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Socratic Method and the Internet Using Tiered Discussion to Facilitate Understanding in a Graduate Nursing Theory Course

Ellen Beth Daroszewski, PhD, RN, APRN-BC Anita G. Kinser, EdD, RNC Susan L. Lloyd, PhD, RN, CNS

An innovative 2-tiered discussion strategy with in-class and online components was used to expand reflection and increase comprehension of course content. Socratic method structured the in- class tier. An unstructured online format followed as the second tier. The authors discuss this approach and provide examples of how the strategy promoted understanding, critical thinking, and social interaction.

Because nursing theory courses con- tain unfamiliar and difficult vocabu- lary, representations, and arguments, they are challenging to students and create trepidation and anxiety. Many faculty avoid theory for the same dis- comfort, awkwardness, and unfamil- iarity. To gain knowledge of theory and develop proficiency in theoretical discourse, students must disengage empirical patterns of knowing and discover how to embrace theoretical notions. Instructional methods that create opportunities for sharing and reflection are essential for students to be able to grasp, manipulate, under- stand, and apply theory.

Reflection and Discussion

Learning strategies using the activity of reflection have long played an ac- tive role in nursing education.1 Incor- porating reflection in a course influ- ences the environment, processes, and focus of learning which reduces anxiety, increases peer support and cooperation, and moves students from passive to active roles.2 Using in- depth self-reflection provides an op- portunity to explore insights support- ing the development of competence, especially when students have sub- stantial nursing experiences upon which to draw.3 One of the strengths of graduate education in nursing is the diversity and richness of opinions, perspectives, and experiences stu- dents bring to the classroom. Gradu- ate faculty need to cultivate reflective instructional strategies for all to bene- fit from the collective wisdom of the class.4-6

NURSE EDUCATOR Volume 29, Number 5 pp 189-191 © 2004; Lippincott Williams & Wilkins, Inc.

In our graduate nursing theory course a 2-tiered discussion strategy was developed to engage the stu- dents, include and examine individual perspectives, and provide a vehicle for sustained reflection. Discussion has long been used as a type of re- flection strategy in higher education in a variety of disciplines including nurs- ing.7,8 Group discussion had been found to further augment reflection and analysis.9

The First Tier: The Socratic Method

The Socratic method was used to structure an in-class discussion of prominent theoretical literature as the first tier. The Socratic method is “a pedagogical technique in which a teacher does not give information di- rectly but instead asks a series of questions with the result that the stu- dent comes either to the desired knowledge by answering the ques- tions or to a deeper awareness of the limits of knowledge.”10 Socrates be- lieved that the most effective way of teaching a student to think and argue logically was to engage the student in

a discussion that included his or her own beliefs and experiences. The So- cratic method works best in demon- strating complexity and uncertainty rather than in eliciting facts, and is most effective if discussions aim to ex- plore underlying structures or com- peting explanations.11

The Socratic method encourages students to reflect and think indepen- dently mimicking critical thinking per- formed at the individual level.12 It is an active and student-centered learn- ing method, one that supports indi- vidual perspectives and helps stu- dents realize that they, their thoughts, and their personal experiences can be an immediate source of learning for themselves and their peers. The So- cratic method increases students’ con- fidence in their ability to reexamine the familiar as well as the new and less familiar, allowing them to make more risky, but often profitable, con- nections among theoretical, historical, and empirical sources of knowledge, context, personal experiences, and in- tuition.12 Knowledge learned through the Socratic method is owned by the student and secured in long-term memory.

NURSE EDUCATOR Volume 29, Number 5 September/October 2004 189

Authors’ Affiliations: Assistant Profes- sors, Dept of Nursing, California State Uni- versity San Bernardino.

Corresponding Author: Ms Daroszewski, California State University San Bernardino, Dept of Nursing, 5500 University Pkwy, San Bernardino, CA 92407 ([email protected]).

The Second Tier: An Online Discussion Board

The second tier of the discussion was developed using an online discussion board. The concept of using an online environment as a second tier for dis- cussion developed out of the desire to increase the sharing of thoughts and experiences beyond class time.13 The time allotted during weekly class meet- ings of 4 hours was not viewed as suf- ficient to allow for a thorough presen- tation, discussion, and processing of course concepts or the intricacies of the theoretical literature. A system for asyn- chronous online discussion was de- signed to permit the students adequate time to respond to discussions initiated in class, allowing time in between the in-class and online discussion for fur- ther reflection. Asynchronous Internet discussions have been used to facilitate group discussion in nursing education with success in traditional13,14 and dis- tance learning programs.15

Tiered Discussion Design

Using the course management soft- ware provided by the university, a course Web site was developed. Stu- dents and the course instructor had 24-hour access to the Web site. Along with a textbook, 10 articles from the theoretical literature were assigned as required reading for the course. The order of the articles followed the de- velopment of course concepts. Each student was responsible for leading a discussion of 1 of the articles during a class meeting. The course instructor challenged the student during the dis- cussion using the Socratic method by asking the student a series of ques- tions about the article and his or her understanding and interpretation of it. Other students were encouraged to ask or answer questions.

All students were required to con- tinue the discussion online on the course Web site by commenting fur- ther on the article, expanding on the in-class discussion, posting or re- sponding to questions, or challenging or supporting the views of other stu- dents. Students were not restricted as to the number of discussion entries they could make or the number of times they could comment on a spe- cific discussion.

Evaluation Methodology

A pilot test of the 2-tiered discussion technique was implemented in a one- quarter graduate nursing theory course. The aims of the implementa- tion were to engage the students in active learning, encourage discussions beyond the course objectives, in- crease understanding of abstract con- cepts, foster critical thinking, and fa- cilitate social interaction.

Seventeen graduate nursing stu- dents completed the tiered discussion as part of course requirements. A sur- vey evaluating the tiered discussion was completed by all students on the last day of the course. The evaluation was reviewed and approved by the Institutional Review Board of Califor- nia State University, San Bernardino.

The evaluation form was devel- oped by the course instructor and re- viewed by 2 other experienced nurs- ing educators supporting content validity. The evaluation consisted of 4 demographic questions and 9 items that students rated on a Likert-type scale of 1 “strongly disagree” to 5 “strongly agree.” The demographic questions assessed gender, age, eth- nicity, and the length of time the stu- dent had been licensed as a RN. The 9 evaluation items assessed the effec- tiveness and value of the tiered dis- cussion format. The final item on the evaluation form was an open-ended request for additional comments. All discussion entries were evaluated for evidence of understanding, sharing, critical thinking, and social interaction.

Findings

The graduate students had a mean age of 41 (27-57) and mean years of practice of 14 (2-31). Fifteen of the 17 students were female. The group con- tained 7 Caucasians, 3 Asians, 2 Lati- nas, 1 African American, 1 Native American, and 1 Latina/Native Ameri- can. Two students did not identify their ethnicity. All 9 survey items were rated between 4.2 and 4.6 represent- ing an exceedingly positive evaluation (Figure 1).

Positive comments were also recorded on the evaluation form. Stu- dents felt the tiered discussion was helpful in stimulating thoughts, articu- lating views, and providing feedback

to keep them on track. They believed it added value to the class and in- creased accountability ensuring a thorough reading of the articles. One student wrote that class discussions were much more stimulating but “en- titled a lot of extra work and hours outside of classroom time.”

Themes derived from an analysis of the online discussion text sup- ported the tiered discussion technique as highly effective for increasing un- derstanding, critical thinking, and so- cial interaction. Entries demonstrating discussion and critical thinking were abundantly evident throughout all weeks of the quarter. As the quarter progressed and as students read and commented further on each other’s entries, it was clearly evident that a mental picture and understanding of each others position with respect to the articles developed. Examples of the online discussion entries are pre- sented in Table 1.

Discussion and Recommendations

The tiered discussion was perceived by all students who participated as highly effective and valuable. In addi- tion themes derived from the text of the online discussion supported its use to promote understanding, critical thinking, and social interaction. The tiered discussion approach may have been more successful in this group of students due to their age and length of experience as nurses. A few of the

190 NURSE EDUCATOR Volume 29, Number 5 September/October 2004

Important part of the course

Increased understanding of course content

Increased understanding of article content

Effective way to share comments on the articles

Effective way to discuss the articles

Increased critical thinking

Increased problem solving ability

Allowed others to help me understand

Increased class social interaction

Figure 1.Tiered discussion evaluation items.

students had been in other classes to- gether.

As a frequently utilized nursing educational methodology, discussion has not been employed to its fullest potential. Traditional in-class discus- sions are not designed to be contin- ued, although they may stimulate stu- dents into further thought sometimes shared informally after class or some- times unshared and lost. The tiering

of a discussion using interactive on- line methods creates a precedent for continued reflection on in-class work facilitating continued cognitive and professional growth for students. In- teractive strategies that engage stu- dents and promote the sustained dis- cussion of pivotal nursing educational components such as theory should become the gold standard in graduate nursing education.

References

1. Hannigan B. A discussion of the strengths and weaknesses of “reflec- tion” in nursing practice and educa- tion. J Clin Nurs. 2001;10:278-283.

2. Davies E. Reflective practice: A focus for caring. J Nurs Educ. 1995;34:176- 174.

3. Cash P, Brooker, J, Penney W, Rein- hold J, Strangio L. Reflective inquiry in nursing practice or “revealing images.” Nurs Inq. 1997;4:246-256.

4. VandeVusse L, Hanson, L. Evaluation of online course discussions. Faculty facilitation of active student learning. Computers & Nursing. 2000;18:181- 188.

5. Chenoweth L. Facilitating the process of critical thinking for nursing. Nurse Educ Today. 1998;18:281-292.

6. Deering C, Eichelberger L. Mirror, mir- ror on the wall: using online discus- sion groups to improve interpersonal skills. Comput Inform Nurs. 2002;20: 150-154.

7. Kobert L. In our own voice: journaling as a teaching/learning technique for nurses. J Nurs Educ. 1995;34:140- 142.

8. Palmer B, Alexander M, Olson-Dinges C. Journal writing: an effective, heuris- tic method for literacy acquisition. Adult Basic Education. 1999;9:71-84.

9. Riley-Doucet C, Wilson S. A three-step method of self-reflection using reflec- tive journal writing. J Adv Nurs. 1997;25:964-968.

10. The American Heritage Dictionary of the English Language, 4th ed. Boston, Mass: Houghton Mifflin; 2000. Avail- able at: http://www.bartleby.com/ 61/97/S0529700.html. Accessed Au- gust 30, 2003.

11. Sanford J. Scholar discusses educa- tional benefits of Socratic method. Stanford University News Service [serial online]. May 2003. Available at: http://www.stanford.edu/dept/news/ pr/03/socratic528.html. Accessed Au- gust 30, 2003.

12. Tan K. Building upon the Socratic method. CDTLink. 2003;7:6-15.

13. Teikmanis M, Armstrong J. Teaching pathophysiology to diverse students using an online discussion board. Computers & Nursing. 2001;19:75-81.

14. Harden J. Faculty and student experi- ences with Web-based discussion groups in a large lecture setting. Nurs Educ. 2003;28:26-30.

15. Cartwright J. Lessons learned: using asynchronous computer-mediated conferencing to facilitate group discus- sion. J Nurs Educ. 2000;39:87-90.

NURSE EDUCATOR Volume 29, Number 5 September/October 2004 191

Table 1. Online Entry Examples of Discussion, Critical Thinking, and Social Interaction

Understanding Reading into Carper’s article, I recognize with her that the fundamental patterns of knowing are the Empirics, Aesthetics, Personal Knowledge and Ethics. I believe that nursing is complex, that’s why it is hard to define. What I know and what I understand from my experi- ence in nursing, is that, it is taking care of a patient as a whole and as a person. Each pattern of knowing is applied to every patient care, regardless of which is more important at that point of time.

If nursing were to adopt a single paradigm, all of the effort spent debating could be channeled into research and increasing the nursing body of knowledge. Endless debates do not promote unity but continue to divide nursing. I really hope that our profession is not debat- ing whether nursing is a “mature” science, and “em- piricism” versus “interpretative,” for another 20 years.

Critical Thinking If it could be adopted as “the” model, more of our at- tention and energy could be devoted to increasing the nursing body of knowledge. One of the things that struck me as I read this article was that this model would be a great model on which to base a nursing business.

I feel that Fawcett is urging nurses to go beyond em- pirical research with the push toward evidenced-based practice. She states in the last sentence of the article en- couragement to apply ethical, personal, aesthetic, and empirical theories to nursing research. I agree with her. I feel that our practice should be based one evidence, but as nursing is beyond a simple science, that evi- dence should come from the “art of nursing” as well.

Social Interaction I have to agree with (another student), nursing is in the midst of a transformation. As far as Kuhn is concerned I really feel that if he was a nurse his whole outlook about nursing and paradigms would be different.

I empathized with (another student) how she felt when her cherished patient passed away, because I had ex- perienced that when I was new in the profession...I was crying hysterically as loud as the family members were, that I was mistaken by others to be a member of the grieving family. My supervisor, of course, didn’t like it; you know what happened next, I was given a time out.