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Clinical conference started at 2:30 p.m. It is the nursing students' first day with me at the hospital. I can feel the tension in the room. They are nervous. They are wondering what this experience is going to be like. For them the questions are: Will I make it through tonight? What is this teacher like? Will she be kind to us or will she intimidate me? Why cannot I remember the drugs that I looked up last night? and Will I make a mistake? For me the questions are: "Will these students conduct safe care tonight?" "How will they react to my questions and my advice for improvement?" and "Will they stop to think before they act?" These are questions unheard by each other but ever present in the minds of the students and teachers as they start a clinical experience together.
As the students leave the conference room to start their work, I am organizing myself for the evening. I have done clinicals many times, but I wonder how I can do it better. I know I must incorporate methods that will help the students to solve problems, think critically, and work with patients and staff in a team effort. But what strategies are the most effective? What strategies do other nursing educators use to help their students link theory to practice? I am using cooperative learning in the classroom and wonder if it will it work in the clinical setting. I wonder what others are saying about the clinical experience. The following is a search of the literature for problem solving using journaling, reflection, and cooperative learning. In ERIC, there are 2,601 citations for critical thinking, for reflection 1,100, for cooperative learning 2,182, for problem solving 5,357. To narrow the search further, I used Cumulative Index to Nursing and Allied Health Literature (CINAHL). The results are critical thinking and nursing 520, reflection and nursing 455, journaling and nursing 15, cooperative learning and nursing 30, reflection, nursing, and critical thinking 32, cooperative learning and clinical nursing 2, cooperative learning, reflection, journaling, and nursing 0. After reviewing the abstracts, I chose the articles that seemed to be appropriate to the purpose of the research. I then read the articles and identified the authorities that were mentioned numerous times. The discussion of the various dialogues will be primarily from nursing and include clinical teaching, critical thinking, journal writing, reflection, and cooperative learning.

Clinical Teaching

Clinical learning activities are the "heart" of nursing programs. They are what shape the student into the professional nurse. Students spend two-thirds of their time in nursing in clinical practice. It is crucial that nursing educators understand this activity. Yet, according to Infante (1981):
clinical learning is the least studied of all nursing education activities. Many aspects of clinical learning are taken for granted, and many are rooted in traditionalism or ‘the way it is always done'. Thus there is ample room for improvement—a variety of strategies can be tested in attempts to use the clinical laboratory in nursing education to achieve learning outcomes. (p. 16)

Studies regarding clinical learning are often about the student's perception of what characteristics make a good clinical teacher (Benor & Leviyof, 1997; Flager, Loper-Powers, & Spitzer, 1988). Benor and Leviyof (1997) found that the students would like effective teachers to exhibit the following characteristics: (1) competency; (2) fair evaluation processes; (3) good instructional skills; (4) good interpersonal relationship; and (5) good personality. This list is in order of importance to the student.
The second area of study is the structure of clinical time. Using an experimental design, Infante, Forbes, Houldin, and Naylor (1989) studied the effects of synchronization of clinical laboratory experiences with instruction in nursing theory and science and collaboration of faculty, students, and nurse practitioners. Findings indicate that students in the experimental group achieved higher scores on the Mosby Assess Test (a comprehensive examination for medical-surgical nursing), college laboratory practicum scores, and grade point averages.
Graham (1995) studied the relationship between critical thinking and how
time is structured in the clinical setting. There were three groups: a control group (sophomore nursing students), a group (junior-level nursing) who spent 5 hours a day for two days in the clinical setting, and a group (junior-level nursing) who spent 2 hours on 1 day and 8 hours the next day in the clinical setting. The Watson-Glaser Critical Thinking Appraisal (WGCTA) form A and form B was used to assess critical thinking. WGCTA form A was administered to all three groups at the beginning of the semester and form B was administered at the end of the semester. There were significant differences in the groups with the comparison group scoring the lowest and the 2-hour/8-hour group scoring the highest. Even though the conclusion was that structuring time in the clinical setting makes a difference in critical-thinking scores, it is not clear as to what was happening in the control group or the effect of using students at different levels—sophomore and junior.

Problem Solving
The student stated, The blood pressure of this patient is 200/150. I rechecked the blood pressure on the opposite arm and it was 180/150. I checked the medication record and there is no order for antihypertensive medications and he has no history of hypertension. I told the nurse and she is calling the doctor.
Problems! Students face them from the time they start their clinical day to the time they leave. They need to be able to use knowledge from what they have previously learned with the problem-solving process to come up with the best solutions. Part of clinical teaching is to assist students to solve problems safely and effectively.
Problem solving, decision making, and critical thinking are often used interchangeably. According to Klaassens (1992), "problem solving is the process used to resolve or answer a proposed question or achieve an answer to a client need" (p. 29). It involves defining the problem, gathering information, analyzing the information, developing solutions, making a decision, implementing the decision, and evaluating the solutions.
Why do college students have difficulty in problem solving? The answer may lie in the fact that students are not at a cognitive functioning level to effectively problem solve. Klaassens (1992) reports that "in spite of the fact that most college courses require formal reasoning ability, most students are functioning at a concrete level based on Piaget's stages of cognitive growth. Estimates vary from 50-80% that some student populations are functioning at this lower level" (p. 29). According to Piaget's stages of cognitive development, the adolescent transitions from concrete operations to formal operation. In formal operations the adolescent can think in more abstract terms. He or she solves problems by making hypotheses, testing the hypotheses, and drawing conclusions (Wong, 1997).
Taylor (1997) showed the difference between nursing students' problem-solving abilities and the problem-solving abilities of a registered nurse (RN). The nursing students had difficulty in recognizing cues that are needed in caring for the patient and making sound decisions. The author suggested that
in order to improve novice problem-solving abilities in the clinical arena, real life situations should be used as the education vehicle. Problem-based learning as the framework for content delivery in undergraduate courses would address some of the defects identified by this study, and students should be introduced to the diagnostic reasoning process as a component of problem-based learning. (p. 336)

There are many models of problem solving that are discussed in the literature which are deemed helpful in promoting problem solving and critical thinking. One model is the Personally Perceived Problem Technique (PPPT) (Russaw, 1997). It is rooted in the inquiry-learning philosophy of John Dewey. There are four steps to the process: (1) exploration, (2) idea generation, (3) solution validation, and (4) evaluation. The tool is helpful to students crystallizing questions about a clinical situation. Another model is the Paradigm of Problem Solving (Klaassens, 1992). There are five steps in this model: (1) scanning, data gathering, (2) formulating goals, (3) planning, (4) implementation, and (5) evaluation. This model allows the student to actively collaborate with the client to solve the problem. Two others are Hypothetic-Deductive Model (HDM) and Knowledge-Driven Problem-Solving Models (KDPS) (Cholowski & Chan, 1995). Cholowski and Chan advocate the use of KDPS because it allows students to bring old knowledge to new knowledge in the problem-solving process. Students are encouraged to "think aloud" and to use interactive dialogue with the expert nurse to help connect nursing knowledge to in order to problem solve.
All of the above models are types of problem-solving models; the differences lie in who assists the students to problem solve and with whom they are problem solving. The PPPT is primarily generated with the help of the teacher. The process involves the teacher questioning the student at each of the steps so that students identify their own learning needs. The Paradigm of Problem Solving is primarily assisting the student to learn to problem solve with the patient. The student and patient are collaborating together to solve the problem. Both HDM and KDPS are to assist the student in self-directed learning. The difference lies in HDM using a systematic approach and KDPS using the process of categorization. Knowledge content is interconnected by rational links, getting the student to connect hypothesized diagnoses with reorganized clinical data and rearranged knowledge structures.
Three strategies were mentioned in the literature that may assist problem-solving ability:
1. Concept mapping is used to assist students in organizing the data about their patient in preparation for caring for them (All & Havens, 1997).
2. In Patho-flow Diagraming (Reynolds, 1994), the teacher assists the student to use the nursing process and pathophysiology to diagram the concepts in relationship to the problems presented.
3. The use of the Taba teaching model, called concept formation, assists students to become active participants in the thinking process and not mere by-products of memorization. The teacher uses signs and symptoms of the patient for whom the student is caring. With the use of guided questions, the students categorize and hypothesize to come up with a solution (Malek, 1986).
All three strategies are taught during pre-conference or post-conference time. All three strategies involve identifying the concepts and assisting the students in relating characteristics that define the concepts. These processes assist the student in storing the information/knowledge when needed. Both Patho-flow diagraming and concept mapping provide a clearer understanding of the clinical situation through the use of visual representation. Patho-flow diagraming is sequential representation. Concept mapping is like a road map with connecting pathways. Taba uses dialogue between the teacher and students in the identification of the concepts.



Decision Making

After the students have spent time in pre-conference, the rest of the time is spent in actual patient care. Students are expected to apply knowledge from the classroom to the patient. They are confronted with decision-making opportunities related to nursing intervention. The faculty make rounds to assist students in problem solving as well as assessing their progress. The time the faculty spend with the student does seem to make a difference in clinical decision making. According to Wang and Blumber (1983), interaction between students and teacher falls into three equal levels: (1) 1 minute or less; (2) 1-6 minute; and (3) 20 minutes or less. The less time the faculty spends with the student, the more lower-level interactions occur. "The results of this study indicate that students' thinking abilities may not be encouraged by faculty due to the preponderance of low-level techniques, or that the students do not have necessary information for clinical decision making" (p. 149). The implication is that faculty need to spend more time with students and use higher-level interaction techniques. But is that possible with the numbers of students a clinical instructor usually is supervising?
In nursing, decision making is often interchangeable with problem solving, but they are different. "Solving a problem may require making a number of decisions and making a decision may involve solving a number of problems" (Kozier et al., 1995, p. 190).
There are many definitions of clinical decision making. Shamina (1991) defines clinical decision making as "command of the knowledge base related to the decision, and the ability to select and combine facts appropriately from this knowledge base" (p. 59). She examined the effects of systematically teaching decision analysis to students. The results showed the nursing students were able to prioritize clinical interventions in accordance with clinical experts. They continued to do so after they had been taught this method.
Tsychikota (1993) "defined clinical decision making as the formulation of hypotheses and/or the selection of nursing interventions, and includes the thoughts that precede choice" (p. 389). In her study, the group that had internal locus of control verbalized more decision-making elements than those with external locus of control. Therefore, "the internal subject used significantly more of complex decision-making processes than did the external subjects" (p. 394). The researcher suggested
that learning [decision making] can be facilitated by using guided discussion and research in case studies that are composed of data sets of varying complexity and degree of ambiguity. In addition, nurse educators can help students learn how to make decisions under circumstances that closely reflect actual practice by sharing personal experience and expertise with them. (p. 396)
Jenks (1993) recognized that a complex activity like clinical decision making entails multiple patterns of knowing. She used a qualitative research methodology to gain a practice-based understanding of clinical decision making. She reported on personal ways of "knowing." Personal ways of knowing included the patient, the doctors, and interpersonal relationship with staff. These affected nurses' clinical decision making. Jenks concluded that "creating teaching methodologies that recognize the importance of the multiple patterns of knowing in clinical decision making could well result in more effective education for clinical practice" (p. 405).



Critical Thinking

In post-conference, I usually share the definition of critical thinking suggested by Paul (1993): "Critical thinking is thinking about your thinking while you are thinking in order to make your thinking better" (p. 91). It is the one definition that students seem to understand. It also corresponds with Rubenfield and Scheffer's (1995) simple formula which helps student nurses to understand thinking and doing aspects of nursing so that they can reach their goal of "being a good nurse." "The patient + you + thinking skills + content knowledge + nursing process (problem solving) = good nursing" (p. 39).
There does not seem to be agreement about the definition of critical thinking, but
Facione (1984) states: "Whatever ‘critical thinking' means, it simply cannot be
allowed to mean anything a person wants, for at that abysmal level of individualistic relativism, communication breaks down entirely" (p. 255). Dewey (1933) describes the process of thinking:
Thinking enables us to direct our activities with foresight and to plan according to end-in-view, or purposes of which we are aware. It enables us to act in deliberate and intentional fashion to attain future objects or to come into command of what is now distant and lacking. By putting the consequences of different ways and lines of action before the mind, it enables us to know what we are about when we act. (p. 17)

The Foundation for Critical Thinking (1997) lists the following that would be helpful in teaching critical thinking.
1. Help students to better produce and assess intellectual work as well as act more "reasonably" and "effectively" in the world affairs and personal life. 2. Help students assess their work and action using intellectual standards essential to sound reasoning and personal and professional judgment.
3. Help students exercise more skilled and proficient reasoning and problem solving in a diversity of fields.
4. Help students think more clearly, more accurately, more precisely, more relevantly, more deeply, more broadly, and more logically.
5. Help students to become lifelong learners with more of the capacity to deal effectively with a world of accelerating change. (p. viii)


Critical Thinking in Nursing

The National League for Nursing (NLN) mandates that nursing programs be accountable in assessing critical thinking in nursing education. "The responsibility that nursing faculty feel for ensuring that entry level professionals can make sound professional judgments is grounded ultimately in a concern for health and welfare of the clients and the communities our graduates will serve" (Facione & Facione, 1996b, p. 42). "Nursing ultimately can enhance the quality of their practice by examining their thinking" (Colucciello, 1997, p. 237). Colucciello (1997) found there was a significant difference in critical thinking skills among students at different academic levels.

Critical Thinking in Clinicals
Critical thinking and professional judgment are often used interchangeably, and Facione and Facione (1996b) explains how they are related.
The scope of critical thinking in the context of professional judgment in nursing is remarkably broad. Focusing only on critical thinking in the context of clinical practice is too restrictive. It underestimates the rich range of professional responsibilities expected during management and supervision, peer leadership, public health education, collective bargaining, policy making or membership on boards regulating professional practice standards. (p. 42)

Heaslip (1996) advocates the use of reflection of the narrative notes that are written by students in nursing charts. Students who have the opportunity to reflect on their thought processes will become independent critical thinkers.
A process called "Critical Thinking Rounds" is used to practice dialogue with various levels of nurses and students to enhance critical thinking, decision making, and clinical judgment of students. Using 6 to 14 people at a time, these rounds can be conducted in a conference room or at the bedside of the patient (Schumacher, 1996). Research results were not available at the time of writing the article.
Alexander and Giguere (1996) paired undergraduate and graduate students together to facilitate the development of critical thinking and holistic-intervention competencies. They used a case study approach and concluded that it is a good teaching tool. Whiteside (1997) designed a model based on three dimensions of memory—semantic, episodic, and productive. Their results suggested that critical- thinking skills can be improved with the use of the model. Perciful and Nester (1996) used computer-assisted instruction throughout the clinical experience. The comparison group scored significantly higher than the control group on assessing, analyzing, and evaluating. They suggest that computer-assisted instruction can be used to promote critical thinking.

Reflection and Connecting Theory to Practice
Reflection is a complex process where feelings and thinking are closely linked. Broussard and Oberleitner (1997) define reflective thinking "as careful consideration and concentration regarding one's own thinking" (p. 335). According to Boud et al. (1985), reflection is "an important human activity in which people recapture their experience, think about it, mull it over and evaluate it" (p. 19). Although experience alone does not always produce learning, reflection and experience together do seem to transform the learning into knowledge. "Reflective education aims to help students take each client encounter as unique and constantly arrive at a new or revised interpretation of the meaning of an experience" (Wong, 1997, p. 447).
Schön (1991) argues that a reflective practicum can help form a bridge between the worlds of theory and practice. Although he talks mostly about professionals using reflection as a part of practice, reflection can assist students to learn about their own reality which would help them to link theory they are learning to clinical experience.

Journaling as Reflective Practice
I enjoyed my clinical experience. I feel that when I am at my clinicals that I learn the most about nursing. I did a nursing care plan the way the RNs do in the hospital. I also really enjoyed my time with my patient. I was nervous when I first greeted her. I was afraid I wouldn't be able to communicate well with her because of her shortness of breath, but it wasn't a problem. She let me glimpse a small part of her life and it was very pleasant (Journal 110, p. 5).
In the past 15 years, journal writing has become popular in nursing education. It is a strategy used to develop the practitioner of nursing. It is also believed that it will help bridge the gap between theory and practice and assist students to think critically. Hahnemann (1986) advocates the use of journal writing. "We believe that journal writing has been a valuable tool that encourages clearer thinking and better learning. Our students are able to take theory and apply it in their practice. They have the ability to express their thoughts and feelings in writing" (p. 215).
Facione and Facione (1996a) recognize that journal writing is a valuable source to of evidence of critical thinking in students.
Self-reports can be a rich source of information about students' metacognitive reflection as well as their interpretations, evaluations, and analysis. Student journals structured around questions that call for reasons as well as opinions and explanation as well as description can provide qualitative self-report data. . . . They [journals] invite students to engage in some metacognitive reflection about their own thinking and provide some evidence of both their critical thinking skills, and their habits of mind. (pp. 50, 51)

Degazon and Lunney (1995) discuss the purpose of writing in relationship to the
metacognitive process.
The ability to recognize, analyze and discuss thinking processes, i.e., metacognition develops as the writer focuses on thinking processes. Because metacognition is continuously useful as a tool for self-modification, development of this skill provides a basis for growth as a thinking professional. Discussions with, and writing for others expand the pool of viewpoints from which alternative decisions can be selected. The journal writer should recall one or more clinical situations as soon as possible after the clinical day. . . . Timeliness facilitates accuracy in recognizing, analyzing, evaluating and validating (or refuting) thinking processes that occur in relation to the situation (s). (pp. 271, 272)

The clinical setting is rich with thinking and problem-solving activities. Outside of post-conference there is very little opportunity for the student to discuss these experiences and try to integrate the knowledge and ideas into their own reality. "Thus, much of what occurs in practice remains unspoken and unheard. Journals are a means through which nurses can speak and listen to the voice of practice" (Holmes, 1997, p. 491).
There are various ways that journals can be used. According to Seschachari (1994), "the purpose of the instructor-mediated journal is threefold: to enable students to (1) overcome the fear of writing, (2) enhance their critical thinking, and (3) raise their level of discourse within the discipline, so that they merit higher scores in college-level examinations" (p. 7). Journals can be used for comparing (looking for similarities and differences), summarizing reading or activities just performed, for observation, interpretation of data, criticizing and looking for assumptions, applying fact and principles to new situations, and decision making (Zacharias, 1991). Journal writing can be done as personal journals, dialogue journals, where the student and the teacher maintain a written dialogue throughout the course, class journals, and cooperative learning group journals in which group members share ideas with each other and the teacher (Jacobson, 1989; Reinertsen & Well, 1993; Tryssenaar, 1995). Landeen, Byrne, and Brown (1995) explored the use of journals in identifying important issues facing nursing students when learning in a psychiatric setting. Their conclusion was that the journal provided the student with an opportunity to be more self-reflective in his or her practice.
Journal writing does not come without problems. Paterson (1994) and Zacharias (1991) suggest that journals should have specific questions or guidelines for students to follow and a climate of trust. Abegglen and Conger (1997) used journaling as a tool for critical thinking in a community-health nursing course. They had to change their criteria so that students would reflect and apply community-health nursing concepts and principles to practice. For them, journaling is not just a mere retelling of the experience. At the end of the quarter they had the students give a self-assessment after they reread their journals. The students discovered for themselves how much learning and thinking had taken place.

Dialogue and Reflective Practice
Students engaged in active learning through dialogue retain information and develop cognitive skill (Gelula, 1997; Rossignol, 1997). Through the use of dialogue and reflective practice the essence of nursing practice is facilitated when students and RNs share "therapeutic" practice together (Schumacher, 1996). Paul (1993) defines dialogical thinking:
Thinking that involves a dialogue or extended exchange between different points of view or frames of reference. Students learn best in dialogical situations, in circumstances in which they continually express their views to others and try to fit others' view into their own. (p. 464)

Sedlak (1997) and Wong et al. (1997) discussed the following regarding their findings on dialogue and journal writing. To the researchers, dialogue is a form of reflective conversation. It was found that journal writing and dialogue complemented each other in facilitating student reflection. In the dialogues, the students could share their ideas among peers and gain further insight during the discourse. It was often observed that ideas discussed in dialogue sessions were incorporated in subsequent journal writing. Students expressed the view that the dialogues were stimulating and that they could be exposed to different dimensions in viewing the world.

By using questioning, students learn to justify their position and to support their arguments through logic. Questioning facilitates critical thinking. It moves the student from passive learning to an active form of learning (Lambright, 1995; Schoeman, 1997). Questioning techniques such as teacher high-level questions and probing questions, elaboration of students' ideas, and students' participation may serve to encourage and focus student's thinking in these critical cognitive activities (Rossignol, 1997). Questions in written form help link prior knowledge with skill acquisition, decision making, and the release of feelings (Patton et al., 1997).

Cooperative Learning
Cooperative learning goes far back in history. According to Johnson et al. (1998), cooperative learning is as old as history. A quotation from Eccl 4:9-12 is used.
Two are better than one, because they have a good reward for toil. For if they fall, one will lift up his fellow, but woe to him who is alone when he falls and has not another to lift him up. . . . And though a man might prevail against one who is alone, two will withstand him. A threefold cord is not quickly broken. (p. 1:14)
Throughout history such people as Quintillion, in the first century, Seneca, a Roman philosopher, and Johanne Comenius (1592-1679) believed that students could teach each other and they could learn from each other. Cooperative learning came to the United States through the founding of the "Lancastrian school" in the 1800s. This was a model that dominated American education through the turn of the 20th century. John Dewey promoted cooperative learning as a part of instruction (Johnson et al., 1998).
The first research study on cooperative learning occurred in 1889. Since then there have been more than 600 experimental studies on cooperative learning that considered the competitive versus cooperative environment in the classroom (Johnson et al., 1994). The leading research groups in the field of cooperative learning in the classroom were led by Roger and David Johnson at the University of Minnesota and Robert Slavin at Johns Hopkins University. Their results indicated that cooperative learning increases academic achievement, critical thinking, self-confidence, and cooperative spirit (Gabbert, Johnson, & Johnson, 1987; Johnson et al., 1998; Slavin, 1988a,1988b, 1989). Ellis and Fouts (1997) state: "Cooperative learning is one of the biggest, if not the biggest education innovation of our time. It has permeated all levels of teacher training from preservice to inservice" (p. 165). There continues to be studies at various levels of education as to the effect of cooperative learning on the individual student's achievement, thinking, and interpersonal relationships. Slavin (1989/1990) challenges educators to research how cooperative learning advances higher-order conceptual learning.

Cooperative Learning in Higher Education
College teaching has been changing. According to Johnson et al. (1998), faculty should think about the following principles:
1. Knowledge is constructed, discovered, transformed and extended by students.
2. Students actively construct their own knowledge.
3. Learning is a social enterprise in which students need to interact with the instructor and classmates.
4. Faculty effort is aimed at developing students' competencies and talents.
5. Education is a personal transaction among students and between the faculty and students as they work together.
6. Education is a personal transaction among students and between the faculty and students as they work together. (pp.1:9-11)

If faculty believe this, then learning should take place within a cooperative environment.
In their meta-analysis of the use of cooperative learning in college or adult settings, Johnson, Johnson, et al. (1998) found over 305 studies conducted since 1960 that compared cooperative learning with individualistic learning on individual achievement. Benefits and outcomes of cooperative learning included increase academic success, increase perception of greater social support and establishing better relationships, personal adjustment to college, and more positive attitudes towards the college experience. Springer, Stanne, and Donovan's (1999) meta-analysis of science, mathematics, engineering, and technology also demonstrates, greater academic achievement, more favorable attitudes toward learning, and increased persistence when cooperative learning is used. In my search of the literature on cooperative learning in higher education the benefits of cooperative learning are academic achievement (Daley, Onwuegbuzie, Anthony & Bailey, 1997; Gooden-Jones, 1996; Kim, Cohen, Booske, & Derry, 1998; Necessary & Whilhite, 1996; Pezeshki, 1998; Rupnow, 1996), decreased anxiety, increased motivation, change in attitudes (Fitzgerald, Hardin,& Hollingsead, 1997; Hazelbaker, 1997; Hill & Ross, 1996; McInerney, 1996; Stern, 1996; Watson, 1996), and greater amount of time discussing in groups (Doran & Klein, 1996; Wathen & Resnick, 1997).

Cooperative Learning in Nursing
Nursing recognizes the use of cooperative learning in the classroom as a strategy to promote critical thinking and problem solving. Students taught using problem solving and decision-making skills with the use of cooperative learning had a better self-perception of problem solving and decision making than did the students who were taught using lecture methods (Baumberger-Henry, 1998).
Abegglen and Conger (1997) write of their experience in a Community Health course where faculty tried to infuse critical thinking into the curriculum. The authors believe that nursing requires active learning. "If faculty expect students to think critically, then students must practice and faculty must role model, and one way to model critical thinking is through group discussion and problem solving" (p. 453). The small-group activities remained consistent throughout the year.
Beck (1995) reported that a "cooperative learning model can be an effective means of teaching nursing content" (p. 226). In Beck's (1995) and Thompson and Sheckley's (1997) study on cooperative learning in the classroom, the students commented that it was a positive experience and it increased their thinking.

Cooperative Learning in Clinicals
Cooperative learning as a term does not appear in the literature on clinical activities, but studies with the use of peer collaboration do appear. The primary purpose for using peer collaboration was to increase leadership skills, increase collaboration skills, and to enhance critical thinking. As the result of these experiences, students discovered that their peers were a good resource of knowledge and problem solving as well as enhancing each other's technical skills (Bos, 1998; Ford-Gilboe, Laschinger, Laforet-Fliesser, Ward-Griffin, & Foran, 1997; Gerace & Sibilano, 1984).

I learn a lot from my partner. She and I can talk together regarding the problems that have arisen. I wish every teacher did this. Clinical experience presents many challenges to the students and it is important that clinical instructors understand how learning take place in the clinical setting. Research on clinical learning supports that good clinical teachers possess characteristics that are conducive to students learning, and that structured time in the clinical setting promotes learning and critical thinking. In order to assist students in the problem-solving process they face in the hospital setting, teachers need to be aware of the cognitive level of students and use a variety of strategies that specifically assist them to build on their knowledge in the problem solving process.
My review of the literature shows that methods used to promote critical thinking and reflection in the clinical setting are dialogue, pairing students, computer-assisted learning and the use of journaling. The number studies in these areas, however, are small thus leading to the reason for studying the clinical setting which will be discussed in chapter 3.