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: pertmer@purdue.edu

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.

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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

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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

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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.’’

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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

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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’’.

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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

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(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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