Clear skies ahead: optimizing the learning environment for critical thinking from a qualitative analysis of interviews with expert teachers

“Setting the atmosphere”: Creating a safe environment to facilitate CT

This theme relates to faculty descriptions of establishing a safe environment

Ground rules

Discussing expectations, values, and norms with learners at the start of a classroom or clinical experience

I think it starts off initially with some groundwork setting the atmosphere. Whether that’s a classroom setting, or lab, or clinical, students and faculty … everyone … needs to feel … respected. Their opinions are important. The classroom … needs to be a setting where people feel relaxed and safe … students get a lot of positive feedback and … see that it’s okay to make mistakes or think out of the box, to be creative. S2F16

Building trust

Statements indicating that feedback is intended to support learning and not be shaming

It’s a supportive learning climate with positive role modeling rather than shame-based or criticism-based, overly critical. It’s critical in a healthy sense … critical without being overly critical; thinking without overthinking; feeling without overreacting. Those kinds of things are really important. S3F40

Safe to be wrong

Explicit statements about importance of learning and thought process rather than having the “right answer”

So you remove the intimidation factor. In other words, you can make all the mistakes you want. No one is going to be hearing it. I tell them ahead of time, “I’m not looking at your answers. I’m never going to see them. That’s not what the discussion is about. It’s about what you learn.” S4F10

Respect

Modeling and/or explicitly stating the value of respect

I’m really explicit that I really could care less about what their conclusion is. I care about the argument that they make to support their conclusion. That’s important … for establishing the safety of the environment. S7F10

Empathy

References to empathy in the teacher-learner or learner-learner relationships

I think empathy is [important]—and just as it is another reason why the doctor-patient interaction is very similar to the attending-learner interaction. S8F39

Maintaining the climate: Behaviors and explicit norms and values that sustain the environment for CT

Specific faculty behaviors, norms, values, and expectations of learners for maintaining a supportive environment

Adjust to learner level

Faculty behaviors related to adjusting their teaching to the learner’s level of training and receptivity

If they’re so early in their knowledge base that the challenge for them is just simply to put the knowledge base in … then you can’t challenge that knowledge base; they’re busy still acquiring it. S6F9

If I have different levels of learners, we’ll move upstream starting with the most junior learner, asking some questions and then move on to somebody who’s a little more senior … trying to keep everybody engaged. If you get the sense that someone is intimidated, then you obviously try to make it easy for them, so again, the engagement is not one that’s intimidating or something that’s going to be a fearful experience for them. S8F44

Push

Faculty behaviors of gently pushing, inviting, encouraging, or nudging learners for ideas (includes descriptions of explaining this explicitly to learners)

I have the pictures of the students in front of me. I think it helps to … use their names and to show investment that, “Okay, I heard you. This is what you said, thank you Carol. Josh, can you take Carol’s point one step further?” Sometimes they need that, sometimes they don’t … Sometimes it really does take an invitation to the conversation. S8F15

Then the other thing that I do, and I haven’t seen anything about this in the literature, but I think it helps, is, and I introduce it to my students actually, I warn them, I say, “I’m gonna ask you ‘why’ a lot, and it’s gonna irritate you.” S7F10

What I feel like I’m trying to do in teaching is do that sort of gentle nudging and highlighting of other possible perspectives and encouraging folks, even if they don’t necessarily agree with what’s being presented, to interrogate and think about that disagreement and to be more thoughtful or specific about what it is that they find challenging or wrong or problematic about whatever position it is that I’m presenting. S3F5

Respectful disagreement

Establishing norms of disagreeing with respect and engaging honestly about differences

My experience has been that … you start slowly and build up the trust, the relationship, the safe space that you mentioned earlier for having these sorts of discussions and sort of getting the group to a point where they can have really fruitful disagreements with each other, but also with me as well, and for there to be that … respectful back and forth. S3F7

Some of it is at the outset of the tutorial for me being explicit about the … training that I come from … that expressing disagreement and challenging people is how you express respect, and the worst thing you could do to someone is just sort of say “Oh, that’s nice” to their paper and move on. It’s really that engagement that shows that you think that someone and their thinking is worthwhile. S3F5

Healthy skepticism

Faculty promoting learner stance of skepticism and not accepting information at face value

I’d just like to reinforce that I think critical thinking embodies skepticism; it embodies judgment about reliability of data and incorporates that into final judgment-making; that those are the sorts of things that a competent health professional should, I believe, bring to their approach to their profession. That’s personal, but I think a healthy dose of skepticism is a good way to encourage people to think closely and carefully about how they approach the information they have at their disposal. S3F14

Uncertainty is acceptable

Faculty advocating for learner cognitive recognition and acceptance of uncertainty

The work that we do in ethics emphasizes that there is always uncertainty and that context matters and things are gray as opposed to black and white. I think it’s something that I try and tie into other uncertainties that they might experience and sort of say that it’s not just about the ethics, but it’s about medicine and human bodies and complexity and things like that. S3F5

You can’t put it all together and yet they need to have the confidence and the ability to … make best guesses or to deal with unknowns … I think that’s also really a part of critical thinking that’s important and difficult for students sometimes. S8F5

Tolerance for discomfort

Faculty supporting student (and faculty) affective aspect of tolerating the discomfort of not knowing or struggling with new ideas

One of my theories about critical thinking is that it requires a certain amount of acceptance and tolerance of emotional discomfort, on the part of the student, as well as on the part of the teacher. I think the teacher has to be willing to tolerate the discomfort of asking questions that will challenge a student and allow them to kind of be challenged … Then the student has to have the capacity to … tolerate the not-knowing or the not-being-sure and kind of having to think out loud or to risk being wrong. S4F27

I think if you put someone in a situation that maybe isn’t completely comfortable, because … maybe they’re not as prepared for that particular question, but they tend to learn from that, and really retain that information. S6F38

Part of what I do is encourage and promote that kind of emotional willingness … and acceptance of that sort of discomfort as part of the process. I try to give my students permission to be wrong—to try and fail—to take small steps in the direction that they sort of want to go in terms of their learning, even if it’s not perfect. S4F27

Weathering the storm: Challenges that arise for faculty and learners

Time & effort

Faculty and learner time and effort required

I have noticed that as time becomes more a factor … toward the end of the course one is more inclined to just give a straight answer; but that reinforces the student’s wish, whatever the background of students, simply to memorize … Now it’s very time-consuming to do that … but I’d rather have them work through it than to have them simply told that that is what it is and go away and look it up. S3F14

I see that more and more … “Well, I can just find [it] on the web” … They get frustrated. … I think it causes their brains to hurt a little bit because a lot of them are like, “Where’s the easy answer? Well why won’t you just tell me?” S2F7

Now it’s very time-consuming to do that …, and students … sometimes are not tolerant of being treated in that fashion, but I’d rather have them work through it than to have them simply told that that is what it is and go away and look it up. S3F14

Negative evaluations

Pushing students to think can result in negative evaluations from learners

I’ve mentioned the feedback tends to vary from very positive to occasionally very negative. I think if I was looking for a technique that would win the teacher the popularity stakes, I probably wouldn’t go for critical thinking. S3F37

I don’t always have great evaluations. Some students don’t—I tend to push this—not this concept, but I push students to think. I want to push students to think. I’m very passionate about it. Some students don’t react well to that. There’s always the few that are—think of it as me being mean or critical, but it’s not. It’s honestly only to help them and help them evolve as a professional nurse. S2F7

Learner challenges: Technology shortcuts

Technology providing superficial information and limiting learners’ thinking

I believe the electronic medical record has not facilitated clear medical communication. We get lots of words but it’s not very information-dense and there’s a tendency to copy and paste, for instance, the assessment … should have evolved and changed by now, but it’s like a fly in amber: it’s frozen; it’s not changing. S7F13

Learner challenges: Resistance to effortful learning

Students not wanting to think through issues

If they give answers such as, “Because that’s the way we always do it”, or it’s very obvious that they’re just trying to regurgitate some information that they know, but they’re not really applying the info, I can usually pick up on it pretty quickly. Usually, by their answers I can tell if they’ve thought through the alternatives, and/or if they just said an answer that they thought that that’s typically how we do it, and that’s why we should do it, in that case. S6F38