Questioning Skills of Clinical Facilitators Supporting Undergraduate Nursing Students

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lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/jocn.13761
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DR. NICOLE (NIKKI) MARGARET PHILLIPS (Orcid ID : 0000-0002-6821-4983)
Received Date : 21-Sep-2016
Revised Date : 20-Dec-2016
Accepted Date : 28-Jan-2017
Article type : Original Article
TITLE PAGE
Full title (concise and descriptive)
Questioning skills of clinical facilitators supporting undergraduate nursing students.
Author details:
Nicole M. PHILLIPS PhD, MNS, GDipAdvNur(Ed), DipAppSci(Nurs), BN, RN, Associate
Professor, Deputy Head of School and Director of Undergraduate Studies 1, 2
Maxine M. DUKE PhD, Med, BAppSci(AdvNurs), RN, Alfred Deakin Professor, Chair in
Nursing Development, Head School of Nursing and Midwifery & Director Centre Quality
and Patient Safety (QPS) 1, 2
Rona WEERASURIYA PhD, MHP, BAppSc(Psyc), Research Fellow1
Affiliations
1. School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia;
2. Deakin University Centre for Quality and Patient Safety (QPS), School of Nursing
and Midwifery, Geelong, Victoria, Australia.
Contact details for the corresponding author
Associate Professor Nicole Phillips
School of Nursing and Midwifery
Faculty of Health
Deakin University
Geelong. 3220

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Victoria
Australia
Email: [e-mail]
Ph: [phone]
Contact details for Maxine Duke
Alfred Professor Maxine Duke
School of Nursing and Midwifery
Faculty of Health
Deakin University
Geelong, 3220
Victoria
Australia
Email: [e-mail]
Ph: [phone]
Contact details for Rona Weerasuriya
Dr Rona Weerasuriya
C/O School of Nursing and Midwifery
Faculty of Health
Deakin University
Geelong, 3220
Victoria
Australia
Email: [e-mail]
Ph: [phone]
Funding
This study was funded by the School of Nursing and Midwifery, Deakin University, Geelong,
Victoria, Australia.
Acknowledgements
The authors acknowledge biostatistician, Dr Mohammadreza Mohebbi from the Deakin
Biostatistics Unit, Faculty of Health, Deakin University.

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ABSTRACT
Aims and objectives. To report on a study investigating questioning skills of clinical
facilitators who support the learning of undergraduate nursing students.
Background. The ability to think critically is integral to decision-making and the provision
of safe and quality patient care. Developing students’ critical thinking skills is expected of
those who supervise and facilitate student learning in the clinical setting. Models used to
facilitate student learning in the clinical setting have changed over the years with clinicians
having dual responsibility for patient care and facilitating student learning. Many of these
nurses have no preparation for the educative role. This study adapted a comparative study
conducted over fifteen years ago.
Design. Descriptive online survey including three acute care patient scenarios involving an
undergraduate nursing student. Participants were required to identify the questions they
would ask the student in relation to the scenario.
Methods. 133 clinical facilitators including clinical teachers, clinical educators, and
preceptors from five large partner health care organisations of one Australian university
participated.
Results. The majority of questions asked were knowledge questions, the lowest category in
the cognitive domain requiring only simple recall of information. Facilitators who had
undertaken an education related course/workshop or formal qualification asked significantly
more questions from the higher cognitive level.
Conclusion. The study provides some evidence that nursing facilitators in the clinical setting
ask students predominantly low level questions. Further research is needed to identify
strategies that develop the capacity of facilitators to ask higher level cognitive questions.

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Relevance to clinical practice. Clinical facilitators should undertake targeted education that
focuses on how to frame questions for students that demand application, analysis, synthesis,
and evaluation.
Keywords. Questioning, nurse education, clinical facilitator, clinical teacher, preceptor,
clinical educator, clinical decision-making, quality and safety, low level, high level.
SUMMARY BOX
What does this paper contribute to the wider global community?
• There is further evidence that nursing clinical facilitators ask questions that are
predominantly from the lower cognitive level that do not facilitate critical thinking,
rather simple recall of information.
• This study provides some evidence that undertaking an education focused course can
impact a facilitator’s ability to ask questions from the higher cognitive level.
• Further research should be conducted to identify strategies that develop the capacity
of facilitators to ask higher level cognitive questions that promote critical thinking in
health professionals.
INTRODUCTION
Internationally nurses plan and manage care for patients with individual needs, in a variety of
contexts and with a focus on meeting specific goals of care. To provide safe and quality
patient care, nurses need to be critical thinkers. As no two patient situations are the same
nurses need to be able to apply their knowledge to unique situations (XXPhillips & Duke
2001). Developing the critical thinking skills of nursing students is therefore an imperative of
clinical learning programs and is an expectation of those facilitating learning in the clinical

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setting (Sullivan 2012, Gaberson et al. 2015, Wallace & Moughrabi 2016). Questioning is
one strategy used by clinical educators to develop nursing students’ clinical reasoning skills
(Hunter & Arthur 2016).
BACKGROUND
While questioning is a well recognised teaching strategy, there is some evidence in the
literature that teachers mainly ask lower level questions that do not encourage critical
thinking (Gul et al. 2010, Saeed et al. 2012, Tofade et al. 2013). Questions from the lower
level in the cognitive domain foster simple recall and/or basic understanding of information,
for example, the ability to paraphrase or summarise information (Bloom 1956). Whereas
questions from the higher level in the cognitive domain involve the ability to apply, analyse,
evaluate and create (Anderson & Krathwohl 2001).
Bloom’s (1956) taxonomy in the cognitive domain classified intellectual processes into low
and high levels to promote higher forms of thinking in education, such as analysing and
evaluating, rather than simply remembering facts and rote learning. The domain refers to the
attainment of knowledge and intellectual skills, is developmental, and is classified according
to level of behavior from the basic to the complex. There are six major categories starting
from the simplest behavior to the most complex: knowledge and comprehension (low level);
application, analysis, synthesis and evaluation (high level). In the 1990s the classification
system was adapted (Anderson & Krathwohl, 2001) and Bloom’s version involving nouns
was revised to verbs, for example the knowledge category became ‘remembering’ and
comprehension ‘understanding’. In the higher cognitive level the top two categories were

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interchanged, so Bloom’s original synthesis and evaluation categories became ‘evaluating’
and ‘creating’, with creating the highest category. Currently in education both Bloom’s
original version and the adapted version are used.
This current study drew from Bloom’s original taxonomy to remain consistent with the
original study (XXPhillips & Duke 2001). Presently in Australia a range of supervision
models are used to support nursing students in the clinical setting. This study adapted a
comparative study conducted by the researchers over fifteen years ago, when models for
clinical facilitation in Australia and other developed countries were predominantly a 1:8
clinical teacher to student ratio, or, a 1:1 preceptor to student ratio (XXPhillips & Duke
2001). Models of facilitation have evolved over time as have facilitator role titles. Titles
describing the clinical supervisor role may now include clinical teacher, clinical educator,
clinical facilitator, preceptor, buddy, clinical associate, and clinical coach. Regardless of the
title ascribed the nurses in these roles are responsible for facilitating nursing students in some
capacity in the clinical setting and would be expected to ask questions. Nursing students can
potentially be facilitated, in ratios that range from 1:8, 1:10, 1:30 or 1:1 and often involve a
clinician as ‘buddy’ or preceptor as well as a supervising clinical facilitator. In addition, in
some supervision models the person facilitating student learning at the ward level may not be
responsible for conducting the student’s formative or summative assessment.
The original study (XX Phillips & Duke 2001) involved clinical teachers and preceptors and
investigated their level of questioning. While the study was small (n= 28) the study clearly
resonated with nursing educators and other health professionals being regularly cited in the
international literature. The findings indicated that both the clinical teachers and preceptors
asked questions predominantly from the lower cognitive level. 65.1% of the questions asked
by the clinical teachers (n = 14) were low level compared to 87.4% of the questions