W.A.I.T.: Impact on Teaching Clinical Judgment

by Susan Sportsman, RN, PhD, ANEF, FAAN

After being a faculty for many years, I find that I often want to “instruct” my family and friends. This urge is particularly prevalent with my husband. Being a very nice man, when I begin to “instruct” him, he appears to be listening (he looks my way), but the look in his eyes says very clearly,  “I have no intention of doing whatever it is that she is saying.” When I see this look, I always say, “W.A.I.T.—Why Am I Talking?

For the last several months in this blog, I have been highlighting the Clinical Judgement Model developed by the National Council of State Board of Nursing (www.ncsbn.org/next-generation-nclex.htm).  As you may remember, this model emphasizes that problem solving and critical thinking are the unobserved activities that together propel us toward making an appropriate clinical judgement. Thus, our goal as a faculty is to facilitate students’ acquisition of necessary knowledge and also the ability to adapt their knowledge to the particular context in which they are practicing.  When faculty in class, lab, or clinical experiences spend the majority of time “instructing,” students are not being encouraged to put the pieces together in a particular context. I suggest that when we find ourselves in any teaching situation talking more than the students, we should ask ourselves, “W.A.I.T.  Why am I talking?” Why is this pause in our instruction so important?

A review of ways that the human brain thinks and solves problems will help us answer this question.  Solving problems can happen one of two ways:  (1) We can pull information from memory, finding and filtering new information, then combining the information and weighing the alternatives to make a decision; or (2) a “gut instinct,” which comes from the more primitive emotional part of our brain—somewhat like the mental equivalent of a reflex.  However, the most creative problem solving is the process of using both approaches—mulling over a problem and then letting our unconscious mind take over (Phillips, 2006).

Neuroimaging has given us a look into the functioning of the brain during problem solving.  The striatum (found in the inner core of the brain) has three sections and each section seems to work the hardest during a specific decision-making process. One section is activated at the start of the process, as if it was managing the organization of the thoughts. The second part starts up when the analysis of the options is under way, and the third appears to control preparation of actions to be taken. Interestingly, another area of the brain important in problem solving is the prefrontal cortex at the front of the brain.  Even when the person has abandoned the actual decision-making process and turned to routine tasks, the brain is still engaged with the idea.  Often the solution will “pop” into your brain, when you least expect it (Millraney, 2019).

Willis (2007) provides us with some principles about ways to enhance students’ learning based upon research into the activities of the brain, including:

  1. When students engage in cooperative group learning activities, a brain scan shows facilitated passage of information from the intake areas into the memory storage regions of the brain.
  2. Based upon neuroimaging, we know that the more a student is engaged in a learning activity with multiple sensory modalities, the more parts of the brain are actively stimulated.
  3. The process of collaboration is associated with increased neural activity in relational and emotional memory connections and long-term memory storage.

 To summarize, students experienced a greater level of understanding of concepts and ideas when they talked, explained, and argued about them with their group, instead of just passively listening in a lecture or reading a text.

What does an understanding of the neurological activity during problem-solving mean for those of us who are helping students make clinical judgments that are evidence-based and appropriate for the context? Our focus must be on developing teaching-learning strategies that activate this type of neurological activity.  Here are some suggestions that we have not yet discussed in this blog.

Supplements for Lecture

Brame (2016) suggests three activities that can be interspersed throughout a lecture in order to stimulate the neurological activity occurring during problem-solving.

  1. The Pause Procedure—Pause for two minutes every 12 to 18 minutes, encouraging students to work in pairs to discuss and rework the notes they have taken. This approach encourages students to consider their understanding of the lecture material and provides an opportunity for them to question and clarify their understanding (Brame, 2016).
  2. Retrieval practice—Pause for two or three minutes every 15 minutes and asks students to write everything they can remember from the past 15 minutes of lecture. This approach helps student to retrieve information and improve long term memory, it increases the ability to learn subsequent materials, and translates information into new domains. (Brame, 2016)

In Skills or Simulation Lab

  1. Before a demonstration (or brief simulation) ask students to predict the results of the demonstration you are about to give. Ask them to briefly discuss their predictions with another student. After the demonstration, ask them to describe what actually happened and how it was different from their prediction. This approach asks students to test their understanding of a system by predicting an outcome. If their prediction mirrors the demonstration, this reinforces their understanding, and if it does not, it helps them see the misconception and prompts them to restructure their mental model (Brame, 2016).

Activities to Replace Part of Lecture

If you are teaching a process or a sequence of actions, you might try this approach:

  1. Give students the steps of the process on strips of paper that are jumbled; ask them to work together to reconstruct the proper sequence. This approach can strengthen students’ logical thinking process and test their mental model of a process. (Brame, 2016)

So next time you experience the W.A.I.T.—Why Am I Talking? response in classroom, lab, or clinical, I would suggest that you use these suggestions—or the many other active learning strategies you know—to facilitate the development of clinical judgment in our students.

References

Brame, C. (2016) Active Learning. Vanderbilt University Center for Teaching. https://cft.vanderbilt.edu/active-learning/. Retrieved, April, 2019.

Millraney, L.  (2019) The Brain and Problem Solving: Areas and Process. Chapter 4. Lesson 7. https://study.com/academy/lesson/the-brain-problem-solving-areas-process.html.  Retrieved, April, 2019.

Phillips, H, (2006) FAQ:  the Human Brain, Psychology 302.  Cognitive Psychology.  Study.com. https://www.newscientist.com/article/dn9970-faq-the-human-brain/.  Retrieved, April 2019.

Willis, J. (2007) Cooperative Learning is a Brain Turn-On.  Middle School Journal, 4-13. http://www.radteach.com/page1/page9/page9.html.  Retrieved, April, 2019.

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