How does questioning influence nursing students' clinical reasoning in problem-based learning? A scoping review

Accepted Manuscript How does questioning influence nursing students' clinical reasoning in problem-based learning? A scoping review

Sophia Merisier, Caroline Larue, Louise Boyer PII: DOI: Reference:

S0260-6917(18)30130-8 doi:10.1016/j.nedt.2018.03.006 YNEDT 3801

To appear in: Received date: Revised date: Accepted date:

29 August 2017 16 February 2018 8 March 2018

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HOW DOES QUESTIONING INFLUENCE NURSING STUDENTS’ CLINICAL REASONING IN PROBLEM-BASED LEARNING? A SCOPING REVIEW Sophia Merisier1, Caroline Larue1 & Louise Boyer1 1

Faculty of Nursing, University of Montreal, Montreal, Canada

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Corresponding author

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Sophia Merisier, Faculty of Nursing, Pavillon Marguerite-d’Youville, University of Montreal, C.P. 6128 succ. Centre-ville, Montreal, QC., H3C 3J7, Canada. E-mail: [email protected]

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Acknowledgements

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This work was supported by the Montreal Heart Institute, Ministère de l’Éducation et de l’Enseignement supérieur (MEES), FUTUR team, an interdisciplinary and interuniversity research team subsidized by the Fonds de Recherche du Québec – Société et Culture (FRQSC).

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How does questioning influence nursing students’ clinical reasoning in problem-based learning? A scoping review

Abstract

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Background: Problem-based learning is an educational method promoting clinical reasoning that has been implemented in many fields of health education. Questioning is a learning strategy often employed in problem-based learning sessions.

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Aim: To explore what is known about the influence of questioning on the promotion of clinical reasoning of students in health care education, specifically in the field of nursing and using the educational method of problem-based learning.

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Methods: A scoping review following Arksey and O’Malley’s five stages was conducted. The CINAHL, EMBASE, ERIC, Medline, and PubMed databases were searched for articles published between the years of 2000 and 2017. Each article was summarized and analyzed using a data extraction sheet in relation to its purpose, population group, setting, methods, and results. A descriptive explication of the studies based on an inductive analysis of their findings to address the aim of the review was made.

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Results: Nineteen studies were included in the analysis. The studies explored the influence of questioning on critical thinking rather than on clinical reasoning. The nature of the questions asked and the effect of higher-order questions on critical thinking were the most commonly occurring themes. Few studies addressed the use of questioning in problem-based learning.

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Conclusions: More empirical evidence is needed to gain a better understanding of the benefit of questioning in problem-based learning to promote students’ clinical reasoning.

Keywords:

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questioning, clinical reasoning, nursing education, critical thinking, problem-based learning, educational strategies

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Introduction

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Clinical reasoning informs every care decision in nursing. According to Levett-Jones (2013), clinical reasoning is “the process by which nurses collect cues, process the information, come to an understanding of a patient problem or situation, plan and implement interventions, evaluate outcomes, and reflect on and learn from the process (p. 4)”. Among the many educational methods used to foster clinical reasoning in nurse education programs, problem-based learning (PBL) is one of the most widely employed. However, students’ clinical reasoning is not automatically improved by its utilization. This outcome depends on the educational strategies applied during instruction (Larue, 2008). Since questioning is an educational strategy frequently used during PBL, its effective use is important in developing clinical reasoning.

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Background

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Many authors report that PBL fosters the development of clinical reasoning (Barbeau, 2007; Barrow et al., 2002; Brady, 2008; Cossette et al., 2004; Loftus and Higgs, 2013; Scaffa and Wooster, 2004). However, in their systematic review assessing which methods are the most effective in promoting clinical reasoning, Rochmawati and Wiechula (2010) observed that the studies intended to validate this hypothesis were inconclusive. They observed that the contribution of PBL to the development of clinical reasoning was evaluated with instruments created to assess critical thinking. Even though critical thinking skills are needed to reason, we believe that clinical reasoning goes beyond critical thinking. Facione and Facione (2008) defined this as “the cognitive process involved in clinical reasoning (p. 1)”. Having great critical thinking skills does not guarantee the capacity to use them effectively in clinical situations. Critical thinking is the methodical and logical process in which we analyze an issue and clinical reasoning is the proper application of critical thinking in a clinical situation. Von Colln-Appling and Giuliano (2017) and Simmons (2010) provide extensive definition of these two concepts. According to Larue (2008), although PBL creates a learning context that is favorable to the development of clinical reasoning skills, the outcome depends greatly on the educational strategies used by the students and their tutor. Larue (2008) observed that nursing students mainly used memorization strategies that lead to a superficial level of understanding. They barely used strategies, such as questioning, that encourage higher-order thinking such as elaboration, organization, generalization, or discrimination of information, which leads to a deeper understanding of material and the development of clinical reasoning.

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Very few studies have addressed the effect of different educational strategies used in PBL on the development of clinical reasoning. Among these strategies, questioning seems to be one of the most frequently used (Gilkison, 2003; Larue and Hrimech, 2009). Questioning refers to the act of asking questions during a discussion (Dillon, 2004), a question being defined as a sentence of “interrogative form or function (Wilen, 1991, p. 5)” intended to obtain information or stimulate thought. The use of questioning to foster the development of student reasoning is a strategy that originated with the early Greek philosopher Socrates. Questioning has since been used in combination with many educational methods. In PBL, through questions, students can express their incomprehension, share and validate their comprehension, and deepen their reflection (Brady, 2008; Profetto-McGrath et al., 2004). As for tutors, their questions can stimulate student thinking, help them reflect on their learning, and aid them in the construction of knowledge (Larue, 2007, 2008; Profetto-McGrath et al., 2004; Savin-Baden and Howell Major, 2004). By questioning students, tutors also model the type of questions they should be asking themselves when facing similar problems in clinical settings (Hmelo-Silver and Barrows, 2006). Thus, questioning plays an important role in PBL.

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ACCEPTED MANUSCRIPT 4 The purpose of this scoping review was to explore what is known about the influence of questioning on student clinical reasoning in nurse education, specifically in PBL. An initial review of the literature failed to identify any review with this focus to date.

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Method Framework

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Scoping reviews are used to summarize and diffuse findings and assess the extent of the research, from a broad range of designs, on a specific subject (Arksey and O'Malley, 2005; Grant and Booth, 2009) as well as pinpoint any gaps in the existing literature (Arksey and O'Malley, 2005). The scoping review was guided by Arksey and O’Malley’s (2005) framework, which offers methodological rigor, provides transparency, and improves the reliability of findings. This framework includes five stages: 1) formulate the research question; 2) search for relevant studies; 3) select pertinent studies; 4) chart the data; and 5) organize, summarize, and report the findings.

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Formulate the research question

Search for relevant research

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PICO strategy was used to formulate the aim of this review (Table 1). PICO is well known to improve the quality of research question (Aslam and Emmanuel, 2010). The aim of this review was to answer the following question: what is known about the influence of questioning (I) on the promotion of clinical reasoning (O) of students in health care education (P), specifically in the field of nursing and using PBL?

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With the assistance of an experienced research librarian, a literature search was conducted in CINAHL, EMBASE, ERIC, MEDLINE, and PubMed. The search was limited to studies published between 2000 and 2017. Studies with terms associated with clinical reasoning, questioning, and PBL were targeted using the following Boolean search strategy: (“critical thinking” or “judgment” or “problem-solving” or “reasoning”) AND (“question” or “questioning”) OR (“problem-based”). As shown in Figure 1, after removing any duplications, 754 studies were identified. Select pertinent studies

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A first selection was made to retain only empirical studies published in French or English with the terms “clinical reasoning” and “questioning” appearing in the title or abstract. A total of 54 articles meet these initial inclusion criteria. In the second stage, after reading these articles in full, 42 failed to meet the following inclusion criteria which was to establish a link between clinical reasoning and questioning. The number of articles was then reduced to 12. In the third stage, from browsing the reference list of the articles read, three more studies were added, which brought the number of relevant articles to 15. In the fourth stage, by navigating the Internet, one more article relevant to the subject was found. Subsequently, considering the small number of studies on the influence of questioning on nursing students’ clinical reasoning and with the goal of producing a global portrait of the subject, an additional search in CINAHL with no restriction regarding the publication year was made, which added six more studies from the nursing discipline to this review. In total, 22 articles published between 1973 and 2017 that addressed the link between questioning and clinical reasoning in health care education were included in this scoping review. The relevant of each of these articles to the research questions were discussed and approved by all authors. Studies were excluded when they were outside of dates, non-English or non-

ACCEPTED MANUSCRIPT 5 French, addressed both questioning and clinical reasoning but failed to establish a link between the two concepts. Chart the data

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The papers included in the review were summarized and analyzed using a data extraction sheet according to their aims, population groups, settings, methods, and results.

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Overview of the included studies

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Organize, summarize, and report the findings

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This scoping review comprises 22 articles reporting on 19 empirical studies. They are presented in Table 2 and arranged from newest to oldest. They mainly relied on quantitative approaches, were descriptive and aimed to categorize the type of questions asked by educators according to the cognitive activity required to answer them.

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Although assessing the quality of an individual study is not the purpose of a scoping review (Arksey and O'Malley, 2005), many studies had common design flaws worth acknowledging, such as small sample sizes (Craig and Page, 1981; Giddings et al., 2000; Gilkison, 2003; Phillips and Duke, 2001; Wink, 1993), the use of convenience sampling (Cho et al., 2012; Craig and Page, 1981; Giddings et al., 2000; Hessheimer et al., 2011; Phillips and Duke, 2001; Rossignol, 1997; Sellappah et al., 1998; Wink, 1993), or a reliance on participants from only one setting (Barnum, 2008; Gilkison, 2003; Profetto-McGrath et al., 2004; Scholdra and Quiring, 1973; Sellappah et al., 1998; Valtanen, 2014).

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Thematic overview

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This scoping review presents a descriptive explanation of these studies based on an inductive analysis of their findings. Using the data extraction sheet, the researchers looked for significant themes inherent in the data and clearly link to the aim of the scoping review. Following these themes, the data are present in a brief summary.

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Five themes emerged from the data analysis: critical thinking, nature of questions asked, effect of highlevel questions on critical thinking, beyond the nature of questions asked, questioning and PBL. Critical thinking

The analysis showed that questioning has been studied regarding its effect on critical thinking rather than clinical reasoning. Critical thinking refers to a general thinking process, during which data are analyzed in a way that is independent of their context or origin (Simmons, 2010; Victor-Chmil, 2013). Clinical reasoning, on the other hand, is a thinking process during which data are analyzed in light of a specific clinical context (Levett-Jones, 2013). Considering that these two cognitive processes are intimately linked, as clinical reasoning requires critical thinking, reporting on the influence of questioning on critical thinking is relevant to the study of the influence of questioning on clinical reasoning. In these studies, critical thinking is examined in relation to the nature of questions asked. Nature of questions asked

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The nature of questions asked is central to most studies in the questioning literature. In many of these studies, questions were classified according to Bloom’s taxonomy or similar classification. Bloom’s (1956) taxonomy comprises six cognitive levels: knowledge, comprehension, application, analysis, synthesis, and evaluation. Bloom (1956) established a distinction between the category of knowledge and the following. According to Bloom (1956) knowledge implies the capacity to remember information, while the other categories represent the use of critical thinking. Based on this categorization, many authors referred to knowledge and comprehension questions as representing “low cognitive levels” (Phillips and Duke, 2001; Phillips et al., 2017; Velde et al., 2006), some also considered application to belong to this level (Barnum, 2008; Giddings et al., 2000; Gul et al., 2010; Gul et al., 2014; Profetto-McGrath et al., 2004; Saeed et al., 2012; Scholdra and Quiring, 1973; Sellappah et al., 1998), while “high cognitive level” questions were considered by all authors to use the skills of analysis, synthesis, and evaluation.

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All of the articles based on Bloom’s (1956) taxonomy reported that the majority of the questions asked during learning activities targeted the lower levels of cognition (Barnum, 2008; Craig and Page, 1981; Giddings et al., 2000; Gul et al., 2010; Gul et al., 2014; Phillips and Duke, 2001; Phillips et al., 2017; Profetto-McGrath et al., 2004; Saeed et al., 2012; Scholdra and Quiring, 1973; Sellappah et al., 1998; Wink, 1993). These studies report that educators, regardless of their qualifications or experience and students principally use low-level questions, irrespective of the students’ academic level or course objectives. It was observed that these low-level questions are often closed-ended, requiring a “yes or no answer” that does not stimulate thinking. Many researchers concluded that critical thinking skills might not be developed by the use of questioning (Giddings et al., 2000; Gul et al., 2010; Gul et al., 2014; Saeed et al., 2012; Sellappah et al., 1998) since most questions asked during learning activities targeted student memory and aimed to verify understanding rather than develop cognitive abilities. Consequently, many studies were undertaken to evaluate the effect of various trainings on the use of high-level questions (Craig and Page, 1981; Gul et al., 2014; Velde et al., 2006; Wink, 1993). However, the effect that higherlevel questions have on critical thinking seems to be controversial, as study results on the subject have been inconclusive.

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The effect of high-level questions on critical thinking

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Rossignol (1997) explored the relationship between educators’ use of high-level questions during clinical post-conferences and nursing students’ critical thinking skills using the Watson-Glaser Critical Thinking Appraisal (WGCTA). A significant relationship was observed between the use of high-level questions and nursing students’ critical thinking. However, in one third of the cases, a negative effect was associated with high-level questions; therefore, the contribution of high-level questions to the development of critical thinking could not be confirmed. However, considering that not many high-level questions were asked by the educators, the results should be interpreted with caution.

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Velde et al. (2006) who employed a quasi-experimental design to evaluate the effect of King’s questioning technique on the critical thinking skills of occupational therapy students during a seminar-based class using the California Critical Thinking Skills Test (CCTST), came to the same conclusion. King’s questioning technique is a framework of high-level questions intended to help students deepen their reflection. Even though Velde et al. (2006) observed that students from the experimental group asked more high-level questions, no significant difference was noted between them and those in the control group on the CCTST. This study, although limited to one class, casts doubt on the connection between high-level questions and critical thinking skills. A similar study conducted by Loy et al. (2004) showed that a workshop in which medical students were taught to ask critical questions using Browne’s systematic approach had a positive effect on their critical thinking skills as evaluated by the CCTST. Though Browne did not categorize the questions composing his framework into low or high cognitive levels, by analyzing them in light of Bloom’s (1956) taxonomy, we can see that it is composed of both types of questions, which makes it hard to determine the advantage of one over the other. In sum, from the few studies available, the nature of the questions asked does not seem to be enough to understand the influence of questioning on critical thinking. This perspective is

ACCEPTED MANUSCRIPT 7 shared by those who studied questioning without restraining their analysis to the nature of the questions asked. Beyond the nature of questions asked

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Consistent with the results of other studies, Barnum (2008) observed that the majority of questions asked by athletic training clinical supervisors targeted lower cognitive levels. However, a content analysis of recordings of supervisors and students’ interactions and interviews demonstrated that supervisors used low and high level cognitive questions in two distinctive patterns. In the first pattern, named “strategic questioning”, clinical supervisors used low-level followed by high-level questions to help students address topics in a progressive manner. Doing so, they first assess student knowledge of a subject, then, they verify if they can apply their knowledge to a clinical situation and finally, if they are able to analyze and reflect on that situation. In the second pattern, named “non-strategic questioning”, clinical supervisors asked students random questions, predominantly from the lower cognitive level, with no specific goal in mind. Barnum (2008) observed that the use of the “strategic pattern”, in contrast to the “non-strategic pattern”, encouraged students to deepen their reflection and fostered the development of critical thinking. Hence, Barnum (2008) concluded that the nature of the questions asked is not enough to understand the effect questioning has on critical thinking; it is also important to consider how different questions are sequenced.

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Gul et al. (2010) drew attention to the fact that culture and age have an influence on the use of questioning and consequently on the development of critical thinking. In doing so, they observed that the ability of medical educators to facilitate their interactions with students, to encourage questioning, to answer students’ concerns and to allow enough time for them to respond are important factors in the creation of an environment where questioning can foster critical thinking. Regarding response time, Cho et al. (2012) observed that medical educators in Korea allocated an average of 2.5 seconds to students to answer questions asked during conferences. They stated that, considering that questions asked to medical students required them to use high-level thinking, this amount of time was insufficient. In contrast, Schneider et al. (2004) observed that the amount of time allocated to medical students after asking a question did not influence their success in properly answering it, regardless of the cognitive level of the question. Therefore, these studies show that the benefits of questioning to the development of critical thinking might not lie only in the nature of questions asked.

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Questioning and problem-based learning Despite the importance of questioning in PBL, few studies can be found on the subject. This section reports on the three that we identified.

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Gilkison (2003) undertook a case study to explore how two tutors, the first with a medical background and the second with a humanity’s background, intervened in PBL sessions with medical students according to their expertise. Gilkison (2003) observed that the tutor with a medical background considered it was his responsibility to increase the students’ knowledge, whereas the tutor with a humanity’s background considered she had to encourage students to question each other. Most of the questions asked by both tutors aimed at increasing the cognitive level of the group discussion. Hence, this study pointed out that the benefits of questioning on the thinking process might not rely on the effect of isolated questions, but rather discussions. In contrast, Profetto-McGrath et al. (2004) investigated the use of questioning by 30 tutors and 314 students during PBL sessions over three years of an undergraduate nursing program. Profetto-McGrath et al. (2004) observed that the majority of questions asked represented the lower cognitive levels of the Bloom (1956) taxonomy. They concluded that most questions asked by tutors and students during PBL

ACCEPTED MANUSCRIPT 8 sessions solicited students’ memory and required them to give only short answers, which does not afford the opportunity for reflection nor critical thinking.

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A case study conducted by Valtanen (2014) in a physiotherapy undergraduate program had similar conclusions. Valtanen (2014) analyzed questions asked by 6 tutors and 55 students according to their formal roles during PBL sessions. Content analysis of PBL sessions showed that two times more confirmative questions then transformative questions were asked. Confirmative questions were described as those intended to validate the exactness or comprehension of knowledge; transformative questions were those that challenge student’s comprehension. Moreover, a relationship was observed between the formal role taken by a student and the type of question asked. Students asked more transformative questions when they were discussion leaders. Board recorders, recorders and observers asked very few questions and they were mainly confirmative. Valtanen (2014) stated that this large number of confirmative questions is not congruent with the goal of PBL sessions, which is to promote knowledge construction. This study also emphasized that student answers reflect their thinking, so they need to be considered to understand the influence of questioning on thinking processes.

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Discussion

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This scoping review aimed to examine what is known about the influence of questioning on the promotion of clinical reasoning of students in health care education, specifically in nursing and PBL. The importance of the subject lies in the fact that lives depend on nurses’ clinical reasoning (Facione and Facione, 2008), making it a crucial competence to develop during training (Goudreau et al., 2014). In nursing, PBL has been widely adopted as an educational method. Given that questioning is a learning strategy largely employed during PBL, it is relevant to explore what is known on the influence of questioning on clinical reasoning to maximize its utilization and inform further research.

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The result of this scoping review show that questioning has been studied in nursing, as it has been in general health education, in relation to critical thinking rather than clinical reasoning. Although critical thinking and clinical reasoning are often used interchangeably in the nursing literature (Benner et al., 2008; Côté and St-Cyr Tribble, 2012; Levett-Jones, 2013; Smith et al., 2013; Tanner, 2006; Victor-Chmil, 2013), these concepts are not synonymous. The absence of consensus on their definitions contributes to the perpetuation of this confusion. Critical thinking is indispensable to nursing but is not enough to provide quality and relevant care, as it appears to be just one part of the clinical reasoning process. Assessing clinical reasoning remains a challenge in nursing, as tools available to do so are rare and often inadequate (Deschênes et al., 2011). This might explain the use of tools designed to assess critical thinking.

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In the majority of the studies reviewed, critical thinking was defined using Bloom’s (1956) taxonomy. Originally, this taxonomy was developed to classify educational objectives, and Bloom (1956) was careful to warn against its use to classify questions. Bloom (1956) stated that classifying questions is more complex than classifying objectives, and that classifying questions cannot be done without considering students’ anterior knowledge and the logic underlying their answers. Not considering this information entails that all students use the same cognitive process to answer a given question and that the question and the answer’s cognitive levels are the same. In either case, we believe that these assumptions might not always be true. One student may, for example, answer an evaluation question by carefully weighing the pros and the cons of an option, while another student might answer the same question by simply repeating memorized information without really understanding it. We believe that defining a process as complex as critical thinking—which implies cognitive, metacognitive, and affective aspects—with a few cognitive abilities offers some preliminary clarification on the subject but does not fully cover it. Even though critical thinking does require analysis, synthesis, and evaluation, to conclude that the enhancement of these abilities is a consequence of high-level

ACCEPTED MANUSCRIPT 9 questions, without taking into consideration other aspects that influence questioning or critical thinking, prevents us from full comprehension. In addition, the frequency of behavior such as asking high-level questions does not seem to dictate its effect on students.

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This way of defining critical thinking as a product of the questions asked, without considering the mental processes involved in answering them, represents a behaviorist perspective in which learning equals “the form or the frequency of an observational performance (Ertmer and Newby, 2013, p. 48)” influenced by environmental factors. This view underpins a linear and hierarchical definition. We, on the other hand, view critical thinking and questioning from a more constructivist perspective, in which the former is seen as a cyclic, iterative, and dynamic process where different phases can be achieved randomly and in concomitance and where questioning is perceived as a tool to help students build knowledge through discussion.

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Blooms’ taxonomy is predominant in the nursing literature. The studies based on this framework concluded that nursing students’ critical thinking might not be promoted by questioning habits, since most of the questions asked targeted low-level cognitive skills as memorization and recall. These studies call attention to the fact that questioning is much more than just the type of questions asked, as this cannot in itself explain the benefits of questioning on students’ thinking processes. These facts are supported by studies that employed a qualitative methodology (Barnum, 2008; Giddings et al., 2000; Gilkison, 2003). From these studies, we retained that the influence of questioning on the thinking process might be most visible by considering the effect of the whole conversation inspired by a question instead if its isolated effect.

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Another aim of this scoping review was to explore what is known on the influence of questioning on clinical reasoning in PBL. The paucity of empirical work on the subject does not permit the formulation of definitive conclusions. Nevertheless, the studies identified raise concern about the way questioning is employed during PBL sessions, given that it was observed in two studies that the majority of questions asked did not aim to elevate students’ levels of thinking (Profetto-McGrath et al., 2004; Valtanen, 2014). Furthermore, these studies showed that the benefits of questioning might vary among students depending on the formal roles they take on and the educational background of their tutor. Considering that student’s formal roles often change from one PBL session to another in most PBL models, this first finding seems less problematic. However, the second finding is more concerning if students are often guided by the same tutor for a long time.

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In sum, this scoping clarifies the influence of questioning on the thinking processes of nursing students, but ambiguity remains, as the conclusions of these studies are controversial. This might be because the frameworks or methodologies they employed only partially covered the inquiry. We identified a number of gaps relating to these aspects that need to be considered in future research, including the use of adequate instruments assessing the thinking process, the use of a thinking process framework specific to nursing, the consideration of students’ questions as much as educators’, the consideration of students’ reactions to questioning, the consideration of educators’ and students’ perspectives of the use of questioning, the consideration of the cognitive as well as the metacognitive and affective aspects of the thinking process, and the focus on dialogue rather than on individual questions.

Limitations We cannot guarantee that all relevant studies have been included in this scoping review as the limited time frame, language and databases may have affected the number of articles found. In addition, this review was built from the conclusions of small and descriptive studies. Finally, our conclusions may have been influenced by the constructivist perspective.

Implications for education

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The findings of this scoping review underline some practical implications regarding the use of questioning in learning activities. First, educators need to encourage a learning environment where questioning is welcome and perceived positively. Second, the benefits of questioning need to be assessed through the generated discussion rather than by individual questions. Interactions should support students to clarify their thoughts and should guide their reasoning processes. Third, questioning needs to be used in a purposeful way for the promotion of clinical reasoning. Finding the correct answer should not be perceived as the most important part of questioning; rather, the rationale underlining it should. Finally, educators and students should both receive training on questioning to increase its effectiveness on thinking processes.

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Conclusions

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Conflicts of interest disclosure

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The aim of this scoping review was to explore what is known on the influence of questioning on nursing students’ clinical reasoning. Unfortunately, no studies were found on this subject, as questioning has been studied in relation to critical thinking but not clinical reasoning. Although every paper claimed the benefits of questioning in fostering thinking processes, more needs to be done to reinforce the empirical evidence on the subject. The assessment of the direct impact of questioning on students’ thinking processes is needed to move beyond the descriptive level of information available on the subject. Questioning is a powerful tool for educators, as it can be used with any learning method; hence, its proper use is essential in fostering the development of clinical reasoning.

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The author(s) declare that they have no competing interests.

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References

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ACCEPTED MANUSCRIPT 14 Table 1. Development of the research question using the PICO strategy PICO Students in health care education, specifically in nursing, using problem-based learning

I: Intervention

Questioning

C: Control

Not applicable

O: Outcome

Promotion of clinical reasoning

AC

CE

PT

ED

M

AN

US

CR

IP

T

P: Population of interest

ACCEPTED MANUSCRIPT 15 Table 2. Description of included studies Reference

Country

Phillips et al. (2017)

Australia

Setting Nursing

Purpose

Design

To explore the level of questions asked by clinical educators

Quantitative, descriptive

Sample

Findings

133 nurses

73% of questions asked were at lower cognitive levels

6 tutors and 55 students

More confirmative questions than transformative questions were asked

Questionnaire

Finland

Physiotherapy

Qualitative, descriptive Case study Observation

Pakistan

Saeed et al. (2012)

Nursing

To evaluate the effect of a training program on the amount of high-level questions asked

M

Didactic courses

Medicine

PT

South Korea

ED

Gul et al. (2010)

Cho et al. (2012)

United States

AC

Hessheimer et al. (2011)

CE

Didactic courses

Dental hygiene

Didactic course

Quantitative

72 educators

Randomized, controlled trial

AN

Gul et al. (2014)

US

CR

Tutorial

To explore the use of questioning according to participants’ formal functional roles

IP

Valtanen (2014)

T

Clinical experience

To explore teachers’ perceptions of their questioning techniques and their actual use of them

Tutors and group leaders asked more transformative questions Observers, recorders, and board recorders asked more confirmative questions Predominance of low-level questions 1 second was given for students to answer a question

Pre- and posttest

Intervention group asked more high-level questions

Observation Quantitative, descriptive

33 teachers

Questionnaire

In 40.4% of the class, questioning was not used at all 2.5 seconds were given for students to answer a question

Observation Teachers with more experience asked more questions

To explore the effects of low- and highlevel questions on learning and students’ perceptions of questioning

Quantitative

23 students

Quasiexperimental, crossover design with one group

No significant difference was found in student performance between low- and high-level questions on the exam Students reported positive perceptions of questioning

Questionnaire Barnum (2008)

United States

Athletic training

To explore clinical supervisors’ use of questioning

Qualitative Case study Observation

Clinical

8 clinical supervisors and 24 students

Predominance of low-level questions Identification of two questioning techniques: strategic and non-strategic

ACCEPTED MANUSCRIPT 16

United States

Occupational therapy

Seminar

To evaluate the effect of King’s questioning framework on students’ critical thinking

Quantitative

To explore the type and level of questions asked by educators and their students

Tutorial United States

No significant difference was found between the experimental and control groups regarding students’ critical thinking skills

30 tutors and 314 students

Predominance of low-level, factual questions

60 students

No significant difference was observed between groups allotted 3 seconds to answer a question and groups allotted 6 seconds

69 students

Students from the experimental group showed better critical thinking skills by scoring higher on the CCTST

2 tutors and their students

Questioning was mostly used to increase the cognitive level of group discussion

Observation

Medicine

To explore the effect of wait time on the response rate to highlevel questions

Quantitative

Quasiexperimental design

AN

Schneider et al. (2004)

Quantitative, descriptive, comparative

CR

Nursing

US

Canada

64 students

Quasiexperimental design with control group California Critical Thinking Skills Test (CCTST)

ProfettoMcGrath et al. (2004)

questioning

T

Velde et al. (2006)

Interviews

IP

experience

M

Didactic courses

United States

Medicine

Medicine

CE

United States

PT

Clinical experience Gilkison (2003)

Quantitative, prospective, Observation CCTST

To explore the use of questioning according to the tutor’s background

AC

Tutorial

To explore the effect of questioning training on students’ critical thinking skills

ED

Loy et al. (2004)

Qualitative Case study Observation

Tutor with a medical background felt it was his responsibility to increase student knowledge

Interview

Tutor with humanities background felt it was the students’ responsibility to question each other Phillips and Duke (2001)

United States

Nursing

To explore and compare the use of questioning by clinical supervisors and preceptors

Quantitative, descriptive, comparative Questionnaire

14 clinical supervisors, 14 preceptors, and 22

Clinical supervisors asked more questions and more highlevel questions than preceptors Clinical supervisors and preceptors asked more low-

ACCEPTED MANUSCRIPT 17

Nursing

To explore clinical supervisors’ use of questioning

Mixed

To determine if there is an association between clinical supervisor characteristics and the level of questions they ask

Quantitative, descriptive, comparative

To explore the relationship between selected discourse strategies and student critical thinking

Quantitative, descriptive

Observation

Clinical experience Nursing

Clinical postconference

Rossignol (1997)

United States

Nursing

Questionnaire

26 clinical supervisors

Predominance of low-level questions

10 teachers and 57 students

M

United States

Nursing

To evaluate the effect of a training program on the number of high-level questions asked

ED

Wink (1993)

CE

PT

Clinical post conference

Wang and Blumberg (1983)

United States

Nursing

AC

Clinical experience

Craig and Page (1981)

Canada

Nursing

Clinical post conference

No association found between level of questions and clinical supervisors’ characteristics or students’ academic level Questioning was the most frequently used discourse strategy

Observation

A significant association was observed between high-level questions and students’ critical thinking; 1 out of 3 times this association was negative

Watson-Glaser Critical Thinking Appraisal (WGCTA)

AN

Clinical postconference

Observation

Predominance of low-level and closed-ended questions with the aim of validating knowledge, comprehension, actions, and feelings

CR

Australia

US

Sellappah et al. (1998)

5 clinical supervisors and 8 students

T

United States

level questions

IP

Giddings et al. (2000)

students

Quantitative

14 educators

Quasiexperimental

Predominance of low-level questions A significant increase in the number of high-level questions asked by educators was observed

Pre- and posttest Observation

To describe questioning techniques used by clinical supervisors

Quantitative, descriptive

44 clinical supervisors

Low-level teaching methods were the most frequently used, such as asking a direct question and giving information

To evaluate the effects of a training program on the number of high-level questions asked

Quantitative

14 clinical supervisors and their students

Predominance of low-level questions

16 clinical supervisors and an

Predominance of low-level questions

Quasiexperimental Pre- and posttest design with control group

A significant increase in the number of high-level questions asked was observed after the training

Observation Scholdra and Quiring

United States

Nursing

To explore the relationship between the level of questions

Quantitative, descriptive

ACCEPTED MANUSCRIPT 18 (1973)

Observation

average of 9 students per class

No association was found between the level of questions asked and the course objectives

AC

CE

PT

ED

M

AN

US

CR

IP

T

Clinical post conference

asked by clinical supervisors and course objectives

ACCEPTED MANUSCRIPT 19

Highlights

T IP CR US AN M ED PT CE



Questioning has been studied in relation to critical thinking not clinical reasoning Most questions asked during learning activities targeted students memory rather than their cognitive abilities More empirical evidences are needed to understand the influence of questioning on clinical reasoning

AC

 

Figure 1