Nursing Teaching Strategies by Encouraging Students’ Questioning, Argumentation and Explanation

Estrategias de Enseñanza de Enfermería, fomentando a los estudiantes a la cuestión, la argumentación y explicación

Dayse Neri de Souza Francislê Neri de Souza About the authors

Abstracts

Nursing students need to develop competences in the field of explanation, argumentation and questioning as they are pivotal to foster a relationship with their patients and achieve a greater humanisation of care. The objective of this paper is to analyse the perception of 1st-year nursing students with regard to the humanisation of care provided to patients by encouraging them to discuss real-life episodes. The study is qualitative and content analysis used the students’ questions, explanations and argumentation as core discourses. Among other conclusions, results point towards the importance of promoting activities that encourage the different nursing students’ discourses and the ability to understand the humanisation and dehumanisation patterns arising from the real-life episodes used as case study.

nursing education; questioning; explanation; argumentation; discourse; strategies; active learning


Los estudiantes de enfermería tienen necesidad de desarrollar competencias de explicación, argumentación y cuestionamiento porque estas son fundamentales también para que puedan mantener una relación con sus pacientes en el sentido de una mejor humanización de los cuidados. El artículo presente tiene como objetivo analizar la percepción de los alumnos de 1er año de enfermería respecto a la humanización de los cuidados a los enfermos, en el contexto del incentivo a la discusión de episodios de la vida real. El estudio ha sido de carácter cualitativo y el análisis del contenido tuvo como principales discursos las preguntas, la explicación y la argumentación de los estudiantes. Los resultados apuntan, entre otras conclusiones, a la importancia de la potencialización de las actividades que estimulan los diferentes tipos de discursos de los estudiantes de enfermería y la capacidad en entender los estándares de humanización y deshumanización a partir de episodios de la vida real usados como caso de estudio.

educación en enfermería; cuestionamiento; explicación; argumentación; discurso; estrategias; aprendizaje activo


Os estudantes de enfermagem necessitam desenvolver as competências de explicação, argumentação e questionamento porque estas são fundamentais também para que possam manter uma relação com seus pacientes no sentido de uma melhor humanização dos cuidados. O presente artigo tem como objetivo analisar a perceção dos alunos do 1º ano de enfermagem acerca da humanização dos cuidados aos doentes, no contexto do incentivo à discussão de episódios da vida real. O estudo foi de cariz qualitativo e a análise de conteúdo teve como principais discursos as perguntas, a explicação e a argumentação dos estudantes. Os resultados apontam, entre outras conclusões, para a importância de se potencializar as atividades que estimulam os diferentes tipos de discursos dos estudantes de enfermagem e a capacidade de perceberem os padrões de humanização e desumanização a partir de episódios da vida real usados como caso de estudo.

ensino de enfermagem; questionamento; explicação; argumentação; discurso; estratégias; aprendizagem ativa


Introduction

Nursing students are expected to develop critical thinking competences and make decisions regarding patient care. In the words of Myrick and Yonge(11. Myrick F, Yonge O. Preceptor questioning and student critical thinking. J Prof Nurs. 2002 May;18(3):176–81. ) “Clinical decision making and the ability to make a clinical judgment requires relevant knowledge for application to the clinical situation, skill in data collection, and knowledge of appropriate strategies for effective problem solving with patients. Clinical decision making requires the ability to think critically”.

These authors consider that the formulation of stimulating and challenging questions is the most important skill that the clinical nurse instructor or preceptor can provide and add: “At best, effective questioning can trigger preceptees to think critically and thus enhance their problem-solving and clinical decision-making abilities by stimulating the highest level of thought processing”(11. Myrick F, Yonge O. Preceptor questioning and student critical thinking. J Prof Nurs. 2002 May;18(3):176–81. ). It is believed that when faced with issues about patients’ real-life situations, students can make effective clinical decisions, remember relevant knowledge, interpret and adapt this knowledge in light of the specific situation that is questioned.

While discussing the importance of the nurse preceptor’s questioning skills to help promote and develop the students’ critical thinking these authors state that the inclusion of questions "can challenge the way preceptees think, encourage them to justify or clarify their assertions, promote the generation of original ideas, explanations, or solutions to patient problems, provide mental and emotional tools to help resolve dilemmas, promote discussion, and evaluate learning."(11. Myrick F, Yonge O. Preceptor questioning and student critical thinking. J Prof Nurs. 2002 May;18(3):176–81. )

Despite this, researchers have realised that students do not formulate questions and when they do they are scarce and of a low cognitive level. These few questions are almost exclusively for the purpose of memorising information or lead to yes/no-type answers. Frambach et al.(22. Frambach JM, Driessen EW, Beh P, van der Vleuten CPM. Quiet or questioning? Students’ discussion behaviors in student-centered education across cultures. Stud High Educ [Internet]. 2013 Jan 9 [cited 2014 Sep 24];39(6):1001–21. Available from: http://www.tandfonline.com/doi/abs/10.1080/03075079.2012.754865
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) attribute this questioning pattern to several factors: “Uncertainty and tradition, group relations and face, hierarchical relations, and achievement and competition were generally found to inhibit students from speaking up, asking questions, and challenging others in discussions.”

In their research the same authors(22. Frambach JM, Driessen EW, Beh P, van der Vleuten CPM. Quiet or questioning? Students’ discussion behaviors in student-centered education across cultures. Stud High Educ [Internet]. 2013 Jan 9 [cited 2014 Sep 24];39(6):1001–21. Available from: http://www.tandfonline.com/doi/abs/10.1080/03075079.2012.754865
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) discuss four cultural factors and six contextual factors which inhibit and increase the eastern and western nursing students’ argumentative behaviour. These four cultural factors are: (1) uncertainty and tradition, (2) group relations and face, (3) hierarchical relations, and (4) achievement and competition. By comparing results the authors realised that the factors inhibiting the discussion process were stronger in the students from non-western institutions. The six contextual factors found in the discussion behaviour were: (1) the nature of students’ prior school education, (2) the scope of PBL implementation, (3) students’ personal characteristics, (4) language of instruction, (5) tutor behaviour and (6) the assessment system.

On the other hand Lim(33. Lim FA. Questioning: a teaching strategy to foster clinical thinking and reasoning. Nurse Educ [Internet]. 2011;36(2):52–3. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21330888
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) believes that the strategy of posing questions to the students individually or in groups during class or throughout the clinical day may help increase interaction, improve clinical thinking and promote the implementation of an evidence-based practice. With this in mind, the same author suggests a set of questions to be used periodically with students. For example: What’s the plan for this patient? What should you focus on when assessing this patient? iii) Did you wash your hands? Did you ask what your patient’s name and birth date were?

Additionally, it is understood that the strategies improving the students’ quality of interaction through questioning, argumentation and explanation should not be limited to the classroom. Nowadays, one must introduce information and communication technologies to promote active learning and consequently students’ critical thinking. However, Montello and Bonnel(44. Montello L, Bonnel W. The versatile question: Diverse uses of questioning in online and traditional learning. Teach Learn Nurs [Internet]. National Organization for Associate Degree Nursing; 2009 Jul [cited 2014 Feb 27];4(3):71–5. Available from: http://linkinghub.elsevier.com/retrieve/pii/S1557308708001054
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) believe that “questions posed in the online setting can be more easily misunderstood than those posed in the classroom”, and that “Questions can also help online students engage with others” as well as with the teacher, thus increasing the dynamics of online classes. These authors conclude their review article acknowledging that further research is needed on how to better include questioning techniques, emphasising the students’ role in the questioning process.

Taking into account the online interaction context, Beaudin's(55. Beaudin BP. Keeping Online Asynchronous Discussions on Topic. J Asynchronous Learn Networks. 1999;3(2):41–53. ) "survey of 135 online instructors suggested that the best way to hold asynchronous discussions on topic is to design good questions with pedagogical purpose, provide guidance with the questions, reword questions when needed, and provide discussion summaries. For this author designed questions are clear, concise, and directly related to the purpose of posing the question. A good question, based on Bloom's taxonomy, can also promote active learner engagement."

One agrees with Tracey & Nichol when they state that in nursing education little has been written about the importance of effective questioning as a teaching technique to develop active learning. Based on this research and many others, it is clear that effective questioning techniques improve students’ learning, their level of knowledge, trust and communication skills. However, one admits that only by raising issues in complex and real contexts is it possible to improve the students’ analysis, creativity and argumentation skills. The effective questioning, argumentation and explanation process is demanding. It involves planning and structuring the questions or the argument in such a way that they are appropriate and fit the educational purposes one wishes to attain.

Profetto-McGrath, Smith, Day & Yonge(66. Profetto-McGrath J, Smith KB, Day RA, Yonge O. The questioning skills of tutors and students in a context based baccalaureate nursing program. Nurse Educ Today. 2004;24:363–72. ) conducted a quantitative research with 30 nursing tutors and 314 students to describe and compare the levels and type of questions developed by them. They reached the conclusion that most questions posed by the tutors and students of the first three years of training in nursing stood at a low cognitive level and were used for the purpose of obtaining factual information and yes/no-type answers. One agrees with these authors when they acknowledge that in order to increase the complexity of education in nursing and its effective practice both teachers and students must have the ability to pose a greater variety of analysis, synthesis and assessment questions to be used in different settings. Therefore, one expects an increase in the number of analysis, synthesis and assessment questions as well as questions that entail exploring and explaining to achieve an active learning that eases the critical thinking process.

Sellappah, Hussey, Blackmore, McMurray(77. Sellappah S, Hussey T, Blackmore AM, Mcmurray A. The use of questioning strategies by clinical teachers Conceptual framework. 1998;28(1):142–8.) confirm the results arising from other researches, in this case clinical teachers of Australian Universities who posed questions of a low cognitive level (91.2%). They also recommend that clinical teachers are taught how to pose questions, especially questions with a high cognitive level. Additionally, this study revealed that high-level questions posed by clinical teachers are positively interrelated with high-cognitive-level answers given by the students (r=0.9, P=0.001).

In light of this, one understands that the act of questioning and argumentation can stimulate reasoning as well as the skills needed to solve the problems underlying critical thinking. Therefore, the incentive to question, argue and explain phenomena are efficient strategies to promote the nurses’ education and active learning. Making reflective questions and preparing well-structured arguments are the most important activities in any science, so these skills are essential for learning. Asking good questions and arguing is a creative act which becomes a tool for learning about nursing as well as learning how to do nursing. Asking questions and arguing help us to make sense of the world and add meaning to information and the contexts in which we live, thus increasing our ability to explain.

As seen before, teachers’ questions still overpower the classroom and are of a low cognitive level in addition to lacking the pedagogical intent to build knowledge. Bastable(88. Bastable SB. Nurse as Educator: Principles of Teaching and Learning for Nursing Practice. 2nd ed. London: Jones and Bartlett Publishers; 2003. ) shows that the proper use of questions is one of the general principles to be used by all nursing faculty. This author presents three types of question: i) factual or descriptive questions, ii) clarification questions and iii) high-level questions.

For several decades, studies in this area have focused on teachers’ questions. However, it is acknowledged that researchers have been increasingly encouraging student-based questions as well as the study of students’ questions. This new emphasis follows the general trend of student-centred education, focusing on the students’ autonomy and their being responsible for their own learning process - Active learning.(9,10)

For example, Neri de Souza(99. Neri de Souza F. Questions in Chemistry Learning in Higher Education. University of Aveiro; 2006. ) conducted a research to study the sort of difficulties arising from students’ questions and explanations. He concluded that the nature of the difficulties revealed by the questions and explanations is different. The questions arose in more naturalistic contexts, whereas the difficulties were complex and classroom-based. However, the explanations show difficulties that do not relate to the teaching-learning process. These difficulties are more related to the concepts themselves, and in the students’ questions these concepts are treated regarding other concepts and academic contexts. In this sense, these two activities complement each other, especially when situations-problems require an explanation for difficulties raised by the questions. Questions can lead to a “return” to the strategies and tools used in the teaching and learning process.

The present research analysed the perceptions of 1st-year nursing students regarding Anthropology and Sociology of Health, by encouraging the questioning, argumentation and explanation process following some active teaching strategies. For this purpose, stories about the humanisation of healthcare in real contexts were used.

Social sciences are included in the curriculum of nursing courses in order to provide future nurses with the socio-cultural aspect of care. The socio-cultural factor in healthcare or disease has become paramount in undergraduate nursing degrees due to its acknowledgement by health professionals and social scientists, arising from the changes in societies and increasing respect for the patients’ cultural diversity. Thus, nurses need to receive proper training in order to provide cross-cultural care.

The turning point for this new perspective arose with Madeleine Leininger’s theory which fostered a new insight into nursing and the care process. According to Oriá, Ximenes and Alves(1111. Oriá MOB, Ximenes LB, Alves MDS. Madeleine Leininger and the Theory of the Cultural Care Diversity and Universality: an Historical Overview. Online Brazilian J Nurs. 2005;4(2). ), Leininger’s theory is pivotal in nursing as it unveiled the meaning of cultural care, the practice of care, which is specific to each culture and such cultural factors as religion, politics, economics, the way the world is perceived, the surrounding environment, gender among other factors which may influence human care.

According to the same authors, Leininger acknowledges that in practical terms there is a cultural and universal diversity of care which needs to be known and understood so that nurses are able to help their patients in a humane and satisfactory way.

Leininger's theory is consistent, for example, with the Portuguese reality, namely the National Health Programme 2011-2016 which highlights the need to implement the Conceptual Model that aims to "maximise health gains in population by aligning and integrating sustainable efforts from all sectors of society, such as the focus on access, quality, healthy policies and citizenship". In this field one also highlights the Brazilian reality as, in 2000, the National Programme for the Humanisation of Hospital Care (PNHAH) of the Ministry of Health was regulated, highlighting a new culture of health care in addition to "improving relations between professionals, between users/professionals (face-to-face interactions) and between the hospital and the community (socio-communitarian interactions), aimed at improving the quality and effectiveness of the services provided by these institutions"(1212. Deslandes SF. Análise do discurso oficial sobre a humanização da assistência hospitalar. Cien Saude Colet. 2004;9(1):7–14. ). According to the same author, the programme enabled a more transversal perspective of the welfare policy presently entitled "Humaniza SUS".

In his research done with families having newborns, Boehs(1313. Boehs AE. Análise dos conceitos de negociação/acomodação da teoria de M. Leininger. Rev Lat Am Enfermagem. 2002;10(1):90–6.) concluded that work performed from an anthropological perspective presents a huge challenge. It entails understanding the nurses’ culture, which entails moments which are protective of the professional model whilst observing the patients in their own world, in addition to understanding their actions and still managing to be a nurse.

Naturally, students are not expected to have a preconceived broad sense of nursing. However, the intention is to understand some of the difficulties, perceptions and preconceptions pertaining to the role of nurses and of nursing itself, while raining awareness to the importance of humanising care.

Over the decades research has been done on the concept of humanising nursing. These studies have stressed the need for an understanding that goes beyond the technical and instrumental elements of the services.

One of the aspects that were revealed regarding the humanisation of care hint towards how the patient is perceived in anonymity, i.e. the depersonalisation of the patient. This issue has been studied since the 1990s by Leclainche(1414. Leclainche X. É preciso humanizar o hospital. Rev Paul Hosp. 1962;10(5):7–10.),who states that patients are not the focus of attention but rather a figure, a case, an object. This situation leads to consideration on the role of nursing in care provision, questioning the quality of care provided when tasks are fragmented, thus leading to a loss of the perception of the patient in a holistic manner.

In 1968 Gelain(1515. Gelain, I J. Humanização do hospital. RevPaul Hosp. 1968;16(1):3–7. ) had already highlighted that the already poor provision of health care in nursing with regard to patient care had been deteriorating along with the technological development that has hindered human relations, leading to an individualistic, calculative and, consequently, cold relationship between the stakeholders. In the 21st century this perspective remains unchanged. The authors of the present paper are not opposed to technology but consider that the provision of health care, as stressed by Franco e Florentim(1616. Franco, M and Florentim R. A satisfação dos utentes em serviços de saúde: um estudo explicativo sobre o Departamento de Pasiquiatria e Saúde Mental do Centro Hospitalar da Cova da Beira. A Satisf dos utentes. 2006;24(1). ), must strive to attain patient satisfaction.

The perspective of the professional in nursing is different from the patients’ perspective and might well be the factor that needs studying. Whereas the healthcare professional is concerned with decreasing the number of mistakes and with the improvement of practices, the patient wants to be assisted in comfortable and safe conditions.

One agrees with Oliveira, Collet and Viera(1717. Oliveira BRG, Collet N, Viera CS. A humanização na assitência à saúde. Rev Latino-am Enferm. 2006;14(2):277–84.) when they state that “humanisation depends on the ability to talk and listen, because worldly things only become human when they are subject to dialogue with peers, i.e. enabling dialogue in human relations and interactions not only as a verbal communication technique which has a pre-set goal but also as a means to get to know the other, understand him and set common goals that may lead to reciprocal well-being.”

In light of this complex and comprehensive reality, with the objective of contributing to a more humanising practice, one believes that, like Casate e Corrêa(1818. Casate JC, Corrêa AK. Humanização do atendimento em saúde: conheciento veiculado na literatura brasileira de enfermagem. Rev Latino-am Enferm. 2005;13(1):105–11. ), the training of nursing professionals may contribute to a change in this situation. The objective is to rethink the training component which is still focused on nursing technical factors and suggest the inclusion of psychological, sociological and anthropological aspects in the curriculum to enable the discussion of more humanistic subjects with the students and thus instruct them to the importance of humanising healthcare and consequently increasing the quality of care provided.

This proposal is emphasised by the Portuguese Nursing Council (2001), which addresses the humanisation of care as an extension of nursing, via its ethical component, achieved through the relation between the nurse and the patient as well as the respect for patients’ rights. Following this line of thought, Watson(1919. Watson J. Enfermagem: Ciência Humana e cuidar uma teoria de enfermagem. 1a ed. Lisboa: Lusociência; 2002.) stresses that “nursing is a profession that has the social and ethical responsibility, both for the individual and for society, to provide care and be at the forefront of the society’s present and future care needs”.(1919. Watson J. Enfermagem: Ciência Humana e cuidar uma teoria de enfermagem. 1a ed. Lisboa: Lusociência; 2002.)

Method

In light of the fact that many students do not know the subject of Sociology and Anthropology in Health nor its contents, some questions were raised by the teacher: What prior knowledge do students have about the content of the subject?; ii) Do students understand the importance of this subject in the context of an undergraduate degree in nursing?; iii) Can one understand the students’ problems and expectations through their explanations and questions?; iv) Can students be encouraged to formulate questions, arguments and explanations?; v) Can one understand how students feel about the humanisation of care keeping in mind different discourses?

Based on these questions one intends to analyse students’ perceptions on the topic of humanisation of care, an approach to be dealt with in the discipline of Anthropology and Sociology of health, by encouraging them to question and explain. The activities were based on situations selected to promote reflection on the attitudes that health professionals should exercise when faced with similar cases with future patients. The activities consisted of the reflective discussion of three episodes. Two episodes occurred in real-life contexts and one was based on a television series.

For a better understanding, Figure 1 presents the used activities and strategies

Figure 1
Sequence of activities used to encourage student interaction

The first activity was performed on the first day prior to the teacher presenting the programme for the discipline. The proposal was to get to know the real story of Ms. Beatriz, a 93-year-old woman, aided in the emergency room of a hospital in Lisbon. The objective was to see if the students were able to guess what they were going to study in the subject based on the story presented. The activity consisted in reading the story and associating it with the discipline. Two guiding questions were presented to the students: Can you find a connection between the text and the importance of studying Anthropology and Sociology of Health? Reread Beatriz’s story and prepare one or more questions about the episode.

For the second activity an episode of the TV series Dr. House was used with the objective of addressing the issue of the humanisation and dehumanisation of the care provided by healthcare professionals to patients going to the hospital. The students were teamed in pairs and asked to select scenes portraying the humanisation and dehumanisation of care. Following the selection, the students had to prepare questions on the scenes. The TV series Dr. House is well-known for the doctor’s behaviour with his patients.

In the third and last activity the students were invited to know the real story of Ms. Solange, a woman who got HIV from her husband, a case mentioned in one of the chapters of Deslandes’s book(2020. Deslandes SF. Humanização dos cuidados em saúde: conceitos, dilemas e práticas. Rio de Janeiro: Editora Fiocruz; 2006.). The students were asked to simulate a jury in class. The group was divided in three groups. One of them argued the healthcare professionals’ point of view, whereas the other group argued Ms. Solange’s situation. The third group of students was responsible for hearing and judging the arguments for and against.

The purpose of the activities was to promote students’ reflection on the issue of humanisation of care and encourage interaction as well as different discourses arising from the elaboration of questions, arguments and/or explanations.

The software webQDA(2121. Neri de Souza F, Costa AP, Moreira A. Questionamento no Processo de Análise de Dados Qualitativos com apoio do software WebQDA. EDUSER Rev Educ [Internet]. 2011;3(1):19–30. Available from: www.eduser.ipb
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,2222. Neri de Souza D, Costa AP, Neri de Souza F. Avaliação da Perceção dos Formandos sobre o Software WebQDA. II Congresso Internacional TIC e Educação (ticEDUCA2012). Lisboa: ticEDUCA2012; 2012. P. 365–76.) was used to analyse the data content. The analysis included the validation and increase of internal consistence using an iterative process which is similar to that recommended by Frambach et al.(22. Frambach JM, Driessen EW, Beh P, van der Vleuten CPM. Quiet or questioning? Students’ discussion behaviors in student-centered education across cultures. Stud High Educ [Internet]. 2013 Jan 9 [cited 2014 Sep 24];39(6):1001–21. Available from: http://www.tandfonline.com/doi/abs/10.1080/03075079.2012.754865
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), presented in Figure 2.

Figure 2
Coding and analysis process

Results

The participants in the study were 1st year nursing students attending a school in the northern region of Portugal during the academic year 2007/2008. From the 50 students enrolled, 48 were present in the classroom and participated in the activity voluntarily. With regards to gender, 14 were male and 36 female.

The two dimensions of data analysis that follow are based on i) evidence of the students’ cognitive level of learning as seen from their questions, explanations and arguments, and ii) the theme categories of dehumanisation of care used in Howard’s model, dating from1975(2020. Deslandes SF. Humanização dos cuidados em saúde: conceitos, dilemas e práticas. Rio de Janeiro: Editora Fiocruz; 2006.).

In order to analyse the first dimension regarding the level of complexity and understanding in learning, one used an adaptation of Biggs and Collis’s SOLO taxonomy(2323. Biggs JB, Collis KF. Evaluating the Quality of Learning – the SOLO Taxonomy. New York: Academic Press; 1982.) performed by Neri de Souza(2424. Neri de Souza F, Moreira A. Perfis de Questionamento em Contextos de Aprendizagem Online. Rev Iberoam Informática Educ. 2010;12:15–25. ).

These levels of formalisation of thought are classified into:

  1. Pre-structural - corresponds to a level in which students mention scattered pieces of information that are not organised and make no sense;

  2. Uni-structural - students make simple and obvious connections with the content, but only one aspect of the task is mentioned and there is no relationship between facts and ideas;

  3. Multi-Structural - students establish some connections, but they lack the meta-connections between the content and the meaning of the whole;

  4. Relational - students seek to assimilate knowledge in an attempt to appreciate the meaning of the part with regards to the whole.

  5. Abstract Extensions - students make connections not only within a single area, but also beyond, seeking to generalise and transfer the principles to other specific cases(24).

The other dimension of analysis used Howard’s model for the analysis of “Dehumanisation”(2020. Deslandes SF. Humanização dos cuidados em saúde: conceitos, dilemas e práticas. Rio de Janeiro: Editora Fiocruz; 2006.), with several categories: i) People in a sterile static environment; ii) People as icebergs; iii) Isolated people; iv) People with no choice; v) Person receiving care; vi) Substandard; vii) Person as problem; viii) Person as object; ix) Person with less value; x) Technology; xi) Experimentation.

In the scope of this analysis and to better answer the research questions one needed to develop a third analysis dimension called Humanisation. Despite the fact that, to a certain extent, one may obtain this dimension from reversing Howard’s model, the need to understand the most synthetic form of humanisation expressed by the students, led to the development of the following categories: i) Psychology – Feelings; ii) Scientific technique; iii) Social relations and iv) Ethics.

For the purpose of this study one analysed the interconnections of the SOLO Taxonomy, aspects of the humanisation of care and Howard’s theory of dehumanisation with three types of discourse produced by the students which constitute the data to be analysed: i) Questions, ii) Explanation and iii)argumentation. The discourses were done in written based on three different episodes. As seen from Table 1, the students produced questions (55.6%) and explanations (44.3%) regarding Beatriz’ episode but they did not develop any argumentative discourse. On the other hand, for the activity involving a simulated jury on Ms. Solange’s story no one asked explicitly for the posing of questions as done with Beatriz’s story. The strategies used are justified because these episodes do not have this type of discourse. With regards to the activity developed around an episode of Dr. House, one highlights the questions (25.3%), explanations (37.3%) and argumentations (37.3%) written by the students on the (de)humanisation of care.

From table 1 it is clear that the emphasis or explicit request that leads students to ask questions, develop arguments or utter explanations is directly linked with the level of participation and discussion in a classroom environment.

For a broader vision of the levels of these different discourses, in Table 2 one presents its ranking in relation to the SOLO taxonomy. The analysis indicates that, in general, students present a low level of complexity and understanding as seen from the questions (52.3%), explanations (67.3%) and argumentations (48.8%). The values were obtained from the sum of the values obtained in the pre-structural and uni-structural categories. With regards to the sum of the percentages obtained in the highest levels (relational and abstract extensions) the result was 45.9% for the questions, 24.7% for the explanations and 22.4% for the argumentations. Based on these numbers one can conclude that students uttered ideas of greater cognitive level through the posing of questions. As seen further ahead, the questions developed and coded as Abstract Extensions arose from Dr. House’s episode (n=13). This fact may indicate that the content of videos, as long as they are purposely chosen and adequate, is an excellent means to encourage students to pose questions.

Following there are some examples of the different discourses uttered by the students:

I think Anthropology and Sociology of Health is a discipline in which we study the more human and psychological aspects of the nursing profession, as in the story of former nurse Beatriz, nurse Fatima becomes emotional and says that it is hard for her to see the elderly in these situations, as well as children and other people.

If she had 6 children, why did only one of them go with the mother?

This episode of Dr. House shows many examples of dehumanisation, although there is an episode in which we can witness humanisation at the level of healthcare provision.

To deepen the discussion on the students’ level of complexity and understanding perceived in their discourses, in Table 3 one shows the interrelation between the SOLO Taxonomy and each one of the episodes corresponding to different activities. According to the developed activities, one can see, in general, that students uttered questions, explanations and argumentations of a low cognitive level. This fact is easily understood when the pre-structural and uni-structural levels are added up with regards to the activity on the episodes Beatriz (66.5%), Dr. House (51.1%) and Ms. Solange (55.2%), concerning the multi-structural level, considered as average (4.5%, 11.8%, 19.1%) and the sum of the levels Relational and Abstract Extensions (28,6%,32.8%, 18.1%) considered to be of a high cognitive level.

When one adds the three levels of the highest categories (Multi-structural, Relational and Abstract Extensions) one sees that 44.7% are associated with the Dr. House episode, 33.1% with Beatriz and 44.6% with Solange. From this point of view, there are no differences between the three activities; however, taking only into consideration the values of the Abstract Extensions, the video-based activity is much above the chapter-based activity and slightly above the activity using the PowerPoint presentation. Following there is an example of each one of the discourses.

In my opinion, Anthropology and Sociology in Heath studies human behaviour. This subject is important for nurses as it will help them to better understand the patient and help them to psychologically cope with their disease.

His work requires him to see every patient so he must not take too long in the consultations, thus restricting conversations to what is basic and concrete to be able to treat everyone.

Perhaps the discipline that, I think, relates man and society in health is important for future nurses, in the sense that it helps to understand the different needs and feelings that involve the patient in different stages of life.

As mentioned above, to study the dehumanisation of care one used Howard’s model. One sought to check students’ understanding about the issue of dehumanisation of healthcare through the activities used. From the total questions, explanations and argumentations presented in all activities only 13, 42 and 32 were classified in one of the categories presented in Table 4. Students highlight the professionals’ dehumanisation when they see patients as a problem in 31.3% of the ranked arguments, i.e. reducing the patient to their pathology. For example, a student arguing on the (de)humanisation seen in an episode of Dr. House:

I believe that the coldness and detachment are characteristics which allow him to see rationally, analysing the signs and symptoms without really seeing the patient. For him it is important to find the physical reason (pathology) for the patient’s condition and find a cure.

However, in the explanations, a percentage (30.9%) of the nursing students stress that many professionals do not see the patient as a person but rather as an object. This vision is clear when the student states:

In our opinion, there was humanisation seen in the healthcare team; however, Dr. House did not have the same attitude, his interventions were devoid of humanisation and followed a assistance/technical component for the provision of care.

Concerning the drafting of questions and still based on Table 4, students reported that professionals do not allow patients to choose (38.5%). This idea arises in the motivations, for example, of this question: As a nurse, how would you act in a situation in which even the doctor himself almost quits when there are no plausible solutions? When it is understood that it is the choice of a doctor which is crucial in a specific situation.

Not everything conveyed by students through questions, explanations and/or argumentations can be ranked in the categories as dehumanisation. In this study it was important to understand the underlying humanisation character from the several discourses uttered by the students.

Table 5 reveals that, regarding the dehumanisation of care, the students have reached a level of elaboration which is, in general, greater than the discourse on Dehumanisation with regards to the sum of the questions (N=57), explanations (N=56) and arguments (N=25). However, it is noted that concerning the students’ types of discourse and the categories of humanisation there is relocation with different emphases. Therefore, there were more questions in the scope of the Psychological and Sentimental category with 49,1%, whereas the explanations (66%) and arguments (48%) focused on the Social and Relational category.

There does not seem to be a grounded reason to explain the association of the type of discourse with the different emphases found in the humanisation category. One does also not believe that this fact is directly related to the type of activity where these different discourses were encouraged (see Table 6), as in this event other categories are emphasised.

Although it is not possible to come up with reasons for these trends in this study, it is possible that in more controlled research one can study the existence of these associations. In this study it is important to focus on the different activities and resources that can promote different emphases on the type and depth of the students' discourses. Following are some examples of these discourses associated with different categories of humanisation.

Although the nurse knows that nurse Beatriz did not stand a chance to survive, he never gives up. Why doesn’t he give up?

The doctor is afraid of feeling the patient’s pain and he is entitled to that because no one is forced to suffer along with other people who are suffering.

As he sees the patient suffering, the doctor is going to feel important, and he will feel bad for not being able to help and that can worsen the patient’s condition.

From these discourses one infers that 1st year nursing students have already developed humanisation dimensions based on common sense and are focused on the aspects of feelings and social relations.

Conclusion

After this analysis, one can assert that it is possible, through activities such as reading, simulated jury and video presentations, to use questioning, explanation and argumentation to obtain students’ perceptions and expectations as well as understand their difficulties. This method of active learning can involve students enrolled in the course since the beginning of the academic year and lead them to think about some concepts of the subjects.

The study conducted by Neri de Souza and Neri de Souza(2525. Neri de Souza D, Neri de Souza F. Questioning and Explanation an Active Learning Method. Teaching and Learning IASK-2008: Achieving Excellence and Quality in Education. Aveiro, Portugal; 2008. P. 394–401.) also found different directions when questions were compared with their explanation. The analysis showed that the questions are so important in diversity and quality as the hundreds of explanations for the analysed situation-problem.

One reinforces that both questions and explanations are complementary and show difficulties of a different “nature”. However, questions can be use in a breather sense with relates to the daily context within a classroom(1010. Teixeira-Dias JJC, Pedrosa de Jesus H, Neri de Souza F, Watts DM. Teaching for Quality Learning in Chemistry. Int J Sci Educ. 2005;27(9):1123–37. ).

The results show that the incentive to the student’s questioning, explanation and argumentation in several contexts and its subsequent analysis is essential to promote reflection on real life situations that future professionals will experience in addition to acquiring the students’ preconceived perceptions and encourage active learning.

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ACKNOWLEDGEMENT

This work is funded by FEDER funds through the Operational Programme Competitiveness Factors - COMPETE and National Funds through FCT - Fundação para a Ciência e Tecnologia (Foundation for Science and Technology) under the PEst-C / CED / UI0194 / 2011 project. Research Centre for Didactics and Technology in Teacher Education - CIDTFF, Department of Education, University of Aveiro, Portugal

Publication Dates

  • Publication in this collection
    Dec 2014

History

  • Received
    30 Apr 2014
  • Accepted
    16 July 2014
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