Clinical Simulation in Nursing (2014) 10, 491-493

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Editorial

Embracing Brain-Based Teaching and LearningStrategies

Nurse educators are tasked with graduating studentswho have higher order thinking, such as critical thinking,clinical reasoning, and clinical judgment. However,research suggests that new nursing graduates often lackentry level critical thinking skills (Del Bueno, 2005;Harris, Eccles, Ward, & Whyte, 2013). Higher orderthinking is defined as the acquisition of complex concep-tual knowledge that increases cognitive ability and isfacilitated by language function (Arwood, 2011). It ispossible that some nurse educators do not have a clear un-derstanding of how these higher order thinking conceptsare acquired. Most nurse educators are between the agesof 51 to 61 years (American Association of Colleges ofNursing, 2014). Many of them teach as we were taught,often using traditional and perhaps timeworn ideas ofthinking about student learning. New evidence-basedteaching practices based on neuroscience suggest thatthe brain learns and thinking builds in a spiral patternrather than the previously thought method of linear patternreinforcement (Arwood, 2011; Cardoza, 2011).

When simulation is focused on completing a skill,action, or intervention only, without a measurement of thestudents’ level of knowing, thinking, or conceptual devel-opment, we produce nursing students who may know whatto do according to the rules, but we are not assured that theyhave a conceptual understanding of why that action wascorrect or best given the client story. For example, if anursing student accurately demonstrates hand washing, wemake the assumption that the student understands universalprecautions and infection control concepts including thechain of infection. When in reality, this habit was part of agrading rubric that reinforces patterned behavior of rightand wrong and is not necessarily based on knowing orconcept development. In other words, the students maywash their hands because we told them to, or we said it isthe right thing to do to decrease infection. Maybe, thestudents are not acquiring concepts for higher orderthinking. These ideas on learning present a challenge forsome nurse educators because faculty ‘‘facilitating’’

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concept acquisition for higher order thinking is differentthan ‘‘faculty teaching’’ or ‘‘faculty doing.’’ We may needto change and adapt to new evidence about how the brainlearns.

Arwood and Kaakinen (2009) offer the simulationbased on learning language model (SIMBaLL) that de-scribes how to use simulation for facilitating conceptacquisition in nursing students and how to design simula-tions with embedded verbal cues and prompts that scaffoldthe development of complex concepts for higher orderthinking. The SIMBaLL model is based on neurobiolog-ical learning systems theory and neuroscience educationaltheory that moves beyond typical educational models toaddress how to design simulation for learning, so nursingstudents can layer concepts to acquire higher orderthinking. The model merges these theories with Piaget’s(1950) four stages of cognitive development in a spiralmodel of the development of learning and thinking. Piagetsuggests that most human beings develop the cognitivestage of concrete operations from 7 to 11 years andsome reach formal operations by the time they are 15 or16 years (Piaget, 1950; Wadsworth, 2004). However, notall adolescents or adults have fully developed all theattribute of the cognitive developmental stage of formaloperations. Indeed, some studies indicate that at leasthalf the American population has not developed all dimen-sions of formal thinking (Elkind, 1962: Kohlberg &Mayer, 1972; Kuhn, Langer, Kohlberg, & Hann, 1977;Schwebel, 1975). Thus, it is possible that a college student(and possibly even his or her faculty) may developmen-tally be a concrete thinker or have not fully developedall dimensions of the formal operations stage. Arwoodand Kaakinen (2009) suggest that when we scaffold andreinforce learning with multiple concrete learning ex-periences in high-fidelity simulation, students have theopportunity to build a strong foundation for formalthinking on graduation. How do nurse educators knowwhich level of cognitive development of higher orderthinking a nursing student has achieved?

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Editorial 492

The SIMBaLL model suggests that learning conceptscan be evaluated by assessing language function andknowledge (conceptual) acquisition with well-thought-outcritical thinking questions and reflection on action. We canassess cognitive development of higher order thinking bylanguage function. Ask the student just as Piaget did, ‘‘tellme why did what you did?’’ When asked a question,nursing students use language to symbolize what they knowand think. At the sensorimotor stage, there is no use oflanguage because there is no conceptual development justsensory input. The preoperational stage is characterized byearly conceptual development but an inability to uselanguage to convey concepts. A concrete thinker hasdeveloped concepts and can use language to conveycomplex concepts one at a time here and now. Concretethinking is rule based and is focused on right and wrongway to do things. At a formal stage, the nursing student willbe able to use language, spoken or written, in terms thepatient, family, and other health care providers understandto explain multiple complex concepts across contextsbeyond the present from a global perspective.

It would make sense then to ask a student during apneumonia simulation or during debrief, ‘‘The patient wasflat. Why did you raise the head of the bed?’’ A preopera-tional student who is beginning to develop concepts may say,‘‘I saw my instructor do that’’ or ‘‘it was on the assessmentrubric to do it this way.’’ The concrete thinker will say, ‘‘Iraised the head of the bed because that is what you aresupposed to do, it is the right thing to do if a patient is havingtrouble breathing.’’ At a formal stage, the student will be ableto use language spoken or written to explain the concept ofoxygenation and the pathophysiology of pneumonia at thealveolar level. Furthermore, they will use language functionto describe how gravity enables optimal expansion of theintercostal muscles and diaphragm in a lay language that thepatient and family can understand. The formal thinker will beable to prioritize, intervene, and hypothesize about whatcould happen next (ideas that cannot be seen or heard) formultiple other patients while caring for the patient with arespiratory condition. Additionally, this learner can assigncare to others during an emergency and can be responsiblefor multiple interventions that take place at one time(Arwood & Kaakinen, 2009).

Once a students’ baseline cognitive developmentalstage of higher order thinking has been assessed, simula-tions with embedded verbal cues, prompts, and questionsdesigned to facilitate the development of more complexconceptual knowing and thinking can be developed. As anexample, preoperational nursing students likes to showand talk about what they can do (patterns they recognizelike measuring blood pressure or washing hands). UsingSIMBaLL feedback for this learner, a nurse educator canuse language to facilitate concept acquisition for concretethinking. In simulation or in debrief, the goal for thestudent learner is to add new knowledge (concepts) towhat the student already knows. A student says to the

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manikin (patient), ‘‘I am going to measure your bloodpressure.’’ But, the student finds the patient has aperipherally inserted central catheter in the right armand lymphedema in the left arm and is not able to measureblood pressure in either arm. Then faculty can ask thestudent in the manikin’s voice, ‘‘Can you take my bloodpressure somewhere else?’’ This statement may causemental turmoil for the student because the textbook wayof measuring blood pressure does not work in thissituation. This stimulates the nursing student to thinkabout other sites to measure blood pressure. This is newinformation about blood pressure that is added to oldinformation that facilitates the layering of concepts forhigher order thinking.

Another way to facilitate complex conceptual knowl-edge in a concrete thinker is to introduce simulations withvarious blood pressure readings on patients with differentdisease states. We can develop a scenario based on a clientwith a diagnosis of hypertension and pain. During thesimulation, the hypertensive patient (manikin) can ask,‘‘Why is my blood pressure so high?’’ Now, the student hasto consider the blood pressure reading based on a diagnosisof hypertension and think about how pain can be linked tohigh blood pressure for this patient. As the studentprogresses through the nursing program, simulations canbe developed that facilitate the layering of concepts thatbecome complex conceptual knowledge for the develop-ment of higher order thinking that is symbolized bylanguage function.

Nurse educators are interested in and want to know ifstudents are developing higher order thinking because ofthe use of high-fidelity simulation as a learning technique.The SIMBaLL model can assist a paradigm change fromtraditional methods of content delivery with passivelearning to active learning in high-fidelity simulation usingbrain-based learning theories. Using a model (SIMBaLL)steeped in brain-based learning theory to design simulationexperiences helps assure faculty write simulation scenarioswith embedded verbal cues, prompts, and questions de-signed to facilitate the development of more complexconceptual knowing and thinking. Future research mightmeasure language function and substantiate conceptuallearning for higher order thinking in nursing students usingthe SIMBaLL model. Emerging evidence calls for apotential change in our own thinking and how we thinkabout how our students learn. Investigating brain-basedlearning theories can inform our practice in simulation,clinical, and lecture.

Jessica Doolen, PhD, RN, APRN-C, CNEAssistant Professor, University of Nevada, Las VegasSchool of Nursing, Las Vegas, NV 89154-3018, USA

Educational DirectorClinical Simulation Center of Las Vegas

Las Vegas, NV 89106, USAE-mail address: jessica.doolen@unlv.edu

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Editorial 493

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