS THROUGH CLINICAL SIMULATION
1
Elengovan Varutharaju &
Nagendralingan Ratnavadivel
1,2
Faculty of Education and Human Development
Universiti Pendidikan Sultan Idris
http://mjli.uum.edu.my/
2
1
Corresponding author: elengovanv@gmail.com
ABSTRACT
Purpose – The study aimed to explore, describe and analyse the
design and implementation of clinical simulation as a pedagogical
tool in bridging the deficiency of higher order thinking skills
among para-medical students, and to make recommendations on
incorporating clinical simulation as a pedagogical tool to enhance
thinking skills and align the curriculum.
Methodology – A qualitative approach using interpretativedescriptive case study design was utilized in framing the research
study. Purposive sampling was used to select 20 final year paramedical students and five teaching staff who participated in this
study. Data was collected through direct and participant observation,
interviews and document analysis. Thematic analysis using Stake’s
Countenance Model was utilized to analyse and present the findings.
Findings – On the basis of these analyses, the study supports
that (i) clinical simulation facilitates the infusion of higher order
thinking skills; (ii) clinical simulation that uses thinking pedagogy
nurtures the development of higher order thinking skills; and (iii)
clinical simulation uses higher order thinking modality to promote,
understand and transfer learning. While facilitators play a crucial
role in engaging learners with higher order thinking modality and
make students’ thinking visible by utilizing the use of metacognition
and self-regulation abilities, learners become more autonomous,
strategic and motivated to apply effort and strategies in a variety of
meaningful contexts.
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Significance – The findings of this study can assist curriculum
managers, college administrators and educators regarding the
inclusion of clinical simulation as an instructional approach to
enhance higher order thinking skills among para-medical students.
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Keywords: Clinical simulation, higher order thinking skills,
instruction and learning strategies, para-medical students.
INTRODUCTION
Infusing higher order thinking skills into the mainstream of education,
notably analysis, synthesis and evaluation, involves the promotion
of thinking, along with teaching methodologies that promote such
thinking, taking place at higher levels of the hierarchy (Kuhn, 2009;
Nickerson, 1987; Perkins, 1987). In Medical and Nursing education,
the teaching of higher order thinking skills is deemed relevant for
the enhancement of clinical competence in areas of critical thinking,
clinical reasoning and problem-solving skills for rendering quality
care (Banning, 2008b; Bridger, 2007; Salvage, 1993; Wong, Koh,
Phua, & Lee, 2005). While numerous methodologies have been made
available for teaching higher order thinking skills (Rajendran, 2008),
selecting appropriate methodology is important for establishing a
learning environment that fosters the development of higher order
thinking and metacognitive abilities. Current advances in the field
of medical technology and artificial intelligence have introduced
clinical simulation as a teaching and learning model for improving
clinical competency.
Clinical simulation involves an attempt to replicate some or nearly
all of the essential aspects of a clinical situation so that the situation
may be more readily understood and managed when it occurs in
real clinical practice (Cioffi, 2001; Morton, 1995). The use of
simulation technology as a tool for experiential learning provides
a mechanism by which students can participate in clinical decisionmaking, practice skills and observe outcomes from clinical decisions
(Brannan, White & Bezanson, 2008; Cleave-Hogg & Morgan,
2002). Clinical simulations facilitate a learning process that is active
and mimics clinical reality in which the learner has the opportunity
to experience the dimensions of clinical practice, ranging from
cognitive, psychomotor and affective domains. Simulations promote
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learning for understanding and meaning rather than rote learning of
facts and principles (Higgs, 1992) and extend the subject matter to
equip learners with skills that can be directly transferred into the
‘real’ clinical setting (Paige & Daley, 2009; Wilford & Doyle, 2006).
Clinical simulation has been advocated as an excellent instructional
tool that binds active participation, provides opportunity for
multiple learning objectives to be taught in a realistic environment
without harming patients and offers students the opportunity to gain
and improve their knowledge in a non-threatening and experiential
environment (Medley & Horne, 2005). It also enhances clinical
competence and decision-making skills (Alinier, Hunt & Gordon,
2004; Issenberg, Mc-Gaghie, Petrusa, Gordon, & Scalese, 2005).
In simulation training, knowledge is constructed by doing and
gathering new experience through experiential learning (Kolb,
1984). The use of the spiral approach in designing simulation
training helps learners to revisit basic ideas, concepts and principles
repeatedly, and building upon them until the students grasp the
full formal apparatus that goes with it. Bruner’s idea of the spiral
approach aids students to construct new ideas and concepts based
upon their past and present experiences (Smith, 2002). In addition,
incorporating ‘think aloud’ strategies provides access to student’s
thought process and insights into the train of thought, the ability
to make connections and the ability to use prior knowledge and
experiential learning for problem-solving (Banning, 2008a).
Growing interest in the use of simulation in healthcare has provided
a strong driving force for embedding clinical simulation as part of the
curriculum of health care education. While much has been written
about the potential of simulation in supporting the development of
professional knowledge and competence at all levels and across all
disciplines (McCallum, 2007; McCaughey & Traynor, 2010), this is
not likely to be realized without evidence to support and understand
how learning is taking place and how it can be supported through
simulation (Bradley, 2006). The study aims to explore, describe and
analyse the design and implementation of clinical simulation as a
pedagogical tool in bridging the deficiency of higher order thinking
skills among para-medical students and make recommendations on
incorporating clinical simulation as a pedagogical tool to enhance
thinking skills and align the curriculum.
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LITERATURE REVIEW
Clinical simulation as an instructional strategy has proven to be
successful in establishing professional knowledge and clinical
competence by bridging the gap between theory and practice (Harder,
2009; Issenberg et al. 2005; Wilford & Doyle, 2006). While most
of these studies focused on the usefulness of clinical simulation in
achieving clinical competence (Issenberg et al. 2005), exploring
how learning takes place in a simulated environment, especially the
infusion of higher order thinking skills, remains to be examined.
Tennyson, Thurlow & Breuer (1987) postulated that problemoriented simulation can be utilized to improve higher order thinking
skills. For example, problem-oriented simulation requires students to
fully employ their knowledge base by generating solutions to domainspecific problems, thus improving the student’s cognitive abilities
employed in the service of recall, problem-solving and creativity.
Enhancing higher order thinking skills involves employment of
knowledge in problem- solving and creativity (Gagne, 1985) that
can enable individuals to restructure their knowledge by analysing
a given situation, working out a conceptual framework, defining
specific goals for dealing with the situation and establishing possible
solutions (Breuer & Hajovy, 1987). Learning through simulation
requires a framework for incorporating educational theories that
support the development of knowledge, skills and attributes. Harder
(2009) pointed out that educational theories can be used as a guide
to learning by way of simulation strategy, whereby scenarios can
be grounded in theory that facilitate active involvement in a rich,
contextual and multilayered experience. Authentic learning created
from simulations provides structured focus on the learning process
that encourages learner’s self-monitoring, has the potential to be
integrated into clinical tasks and can promote deliberation about
specific aspects of practice.
According to Cleave-Hogg and Morgan (2002), simulation experience
offers an environment that activates the relevant prior knowledge
and brings about an awareness of the gaps in their knowledge,
provides a context that closely resembles practice and stimulates
elaboration of knowledge in a risk-free environment. It provides
learners with the freedom to integrate their learning to improve their
dexterity and exercise their judgment and decision-making skills
without endangering a patient. In simulation-modelling processes,
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the use of procedural knowledge, i.e., problem solving capabilities
and some degree of declarative knowledge, i.e., an understanding
of the concepts, could be attained by specifying learning outcomes
during the instructional development stages and by using an effective
pedagogical structure (Atolagbe, Hlupic, Taylor, & Paul, 1997).
Teaching with simulation requires a skilful use of transformational
pedagogies in planning and executing the shift in the mental model
of learners from a teacher-centred to learner-centred approach.
Meece, Herman and McCombs (2003) reported that learners achieve
stronger mastery and performance goals when they perceive their
teachers as using learner-centred teaching practices that involve
promoting relations, encouraging higher order thinking skills and
adapting instruction to individual needs. The use of behavioral
principles for acquiring new psychomotor domain skills, cognitive
principles for conceptualization of knowledge and constructivist
principles for explaining the meaning of the knowledge gained
through the affective domain, supports the simulation framework
(Harder, 2009; Paige & Daley, 2009).
Embedding clinical simulation as a teaching and learning strategy
in the educational process promotes learning for understanding
(Higgs, 1992) and hands-on experience in extending the subject
matter to equip learners with skills that can be directly transferred
into the ‘real’ clinical setting (Paige & Daley, 2009; Wilford &
Doyle, 2006). In addition, simulation-based learning provides
reflective practice for transfer of learning for the improvement of
clinical competencies (Cioffi, 2001; Morton, 1995; Rosen, 2008)
and working in collaboration as part of professional development.
Curriculum that incorporates clinical simulation must provide an
integrated approach and holistic form of learning, fueled by active
participation and interaction and geared towards self-directed
approach where assessment is done authentically. Integrating
clinical simulation across the curriculum demands flexibility and
integration of subject disciplines. Atolagbe et al. (1997) reported
that the development of pedagogy for teaching simulation should
be centred around a curriculum framework that is based on
learning outcomes. In addition, integration of subject discipline
should facilitate revisiting and reexamining fundamental ideas so
that understanding deepens over time to what is known as a spiral
curriculum (Bruner, 1966). As time goes by, students return again
and again to the basic concepts, building on them, making them more
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complex and understanding them more fully. Jeffries (2005) pointed
out that simulation-based education must address the five major
components, namely teacher characteristics, student characteristics,
educational practices, design characteristics of the simulation (the
educational intervention) and outcomes of effective implementation.
In simulation-based learning, lecturers need to be facilitators of
learning with a learner-centred environment where learners are
expected to be motivated and responsible for their own learning. The
lecturers’ paradigm could influence learning outcomes due to their
experiences, knowledge, specific beliefs and instructional strategy
(Atolagbe, Hlupic, Taylor & Paul, 1997). Educational practices
need to focus on promoting active learning, providing appropriate
feedback, facilitating social interaction and fostering diverse and
collaborative learning to facilitate the development of professional
knowledge and competence in providing quality care.
Conceptual Framework
The conceptual framework for this study (Figure 1) is grounded
on the theoretical proposition that Bloom’s Revised Taxonomy
(Anderson & Krathwohl, 2001) provides for infusing higher order
thinking skills at the level of applying, analysing, evaluating and
creating; while the combination of Gagne’s Theory of Instruction
(Gagne, 1985) with Dreyfus Model of Skill Acquisition (Dreyfus &
Dreyfus, 1986) provides the framework for the simulation learning
cycle. In addition, Shulman’s model of learning (Shulman, 2004)
and Eraut’s model of professional knowledge development (Eraut,
1994) that support Gagne’s Theory of Instruction and condition for
learning (Gagne, 1985) facilitate the transfer of learning through the
development of declarative and procedural strategic knowledge.
It is postulated that the infusion of higher order thinking skills in
the pedagogical process by using clinical simulation will bring
about learning for understanding, hence, nurturing the development
of higher order thinking skills among the learners and transfer of
learning. To support the development of the conceptual framework,
the study is based on evidence that there is a positive relationship
between higher order thinking skills, education and performance
(Nickerson, 1987; Pasnak, Kidd, Gadzichowski, Gallington &
Saracina, 2008).
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Figure 1. Conceptual Framework for Enhancing Higher Order
Thinking Skills using Clinical Simulation (Simulation Learning
Model).
METHODOLOGY
Method
An interpretative-descriptive case study design was utilized in
studying 20 final year para-medical students and five teaching
staff chosen via purposive sampling. Case study design provides a
comprehensive and systematic framework for generating inductive
building of theory (Othman Lebar, 2007), especially when the study
is focused on empirical inquiry that investigates a contemporary
phenomenon within its real-life context (Yin, 2003) and based on an
integrated system (Stake, 1995).
The study participants were final year para-medical students in their
sixth semester who were scheduled for emergency care clinical
attachment and who had prior exposure to various clinical placements
in hospitals as well as skills laboratory in the faculty but have not
been exposed to simulation learning. Participating teaching staff had
exposure to simulation demonstration, had assisted in developing
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the simulation laboratory and co-developed the simulation learning
modules. The proposition for this study was: ‘Teaching and learning
using clinical simulation bridges the deficiency of higher order
thinking skills among para-medical students’.
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Clinical Scenarios and Simulation Laboratory Setting
The clinical scenarios and simulation laboratory simulated the
emergency department in line with students’ learning experience
in the triage area, resuscitation bay and post-emergency care. The
development of clinical case scenarios utilized problem-based
triggers that elicit application of prior knowledge, analytical
thinking, synthesizing information, evaluation and creating plans of
action. Problem-based clinical scenarios grounded in constructivist
learning theory with spiral approach design provided the thinking
framework. In addition, student-centred learning, think aloud
strategies, interactive simulation technologies, experiential learning,
collaborative practices and facilitating role of educators in clinical
simulation provided the learning environment that facilitated the
infusion of higher order thinking skills.
Study Procedure
The study was conducted in the simulation laboratory using clinical
scenarios, standardized patients, mannequins and simulators. Six
case studies using real-life clinical scenarios were developed and
utilized to study the possible infusion of higher order thinking skills
within the context of clinical simulation as a pedagogical tool.
Validity and authenticity of the simulation scenarios were assessed
by a panel of experts from clinical and academic backgrounds. The
clinical case study incorporated a scenario that elicits application of
prior knowledge, analytical thinking, synthesizing information and
evaluation. Pre-evaluation was done to gauge participants’ cognitive
and knowledge dimensions using scenario-based questions (clinical
case) and to evaluate students’ cognition based on Bloom’s Revised
Taxonomy (Anderson & Krathwohl, 2001), in accordance with the
objectives of clinical posting. Participants then proceeded through
six sessions of clinical simulation in the simulation laboratory
using simulation-based learning cycle for a period of two weeks.
Both technological fidelity and pedagogical fidelity were utilized
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in facilitating simulation learning. Participants’ performance was
observed, though direct and participatory observation throughout
the simulation sessions during the briefing, performing, discussion,
assessment and reflection stages. Post-evaluation was done at the
end of the sixth simulation session to assess participants’ cognitive
and knowledge dimensions.
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Data Collection
Data were collected through document analysis, direct and
participant observation and interviews.
i.
Documentation
Document analysis and mapping of the simulation module was done
to elicit details of events and references. Document analysis elicited
details of simulation module’s aim, objectives, content coverage,
learning design and learning outcome for the infusion of higher
order thinking skills. Investigators retrieved information through
content mapping to corroborate information and augment evidence
for inference purposes and to achieve identified objectives.
ii.
Direct Observation and Participant-Observation
Direct observation and participant-observation focused on how
learning and teaching using clinical simulation learning cycle
enhanced the development of higher order thinking skills during
simulated learning. Direct observation ranged from formal to casual
data collection, where incidents of certain types of behaviors were
observed using observational protocols. In direct observation, the
investigator took up the role of ‘outsider’ in collecting the data,
while the participant-observation technique provided distinctive
opportunity to perceive reality from the viewpoint of someone
‘inside’ the case study.
iii.
Interview
Focus group interviews using semi-structured open-ended questions
probed about how learners thought in simulated practice, how they
learned from experience and how they made connections between
different clinical cases. Students and facilitators were interviewed
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separately to gauge the emerging pattern of views and opinions for
the convergence of multiple sources of data. All interviews and
observations were recorded after obtaining participants’ permission.
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Data Analysis
Thematic analysis of manifest content and the interpretation of
the underlying meaning of transcription were done to establish the
link between the theoretical proposition and the case description.
Descriptions were coded and analysed for similarities and differences
and regrouped into categories to formulate the themes based upon the
research questions. Stake’s Countenance Model (Stake, 1967) was
utilized to develop the themes derived from theoretical proposition
and case description.
Validity, Reliability and Ethical Consideration
Validity and reliability of the study were maintained through the
triangulation design, by having a chain of evidence through an audit
trail that documented inquiry processes and events in the form of
logs, journals and memos of all activities that were implemented in
the process of study, and members’ check to verify the accuracy of
transcribed data. As for ethical consideration, informed consent was
obtained after providing all participants with salient information
about the study, the voluntary nature of participation, the right to
stop at any time and rights for confidentiality.
RESULTS AND DISCUSSION
The study revealed that the use of problem-based clinical scenarios
grounded in constructivist learning theory with spiral approach
design, student-centred learning, think aloud strategies, interactive
simulation technologies, coupled with experiential learning,
collaborative practices and facilitating role of educators, were key
enablers for the development of higher order thinking skills in
simulated learning. Students who were nurtured using a clinical
simulation learning model demonstrated higher order thinking
pattern, explicit learning through sharing and reflective practices,
had confidence in managing clinical cases and demonstrated good
leadership and social skills.
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Designing simulation-based learning framework requires an
appropriate selection of educational theories and learning
taxonomies that support higher order thinking. Combining Bloom’s
Revised Taxonomy (Anderson & Krathwohl, 2001) with Gagne’s
Condition of Learning and Theory of Instruction (Gagne, 1985)
and the Dreyfus Model of Skill Acquisition (Dreyfus & Dreyfus,
1986) into a simulation learning model provided an effective
theoretical framework for teaching simulation modelling that
supported the infusion of higher order thinking skills. This was
evident in the effective implementation of the simulation learning
model that provided the framework for simulation intervention
and performance evaluation (Refer Figure 1). The present study
submits that the developed simulation learning model grounded on
Gagne’s Condition of Learning and Theory of Instruction (Gagne,
1985) evokes thinking modality, integrates knowledge across
various domains of learning and facilitates the attainment of specific
objectives, including the learners’ paradigm in supporting and
accommodating the differences in the way students construct their
knowledge and transfer of learning to different clinical settings.
One of the research participants taking part as facilitator stated
that “simulation-based learning method provides an effective and
conducive learning environment that complies with the students’
learning needs. Learners can apply knowledge and skills across the
board on the simulated patient and in a controlled environment”.
Grounding Gagne’s model into simulation education has provided
learning effectiveness through situated learning and constructivism
by anchoring instructional activities into meaningful learning to
bring about learning efficiency, instructional effectiveness, transfer
of learning and learner’s interest (Atolagbe et al. 1997; Driscoll,
2000). Cognitive understanding promotes a holistic platform in
which situated cognition can be designed for learners to experience
the complexity and ambiguity of learning in the real world (Paige
& Daley, 2009). By doing so, the simulation framework promotes
shifting teacher-led instruction to student-led learning that enhances
autonomy, strategic thinking, meaningful learning and learning for
transfer.
Combining Gagne’s learning theory with a Dreyfus model of skills
acquisition (Dreyfus & Dreyfus, 1980) in the development of a
simulation design provides an effective framework for transfer of
learning at differing stages of competency; and at the same time,
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supports the development of cognition-based practice. It is noted
that grounding problem-based scenarios at various stages of
competencies trigger the students’ mind in manipulating previously
learned information to create new knowledge. A study participant,
Danial (pseudonym) explained:
Problem-based simulation triggers an increase in
knowledge and skills because it provides the scope
and opportunity for students to think, discuss and
make decisions supported by the encouragement and
guidance by the facilitators in managing the patient.
It also provides more opportunities for the learners to
use the knowledge and skills in handling clinical cases
compared to actual clinical placement.
Tan (2004) claimed that problem-based scenarios promote
understanding that is derived from interaction with the problem
scenarios and the learning environment, whereby engagement
with the problem and problem enquiry process create cognitive
dissonance that stimulates learning; knowledge evolves through the
process of social negotiation and evaluation of the validity of one’s
point of view. In addition, the use of cognitive and constructive
theoretical orientation provides a broad paradigm for grounding
thinking skills (Byrnes, 2008; Slavin, 1991; Rajendran, 2008, Tan,
2004), that have been useful for designing the learning framework
for clinical simulation in harnessing analytical skills, reasoning
skills and reflective practices. Learning through clinical simulation
promotes the development of mental schemes when an individual
interacts with the environment, and in using past knowledge in new
situations to interpret new experience. This is in line with Piaget’s
argument that cognition is grounded in the interface between mind
and environment and the result of the interplay is the achievement
or working towards a balance between mental schemes and the
requirements of the environment (Lutz & Huitt, 2004). Subsequently,
the combination of maturation and action advances an individual
into higher developmental stage and higher cognitive abilities.
Designing simulation module using spiral design facilitates the
infusion of higher order thinking skills and scaffolding of learning.
The use of abstract thinking and logical reasoning in going through
the clinical scenarios, scaffolding students learning experiences to
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different levels through facilitation, collaborative and reflective
practices, facilitates the infusion of thinking skills. In substantiating
the above notion, study participant Bani (pseudonym) explained:
Experience in simulation labs gives much space to
guide students for the application of what they have
learned. If mistakes are identified, it is corrected there
and then as compared to practice in clinical placements
that require zero defects. Facilitators can identify
weaknesses and their strengths and deal with change
to correct mistakes before proceeding to the actual
patient. Students can learn in simulation practice to
explore and discover, interpret findings and provide a
diagnosis without the fear of harming the patient.
Smith (2002), in advocating Bruner’s idea of the spiral design,
postulated that spiral approach facilitates students’ learning in a
manner in which students continually build upon what they have
already learned; it aids in constructing new ideas and concepts based
upon their past and present experiences. Interconnection of new
experiences with prior knowledge results in the reorganization of
cognitive structure that creates meaning and meaningful learning,
allowing one to explore further. Hence, meaningful learning goes
beyond the simple presentation of factual knowledge and actively
engages students in the process of constructing meaning (Mayer,
2002). The study supports Lutz & Huit’s (2004) argument on
Bruner’s idea that learners can acquire certain types of information
at certain stages depending on their cognitive readiness; cognitive
development occurs when learners select and transform information,
construct hypothesis and make decisions, relying on schemes and
mental models. Piaget claimed that higher order cognitive functions
lie in the arena of abstract thinking and logical reasoning that involve
the ability to think inductively, deductively, infer, hypothesize,
conclude and judge the validity of these inferences (Byrnes, 2008);
while Vygotsky’s social cognitive theory suggests that each person
has potential for learning in the zone of proximal development,
where individuals can be moved to a higher level of thinking through
guidance (Lutz and Huit, 2004). Slavin (1991) proposed that it is
important to extend the students’ level beyond their current level of
functioning, but within their ability for abstraction and assimilation.
What is important here is the role of the educator to facilitate learning
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by providing a variety of experiences, allowing students differing
cognitive levels to work together and the use of concrete ‘hands-on’
experience to help learners learn.
Learning through collaborative practices facilitates active involvement
of students that lead to sharing of knowledge, exploration, building
on past knowledge to new knowledge and transfer of learning. For
example, study participant Balu (pseudonym) in expressing his view
on collaborative practices in simulation learning explained, “For me,
the knowledge obtained through the discussion was used to plan and
manage the case. Discussion with peers and facilitators helped me
in clarification and improvement of understanding. The facilitators
mainly probed the discussion to make us think and not just provide
the answers”.
Discussion through a collaborative approach facilitates sharing
of knowledge and improved understanding of clinical cases.
Discussion facilitates self-regulation, self-correcting of mistakes
and prevents recurrence of similar mistakes. According to study
participant Danial (pseudonym), “discussion with colleagues and
facilitators that focused on probing for clarification when mistakes
were made enhanced self-regulation in preventing clinical errors”.
Discussion through collaborative practice clarifies what is going
on in students’ minds, comparing different approaches to problemsolving and decision-making, identifying what is known, what
needs to be known and how to produce that knowledge. This notion
supports Vygotsky’s (1987) idea that intelligence begins in the
social environment, and the social dimension of learning supports
the cognitive development of an individual, i.e., a student must be
free to interact, experiment, articulate and share views and opinions.
By socializing and interacting with others, students learn to adapt
and to adopt new experiences and learn how to deal with them.
When students are allowed to work and reason together, the one who
grasps the concept first is certainly operating in the other’s proximal
zone of development and assists the other to learn to conserve
(Slavin, 1991). This allows more advanced students to teach their
peers on how to grasp the concept and explain the difficulties to a
lesser experienced student.
In addition, using higher cognitive questioning encourages active
student participation that requires students to mentally manipulate
information previously learned to create and support answers with
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logical reasoning, hence yielding higher student achievement (Lewis
& Smith, 2001; Rajendran, 2008). This has been noted in the present
study where the use of ‘why’ and ‘how’ questions as a probing
approach in the simulation process activates thinking that triggers
the use of factual, conceptual, procedural and strategic knowledge
for meaningful learning. In supporting the above notion, study
participant Elaine (pseudonym) explained, “facilitators mainly used
‘why’ questions in establishing the link with history taking, physical
examination, investigations and diagnosis. We can analyse and
interpret the findings to diagnose the case”. Performance comes with
understanding (Shulman, 2004), while Gardner (2008) posits that
performance and action can be strengthened by having a creative
mind to solve problems by thinking ‘out of the box’. Developing the
knowledge dimension beyond the present knowledge level through
‘why’ questions evoke thinking modality of exploring deeper,
seeking connection within subject areas and across subject areas for
inference and evidences in problem-solving and decision-making.
Such practices promote meaningful learning and the development
of strategic knowledge. This notion supports Dart, Burnet, BoultonLewis, Cambell, Smith and McCrindle (1999) who claimed that
deep approaches to learning are significantly related to the learning
environment which are perceived to be highly personalized that
encourage active learning processes.
The present study also discloses that embedding experiential learning
into simulation education provides active learning and hands-on
experience that promotes greater interest in the subject material
and enhances intrinsic learning satisfaction. This can facilitate
understanding and retention of learning, develop desire and ability
to be continuous learners, improve communication and interpersonal
skills, problem-solving, analytical thinking and critical thinking
skills of students. Study participant Ali (pseudonym) in reflecting the
learning experience in simulated practice explained, “Facilitators ask
the rationale for every action taken. The use of small group discussion
engages everyone to participate and pay attention. Facilitators guide
us on how to analyse, interpret and evaluate. If we made mistakes,
facilitators guide us to rectify the mistakes”. Experiential learning
provides a mechanism by which students can participate in clinical
decision-making, practice skills and observe outcomes from clinical
decisions (Brannan et al., 2008; Cleave-Hogg & Morgan, 2002).
The study supports Dewey’s theory that experience and reflection
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equal learning; where it is not just about experience that has the
potential for learning, but the quality of the experience that provides
a measure of its educational significance (Fowler, 2007). Acquiring
physical knowledge requires facilitation of students to internalize
action schemes by repeatedly performing hands-on learning to attain
experience and specified goals (Byrnes, 2008); while exploring the
logic of actions serves as a template for the development of mental
logical structures achieved through reflective practices. In addition,
the use of the learner-centred approach in clinical simulation helps
students to become more autonomous, strategic and motivated so
that they can apply effort and strategies in a variety of meaningful
contexts in and beyond didactic teaching. This was reflected by
study participant Ali (pseudonym) who expressed:
In the simulation session, we managed the case in
total where we clerked the case, performed a physical
examination, provided the diagnosis and managed
the case prior to referral. We had the autonomy to
manage the case and perform in a team. Compared to
the clinical area, we merely follow instruction of what
needs to be done.
Clinical simulation facilitates an active learning process of
experiential learning and peer group learning that provides
opportunity for learners to explore and experience dimensions
of clinical practice that support the development of higher order
thinking skills. Grounding problem-based approach in clinical
simulation has shifted the learning paradigm to a learner-centred
approach, placing students as the focus of learning. Brandes and
Ginnes (1986) cited that student-centred learning allows learners
to take full responsibilities for their learning, promotes growth
and development and develops a higher conception of learning.
Students perceive clinical simulation as a useful learning paradigm
in providing learning experiences and opportunities, autonomy of
practice and improved clinical guidance in enhancing higher order
thinking skills, as it offers a range of learning opportunities that
are not always available in real practice. When students are given
the time, opportunity and guided autonomy in bringing theory into
practice, the outcome of learning reflects on the ability to improve
their learning curve, moving away from rote learning towards
meaningful learning. Baumfield (2004) argued that the development
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91
of thinking skills requires that students are given the time and
opportunity to talk about thinking processes, to make their own
thought processes more explicit, thus enabling them to clarify and
reflect upon their strategies and gain more self-control. Personalized
learning environment encourages active learning process (Dart et
al., 1999), and fosters the development of higher order thinking
and meta-cognitive abilities (Billing, 2007). Learning culture that
places importance on learner-centred education promotes critical
thinking, logical reasoning and problem-solving skills (Pogrow,
2005). The strongest driving force to bring about the transformation
of thinking in education is the students themselves since they must
be empowered to demand excellence and realize that education is a
means for preparing them to be the kind of graduates needed for the
future (McLean & Gibbs, 2009).
In addition to focusing on making students’ thinking visible by
utilizing think aloud strategy, meta-cognition and self-regulation
abilities further harness the development of thinking skills. Banning
(2008a) proposed that think aloud approach provides access to
students’ thought process and insights into the train of thought, the
ability to make connections and the ability to use prior knowledge
and experiential learning for problem- solving. Using think aloud
approach facilitates learners to develop skills in problem-solving,
heuristics and verbalized reasoning and enhances their experience of
using and applying both clinical reasoning and cognitive operatives.
At the same time, educators can access what is going on in the
mind of the student in making the connection between received
stimuli and managing clinical scenario, while learners develop
clinical competence through articulating inference and rationale for
decisions.
The outcome of simulated practice is to bring about learning for
understanding and transfer of learning. Transfer of learning from
Gagne’s perspective (Gagne, 1985) involves the extent to which
the students have the required prerequisite knowledge and skills,
the ability to recall prior learning and develop those cognitive
strategies appropriate for the task. This was noted during simulated
practice and debriefing sessions where students demonstrated
better understanding of clinical cases through self-regulation and
scaffolding of knowledge and cognitive dimension to become
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strategic thinkers that facilitated learning for understanding and
transfer of learning. Study participant Anil (pseudonym) who
participated in the debriefing sessions explained:
Debriefing session is particularly helpful for identifying
the level of students’ knowledge, skills and their ability
in making decisions when handling patients. Students
themselves will realize that mistakes have been done
and at which level of their knowledge and skills. When
there is a mistake made inadvertently, it will be raised
by the facilitator during debriefing sessions. Students
will also tell what needs to be done to ensure that
mistakes are not repeated on real patients. Students can
also express their strength in dealing with the case and
this will strengthen their confidence levels when they
are on the field. They can also indicate new learning
acquired during simulation exercises. This will enable
the students to check and balance what they have learnt.
Perkin and Saloman (1992) illustrated that transfer of learning can
be a result of reflexive transfer that requires well automated patterns
of response that are easily triggered by a similar stimulus condition
or mindful transfer that involves active abstraction and exploration
of possible connections. Bond et al. (2008), in reviewing several
empirical studies, pointed out that learners trained in the performance
of procedures by use of simulation models, can transfer the taught
skills to the workplace. Performance comes with understanding
(Shulman, 2004), and the development of professional knowledge
and competence takes place immediately when knowledge is
put to use (Eraut, 1994). This argument supports Eraut’s (1994)
idea of developing professional knowledge and competence by
strengthening propositional knowledge with procedural knowledge
through performance, practice and action in different contexts. The
simulation environment provides a learning paradigm for students to
acquire hands-on experience that bridges learnt theory and practice
from varying contexts and situations in developing the professional
knowledge. The ultimate aim of clinical simulation is to tie factual,
conceptual and procedural knowledge with strategic knowledge
to bring about the development of the student’s potential and to
enhance the development of higher level cognitive abilities.
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93
Educators as facilitators of learning play an important role in
expediting the potential of clinical simulation as a teaching and
learning tool to enhance higher order thinking skills. The modelling
process portrayed by educators in probing, problem-solving,
providing feedback and being non-judgmental creates a positive
perception on educators in enhancing the culture of thinking. The
role of facilitators in clinical simulation is to carefully select and
guide learning experience that suits learner’s background and
capability, and structure learning situations relevant for realizing
the human potential for rational thinking. Education is a process of
unfolding and developing the potential of the individual (Hamilton,
1996), whereby teaching thinking skills in simulated practice is
not only about making students’ thinking visible (Perkins, 2003)
but creating a learning environment and conditions that stimulate
thinking (Costa, 2001). The implication for educators will be the
need to facilitate learning through the process of reflection on
their experiences, making learning explicit through sharing and
recognizing it as a basis for future learning.
Integrating clinical simulation across the curriculum demands
flexibility and integration of subject areas that would enhance
cognitive abilities and knowledge dimensions in steeping the
learning curve. The present study supports the teaching and
learning paradigm of clinical simulation in integrating knowledge
across various specified learning outcomes which accommodate
differences in the way students construct their knowledge and
facilitate creative problem-solving. Blending thinking pedagogy
with simulation technology can be a very effective tool to help
students learn complex skills, critical thinking, clinical reasoning
and judgment (Howard et al., 2010; Wilford & Doyle, 2006).
For that, the development of pedagogy for teaching simulation
should be centred around a curriculum framework that is based on
learning outcomes (Atolagbe et al., 1997), which places emphasis
on valuing, decision-making, Socratic dialogue, reflective practice
and humanism. In addition, integrating clinical simulation across
the curriculum involves developing pedagogy that goes beyond
situating the learning experiences within the experience of the learner
through the process of dialogue and reflection. In this approach, the
curriculum utilizes dynamic interaction of action and reflection that
supports the notion of praxis (Stenhouse, 1975) or the concept of
thinking out of the box (Gardner, 2008). Grounding the curriculum
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in praxis enhances critical and creative thinking that encourages
educators and students together to confront clinical problems of
their existence and relationship and solving them amicably. Smith
(2000), in supporting the notion, cited that commitment to praxis
fosters collective understanding and sharing of values through
teamwork and collaboration with emphasis on human emancipation.
Incorporating simulation across the curriculum has important
administrative implications that need to be addressed. Our present
experience in developing and maintaining a simulation center in the
College supports Howard et al.’s (2010) claim that implementing
simulation across the curriculum requires a dedicated simulation
coordinator or champion, technological support, adequate facilities,
standardized programming forms, funds for supplies that enhance
realism and workload release time for faculty to gain understanding
related to the use of this innovative yet highly technical teaching
technique.
CONCLUSION
In concluding this study, the results suggest that the unique
experience of clinical simulation can be effectively used as a teaching
and learning tool in bridging the deficiency of higher order thinking
skills among para-medical students. The study reveals that the use
of problem-based clinical scenarios grounded in constructivist
learning theory with spiral approach, student-centred learning, think
aloud strategies, interactive simulation technologies, coupled with
experiential learning, collaborative practices and role of facilitators
are key enablers in facilitating the infusion of higher order thinking
skills in Pre-medical Education. Integrating Bloom’s Revised
Taxonomy with Gagne’s theory of Instruction and Learning and the
Dreyfus Model of Skill Acquisition provide an effective theoretical
framework for teaching simulation modelling that supports the
infusion of higher order thinking skills.
Students have perceived clinical simulation as a useful learning
paradigm in providing learning experiences and opportunities,
autonomy of practice and improved clinical guidance to enhance
higher order thinking skills, as it offers a range of learning
opportunities not always available in clinical practice. In bridging
theory and practice, facilitators play an important role in helping
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Malaysian Journal of Learning and Instruction: Vol. 11 (2014): 75-100
95
students to become more autonomous, strategic and motivated in
applying effort and strategies in a variety of meaningful clinical
contexts to bring about the discovery, transmission and the use
of knowledge. Simulation can be a parallel system in creating an
authentic clinical environment that matches the real clinical setting
to provide a range of learning experiences leading to cognitive
abilities, clinical competence, social cognition and transfer of
learning to real clinical setting. The design and employment of
effective simulation education programs will improve training and
can be an integral part of the curriculum to contribute to quality
improvement of patient care.
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