Clinical Teaching Methods for Stimulating Students' Critical Thinking Critical thinking is a prerequisite to making any sound clinical decision. Many students entering into the fields of speech-language pathology and audiology are not equipped with the necessary critical thinking skills to formulate evidence-based clinical decisions. Clinical educators play an integral role in facilitating the development of students' critical thinking ... Article
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Article  |   April 30, 2016
Clinical Teaching Methods for Stimulating Students' Critical Thinking
Author Affiliations & Notes
  • Samantha J. Procaccini
    Department of Communication Disorders, California University of Pennsylvania, California, PA
  • Nancy J. Carlino
    Department of Communication Disorders, California University of Pennsylvania, California, PA
  • Denise M. Joseph
    Department of Communication Disorders, California University of Pennsylvania, California, PA
  • Disclosures
    Disclosures ×
  • Financial: The authors have no relevant financial interests to disclose.
    Financial: The authors have no relevant financial interests to disclose.×
  • Nonfinancial: The authors have no relevant nonfinancial interests to disclose.
    Nonfinancial: The authors have no relevant nonfinancial interests to disclose.×
Article Information
Professional Issues & Training / Attention, Memory & Executive Functions / Part 1
Article   |   April 30, 2016
Clinical Teaching Methods for Stimulating Students' Critical Thinking
Perspectives of the ASHA Special Interest Groups, April 2016, Vol. 1, 3-17. doi:10.1044/persp1.SIG11.3
History: Received November 30, 2015 , Revised February 28, 2016 , Accepted March 2, 2016
Perspectives of the ASHA Special Interest Groups, April 2016, Vol. 1, 3-17. doi:10.1044/persp1.SIG11.3
History: Received November 30, 2015; Revised February 28, 2016; Accepted March 2, 2016

Critical thinking is a prerequisite to making any sound clinical decision. Many students entering into the fields of speech-language pathology and audiology are not equipped with the necessary critical thinking skills to formulate evidence-based clinical decisions. Clinical educators play an integral role in facilitating the development of students' critical thinking skills. Most clinical educators recognize the significance of, and implications for implementing teaching methods which foster critical thinking. However, many clinical educators demonstrate uncertainty about which methods to employ and how to implement such methods. This article will discuss the selection and implementation of effective teaching methods for developing students' critical thinking.

At the most basic level, critical thinking has been described as a higher order mental process that involves “… extensive thinking to reach a reasonable solution, decision, or convergence acceptable to mind” (Al-Mubaid, 2014, p. 34). Some cognitive theorists and researchers may argue that critical thinking cannot be simplified to a short definition given the complex nature of the cognitive and metacognitive processes that are involved. Halpern (1998)  suggested, on a more intricate level, critical thinking “involves evaluating the thinking process … involves conscious exertion of mental effort … [and can even be] an attitude or disposition to recognize when a skill is needed and willingness to apply it” (p. 451–452).
Teaching critical thinking in the clinical context fosters even more complex challenges. With increased recognition by the American Speech-Language-Hearing Association (ASHA) that clinical supervision is indeed a “… distinct area of clinical practice”, clinical educators in speech-language pathology and audiology must be well-trained to implement effective teaching methods that promote students to critically analyze cases and form evidence-based decisions (ASHA, 2008, p. 1). Clinical educators carry the vital responsibility of facilitating the translation of theoretical knowledge to clinical practice. Developing strong critical thinking skills involves proactive engagement between the clinical educator and the student. While students must be prepared to think critically in challenging clinical contexts, clinical educators must be well equipped to accelerate critical thinking in these challenging clinical environments.
Most clinical educators recognize that clinical teaching methods, which foster critical thinking, must be successfully applied in order to stimulate the next generation of quality clinicians. Although many clinical educators can easily recognize the significance of critical thinking in the clinical context, there is often a large amount of uncertainty about how to select and implement teaching strategies that effectively encourage a high level of critical thinking.
The objectives for this article are (a) to discuss effective methods for developing students' critical thinking skills and (b) to assist clinical educators in selecting teaching methods to best suit the needs of the students they supervise. Specifically, this article will discuss how clinical educators might select and implement the following teaching methods to facilitate critical thinking in the clinical setting:
  1. Four inquiry-based instruction methods

  2. Feedback and strategic questioning methods

  3. Evidence-based practice methods

  4. Metacognitive models of self-reflection

Inquiry-Based Introduction
Recent research has suggested that inquiry-based teaching strategies are highly effective in stimulating critical thinking skills (O'Donoghue, McMahon, Doody, Smith, & Cusack, 2011). Inquiry-based instruction is an approach to teaching and learning that is focused on using and learning content to develop problem-solving and critical thinking skills (Reynolds & Hancock, 2010). Contrary to traditional models of education that focus on a more paternalistic approach to teaching, inquiry-based methodology is student-centered with the instructor assuming the role of facilitator. Students are actively engaged in the process of acquiring knowledge rather than passive receivers of information (Menahem & Paget, 1990). Literature has suggested that active learners who are challenged with applying concepts (as opposed to memorizing facts) are more likely to retain information (Wood, 2004). Inquiry-based methodology is a conscious shift away from behaviorist accounts of learning that focus on successful memorization of factual knowledge via adequate return of information on an exam.
Speech-language pathology and audiology curricula in higher education graduate programs often reflect an epistemology that is subject-based. There is often limited cross-subject integration of courses. Learners are required to assimilate and synthesize knowledge into a meaningful gestalt and then apply the knowledge in a clinical setting. Subject-based speech-language pathology and audiology programs rooted in traditional models of education may find particular challenges in developing methods which incorporate real life scenarios into coursework to ensure proficiency in theoretical constructs, as well as to transfer this knowledge into the clinical setting. Inadequate transfer of theoretical frameworks to clinical practice may further underscore the “…research evidence-clinical practice divide in the mind of the students, reinforcing the lack of applicability outside the classroom of what is taught inside it” (McCabe, Purcell, Baker, Madill, & Trembath, 2009, p. 2).
Speech-language pathology and audiology programs may consider shifting away from traditional, subject-based models of education to a more inquiry-based approach. Inquiry-based instruction methods include problem-based learning, case-based learning, concept mapping, and guided discovery. Approaches to inquiry-based instruction can be placed on a continuum from least to most learner support from the instructor. Problem-based learning involves the least learner support from the instructor and guided discovery involves the most learner support from the instructor. The selection and implementation of specific inquiry-based instruction methods should be dependent on the needs of the learners and the clinical context. Although not studied, hybrid approaches which incorporate all four methods may appeal to clinical and academic curricula such that learners are exposed to a variety of learning environments.
Problem-Based Learning Methods
Problem-based learning (PBL) results from the process of working towards the understanding and resolution of a problem (Menahem & Paget, 1990). Contrary to traditional educational environments that include learning theoretical concepts in the form of lectures and reading assignments, PBL is a curricular approach in which students are posed with a problem prior to any theoretical learning (O'Donoghue et al., 2011). The theoretical emphasis is removed from the learning environment, and students are compelled to expand their knowledge base through solving real patient problems. Reynolds and Hancock (2010)  emphasize that the role of the instructor is to present the patient problem, facilitate questioning, clarify misunderstandings, and facilitate review and reflection. Learners work collaboratively to acquire knowledge and skills through a staged sequence, and the focus of learning is on building problem-solving skills in a real world situation. In the PBL process, learners must tap into their higher level cognitive and metacognitive skills in order to determine what they already know, what they need to know to solve the problem, and what they should do to solve the problem (Reynolds & Hancock, 2010).
Proponents of problem-based learning cite the advantages of the approach to include promotion of deeper learning, enhancement of self-directed learning skills, promotion of interaction between students and educators, collaboration between disciplines, increased retention of knowledge, and improved student motivation (Spencer & Jordan, 1999). Detractors of this approach cite disadvantages with PBL to include increased demands related to cost and staff time, inefficiency due to the need for smaller class sizes, and reduced student acquisition of a core knowledge base (Spencer & Jordan, 1999). Others have cited concerns that PBL does not provide sufficient scaffolding of learning for the student that may result in cognitive overload (Jin & Bridges, 2014).
Although PBL originated in medical education, its popularity in professional therapy education is increasing (O'Donoghue et al., 2011). The PBL approach is similar to the clinical process that speech-language pathologists and audiologists face on a daily basis. As the clinical setting requires the use of functional problem-solving abilities on a regular basis, the PBL approach is well-suited to clinical education curricula. Use of this approach can enhance the development of critical thinking skills necessary to meet the demands in the clinical setting. Novice clinicians must learn how to obtain, analyze, and synthesize information in an effective and efficient manner to meet the often changing needs of the patients served.
Problem-based learning (PBL) has been found to be most effective with smaller numbers of students who are closely supervised by the course facilitator (Reynolds & Hancock, 2010). Given the nature of clinical education in speech-language pathology graduate programs, the PBL approach appears to be adaptable to the needs of student clinicians. Assuming students have a strong undergraduate background in the core knowledge areas, clinical educators can pose clinical problems to graduate students in small working groups. Spencer and Jordan (1999)  suggest that students should work together to solve problems, clarify unclear concepts, and apply acquired knowledge to the problem. Group and peer-to-peer problem solving (versus individual problem solving) may also help to address varying needs and skill levels of the students. Clinical educators may also consider the use of technology in PBL environments. Technology in the form of learning management systems, learning software, virtual environments, three dimensional anatomy models, and interactive white boards are effective applications in PBL paradigms (Greening, 1998). Technology may assist with keeping the learning environment innovative, diverse, and attractive to student clinicians. Simulated cases and the use of technology may also be a valuable and time-efficient training tool for on and off-site clinical educators.
In the context of the university setting, on-site clinical educators may wish to facilitate small groups that are presented with a problem that is challenging yet appropriate to the students' level of experience. For example, a group of novice graduate students may be presented with a clinical scenario addressing the differential diagnosis of developmental dysfluency versus dysfluency behavior in a 3-year-old male child. Clinical scenarios may be obtained from didactic coursework and/or authentic clinical cases in the university clinic. The group would then be required to brainstorm to develop pathways to solve the problem through self-directed study, more group discussion, and evaluation of their conclusions. Off-site clinical educators may be trained to incorporate simulated problem-based cases within the students' routine clinic day. For example, the student is asked to develop a clinical pathway for feeding decisions surrounding a patient who presents with an end-stage progressive neurologic disorder.
Case-Based Learning (CBL) Methods
Case-based learning (CBL) is another student-centered teaching strategy and methodology. It is an authentic, real world approach that stimulates independent learning in a collaborative format and can be viewed as “… middle ground” between PBL and more traditional teaching approaches (McCabe et al., 2009, p. 1). The CBL approach guides students' critical thinking in evidence-based practice (EBP). Learners must gather information about the presenting problem for real life or hypothetical cases and identify information that is relevant or irrelevant. Students must then determine a preliminary diagnosis after which they must plan, implement, and analyze the results of assessment. Finally, students must develop a management plan, including the selection of evidence-based treatment approaches (Chen & Lin, 2003).
Although more traditional teaching approaches often include multiple clinical scenarios that allow students to explore aspects of a particular disorder area, the CBL approach uses fewer cases that are thoroughly investigated to permit more in-depth critical appraisals of the case (McCabe et al., 2009). Effective cases must be relevant, rational, realistic, engaging, challenging, and instructional (McCabe et al., 2009). The instructor needs to carefully select cases to ensure the appropriate complexity level. Students interact with the case meaningfully which provides them with the opportunity to acquire theoretical and practical knowledge. Given the realistic nature of the cases, there is often the inclusion of irrelevant information that the student learner must sift through during the clinical decision-making process (McCabe et al., 2009). Cases of increasing complexity may be introduced as the students progress through the course or clinical experience. The same case can be revisited at various time frames throughout the curriculum as students acquire more academic and clinical knowledge and skills. The case-based approach also permits students to follow a case over a period of time to enhance their understanding of the clinical progression of a particular client rather than just glimpses of a client (McCabe, et al., 2009).
Advantages of CBL include the opportunity for the student to develop deep learning which leads to increased competency in clinical reasoning while in the classroom setting. This is especially important in university settings where clinical placements are at a premium. Disadvantages of case-based learning from the standpoint of the clinical educator are that it can be difficult to develop cases that incorporate content from didactic courses into a smaller number of meaningful cases. Students who are accustomed to traditional methods of teaching have reported increased anxiety transitioning to case-based learning, where they are required to work collaboratively and to develop responses to cases in which there may not be one simple solution or answer (McCabe, et. al., 2009).
The use of real cases in the classroom setting can assist students when they are placed in clinical settings to integrate knowledge acquired in case-based learning to the new setting (McCabe et al., 2009). Instructors cite satisfaction in working through clinical cases with the students as students and instructors are more engaged in the learning process. Similar to PBL, CBL can be used effectively with small working groups of three to four students. Both clinical educators and academic faculty can incorporate case-based learning into the program curricula to help close the theory-clinical practice gap. Early in the graduate program, beginning clinicians can use basic cases to explore the nature of a problem, collect a case history, and develop possible methods to manage the case, including forms of evidence-based assessment and treatment. At each step, students generate clinical questions that they must cooperatively answer to proceed with case management. Initially, feedback or hints from the clinical supervisor regarding the case progression may be necessary. A case example might be a child with a speech sound disorder for whom the primary consideration of the novice clinician may be to rule out organic causes and to determine whether an articulatory or phonological approach should be used.
For more advanced students, cases that are more complex, including multiple diagnoses, limited or incompatible case history information, or behaviorally difficult to manage clients, can be utilized. For example, a child with a speech sound disorder may have co-existing language or hearing deficits or the child may be bilingual with non-English speaking parents. Another application of CBL with more advanced students could be the use of a single case that is revisited several times over the course of a semester to assist students in managing cases based upon the changing needs of the client (e.g., an adult with a lateral medullary infarct who is transitioning from non-oral feedings to an oral diet due to severe dysphagia). Instructor guidance should be faded with more advanced students to promote independence in clinical problem solving.
Concept Mapping Methods
Concept maps are schematic representations that facilitate the student's ability to organize and represent knowledge (Mok, Whitehill, & Dodd, 2014; Novak, Gowin, & Johansen, 1983). Concepts are graphically mapped using circles or boxes with conceptual relationships typically indicated by a connecting line between two concepts. According to Novak and Cañas (2008), words on the connecting line, referred to as “linking words” or “linking phrases”, specify the relationship between the two concepts (p. 1). The concept map serves as a visual schematic to help students organize and structure knowledge within a framework that is constructed one piece at a time (Novak & Cañas, 2008). The fundamental idea of concept mapping suggests that learning takes place by the assimilation of new concepts and propositions into existing frameworks already held by the learner (Ausubel, Novak, & Hanesian, 1986).
The first step in constructing a well-designed concept map begins with a clearly stated focus question or proposition that the development of the concept map will help to resolve (Novak & Cañas, 2008). Information is collected by the student and sequenced in a hierarchy with the inclusive, more general concepts at the top of the map and the more specific, less general concepts arranged hierarchically below. This top down hierarchical approach (moving from general to specific concepts), provides the clinical educator with an effective way to monitor the students' increased critical thinking skills across each semester. Concept mapping is best used in an area or domain of knowledge that is familiar to the student who is constructing the map. For example, in a didactic traumatic brain injury class, the student may be presented with a focus question such as, “What formal assessment measure (from list of 10 assessments reviewed) provides the best prognostic indicator in the recovery process of an adult with a moderate traumatic brain injury?” The student would define the key focal concepts relating to this question and then develop the concepts in a hierarchical structure to answer this focus question. Likewise, concept mapping can be utilized in the clinic to respond to a focus question related to therapeutic intervention such as, “Which therapy approach (the Traditional Cognitive Intervention Approach or the Context-Sensitive Intervention Approach) is most appropriate for your client?” Key concepts are identified and the concept map is constructed linking different domains of the students' knowledge. The expectation is that as students gain more expertise, the concept map will expand to include more interconnections between theoretical knowledge and clinical domains (Novak & Cañas, 2008). One of the benefits of concept mapping may be that the clinical educator can measure the student's knowledge advancement over time. Students are also able to evaluate their expanding knowledge base which may assist with self-reflective practice and overall clinical confidence.
Although concept mapping has been suggested as a viable teaching tool to bridge theoretical knowledge with clinical practice (Carr-Lopez, Galal, Vyas, Patel, & Gnesa, 2014), clinical educators and novice learners may find concept mapping challenging for the clinical environment. Clinical educators may initially need to strategically scaffold and structure the map for the students until they achieve a higher level of independence. Students may need to be placed in small working groups such that independence can be achieved. Concept maps can also be a time consuming pedagogical tool due to the complexities involved in designing, effectively implementing, and objectively assessing the schematic. It may not always be easy to graphically translate complex clinical cases where there may be multiple or equivocal outcomes. Additionally, researchers recommend the use of an objective scoring rubric to effectively assess the student's conceptual knowledge (Sharma & Chawla, 2014). The accuracy of the student's concept map may be compared to a master concept map including the number of concepts, valid propositions, and drawn relationships. The rubric should vary dependent upon the case or question, again requiring extensive planning by the clinical educator.
Given some of the complexities involved in implementing concept maps, clinical educators may secondarily opt to implement a hybrid approach to concept mapping. Visual representation of concepts as a way of assessing a students' in-depth knowledge can certainly be a valuable teaching and learning tool, particularly for visual learners. For example, graphic organizers provide the flexibility of using a variety of formats without the strict adherence to schematic structure and formatting involved in concept mapping (Cummings, Kimbell-Lopez, & Manning, 2015). Additionally, application of varying graphic organizers may allow students to show the sequence and completeness of their thought processes in the clinical environment without the complexity and time requirements associated with the concept map. Within the context of the clinical setting, a student may need to differentially diagnose apraxia versus expressive aphasia for an adult patient during a diagnostic evaluation and then determine the best therapeutic approach to use. The use of a graphic organizer may include a free-form visual schematic that lists the speech and language characteristics associated with each diagnostic classification, the possible therapeutic approaches, rationales for selecting a therapeutic approach, and planned outcomes to facilitate the decision-making process of the student. The obstacle to facilitating a less structured hybrid approach to concept mapping may yield difficulties in objective and reliable assessment as well as removal of a formalized structural framework for the student to learn. For novice students, some may argue that providing a more structurally based framework and learning environment may be better suited to building foundational knowledge. As such, consideration for pairing the idea of concept mapping with other teaching methods, such as case-based learning, may be appropriate in the clinical setting.
Guided Discovery Methods
Guided discovery has been described as “… learning how to learn through the process of discovery and the exploration of knowledge” (Spencer & Jordan, 1999, p. 1282). Evolving from the constructivist philosophy of teaching, guided discovery uses a combination of traditional teaching methods and more learner centered approaches (Spencer & Jordan, 1999). Students learn by doing through a sequenced series of steps, moving from specific to general. The student explores the steps leading to a goal and must develop sufficient knowledge in the subject area to permit further exploration (Spencer & Jordan, 1999). The instructor provides a context for learning by introducing the topic and reviewing the intended learning objectives using more traditional methods of teaching. Learners progress through a series of often self-directed tasks, group discussions, study guides, and real world experiences (Spencer & Jordan, 1999). Learners explore the content and gradually master it through a step-by-step process.
Guided discovery is often utilized in contexts with larger class sizes that are not conducive to a fully problem-based learner approach (Spencer & Jordan, 1999). A recent meta-analysis indicated that guided discovery is a more suitable teaching method than unassisted discovery or direct instruction with novice learners (Alfieri, Brooks, Aldrich, & Tenebaum, 2011). Educational research supports the premise that exploration prior to instruction facilitates learning in novice learners (DeCaro & Rittle-Johnson, 2011). Guided discovery may also be better suited to low knowledge learners—that is, students who have a limited background in, or experience with, a particular concept. This is based on the premise that high knowledge learners have developed schemas while low knowledge learners have not. Additional guidance from the instructor provides increased cognitive load with high knowledge learners but reduces cognitive load with low knowledge learners (DeCaro & Rittle-Johnson, 2011).
As generating hypotheses and strategies for learning can be difficult for students, the use of hints or coaching during problem-solving has been found to be better than pure problem-solving alone (Mayer, 2004). Feedback from the instructor helps the student to identify errors and to employ new strategies for learning. However, the instructor must be selective in the use of feedback to ensure that it is guiding the student to discover new concepts (Luwel, Foustana, Papadatos, & Verschaffel, 2011). Instructors may provide varying levels of feedback which provide information about the answers derived by the learner or the strategies used by the learner (Luwel et al., 2011).
In the context of the clinical setting, use of guided discovery may be better suited to the beginning clinician who has a general knowledge base in the field of speech-language pathology but requires increased support from the instructor in the process of building clinical knowledge and skills. Guided discovery may serve as a prerequisite to the use of more learner-centered approaches, such as problem-based learning or case-based learning. A clinical educator may wish to present a theme or lesson using a traditional teaching method that may include a brief lecture or study guide to introduce the content. Students are then provided with a general learning frame from which they extend their knowledge through a series of more self-directed tasks, such as small group discussions or task-based activities that lead them to a greater understanding of the concept. For example, the clinical supervisor could lecture students on the necessary components of a case history interview and provide them with a case history outline form. Students could then practice conducting case histories with other students with verbal feedback provided by the instructor. Ultimately, a videotaped case history interview could be conducted followed by feedback from peers and the instructor.
Feedback Methods and Strategic Questioning Methods
Feedback in a clinical setting refers to “… information describing students' performance in a given activity that is intended to guide their future performance in that same or in a related activity” (Ende, 1983, p.777). It is well-documented in the literature that feedback is given to confirm or reinforce behavior, correct behavior, and promote improvement in future performance (Barnum, Guyer, Levy, & Graham, 2009; Ende, 1983; Nottingham & Henning, 2014). Over the past 30 years, researchers have described various guidelines for ensuring feedback is effective. Common across most models of feedback is the significance of the timing, frequency, tone, form, and specificity of the feedback. According to Ende (1983), feedback should be undertaken with common goals between the supervisor and student, and based on firsthand observations. Comments on specific performance and behaviors using descriptive non-evaluative language are recommended (Ende, 1983). More recently, Brookhart (2012)  reflected that good feedback should be timely, positive, clear and specific, and descriptive of the student’s work.
A more recent model of supervision has paired feedback with strategic questioning as described in the Supervision, Questioning and Feedback (SQF) Model (Barnum et al., 2009). The model provides clinical educators with a structural framework to assist with developing students' critical thinking. Barnum et al. (2009)  stated that critical thinking in the decision-making process may be better facilitated by scaffolding the level of supervision, questioning, and feedback based on the knowledge and experience of the learner. At the core of the SQF model is the implementation of a strategic questioning method. Strategic questioning consists of consciously adapting the timing, order, and phrasing of questions to help the student process information at increasingly more complex levels. The purpose of strategic questioning is to actively engage students to use increasingly complex processing skills and to help them develop a model of thinking to assist with making appropriate and accurate clinical decisions (Barnum et al., 2009). Strategic questioning within the context of the SQF Model is based on the principles of Bloom's Taxonomy of Educational Objectives with questions phrased to target specific cognitive processing along six increasingly complex levels beginning with basic recall of facts and culminating in evaluating and defending decisions (Anderson et al., 2001; Barnum et al., 2009; Bloom, Engelhart, Furst, Hill, & Krathwohl, 1956).
Clinical educators may more likely facilitate critical thinking within the clinical context if feedback and questioning methods are intentionally strategic and situational to the context and level of the learner (Barnum et al., 2009). The supervision of graduate students in a university clinic or at externship placements provide a favorable opportunity to implement strategic questioning and feedback during each semester as well as across semesters. Video or audiotaping the clinical feedback session may allow for future reference and comparisons of a student's progress and ability to respond to questions of increasing complexity. Questions that require factual information (e.g., What is apraxia of speech?) may be posed initially. As the student gains more experience, more complex questions that require synthesis and application of knowledge are posed (e.g., Give a for and against statement for the implementation of melodic intonation therapy with speech apraxia). Careful corrective or guided positive feedback is provided routinely to assist the student in processing the correct information.
Several other considerations are important in the implementation of strategic questioning and feedback in the clinical setting, including the timing and type of feedback. Clinical educators may consider providing both immediate and delayed feedback in order to assist with providing a more dynamic learning environment. Likewise, the method of delivery of the feedback should be considered, with students benefiting from diversity in the type of feedback (e.g., verbal, written etc.).
Important in this process is the preparation by the clinical educator. Clinical educators must therefore tap into their own cognitive and metacognitive processes in order to maximize the effectiveness of their clinical feedback. The clinical educator may need to prepare for clinical teaching sessions to ensure that a variety of questions at varying levels of complexity are posed and that the questions selected are appropriate for each particular student in their continuum of clinical skills. Clinical educators may consider audio/videotaping student interactions in order to discover any patterns of questioning that are redundant or exclude certain types of questions (Barnum et al., 2009). This type of instructor-oriented, self-reflective practice and training may be an integral component to advancing the student to achieve higher levels of critical thinking.
Evidence-Based Practice (EBP) Methods
According to Sackett, Straus, Richardson, Rosenberg, and Haynes (2000), EBP is the integration of the best available external evidence, clinical expertise, and patient/family wishes when formulating a clinical decision. Evidence-based clinical decision-making is a vital concept that competent clinicians from all clinical disciplines must embrace. Most clinical disciplines are held accountable for ensuring that the best quality services are provided to those they serve. In speech-language pathology and audiology, the Council for Clinical Certification in Audiology and Speech-Language Pathology (CFCC) requires that those seeking the Certificate of Clinical Competence in Speech-Language Pathology possess knowledge in integrating research principles into evidence-based clinical practice in Standard IV-F (ASHA, 2013). Therefore, clinical educators must prime students to consistently incorporate EBP methods within the clinical setting.
Studies have indicated that while clinical educators and clinicians recognize the significance of implementing an EBP framework in the clinical setting, many are challenged with how to effectively translate EBP to real clinical decisions. According to Togher et al. (2011), surveys completed by academic and clinical staff revealed that students were perceived as being more adept at applying EBP in academic assignments compared to when making real clinical decisions. Similarly, studies have also addressed the potential for many clinicians to rely more heavily on clinical expertise as opposed to external evidence to guide decision-making (Hart & Kleinhans, 2014; Manns, Norton, & Darrah, 2015; McCurtin & Clifford, 2015; O'Connor & Pettigrew, 2009). Disparities between evidence-based theory and evidence-based clinical practice highlight the significance of selecting clinical teaching methods that foster more consistent implementation of EBP within the clinical setting.
Traditional methods for teaching EBP include models which systematically guide an EBP framework. For example, Straus, Richardson, Glasziou, and Haynes (2005)  discussed five steps for making a clinical decision: (a) pose a clinical question; (b) find the evidence; (c) critique the evidence; (d) integrate patient values and clinical expertise; and (e) assess the effectiveness. Permeating academic curricula with EBP theory will assist students with acquiring basic conceptual knowledge but may not easily translate to the clinical setting (Hart & Kleinhans, 2014; Spek, Wieringa-de Waard, Lucas, & van Dijk, 2013; Togher et. al., 2011). Active learning (learning by doing), as opposed to passive learning methods (didactic lectures), may be more useful in clinical contexts (Gleason et al., 2011; Miller & Metz, 2014). Difficulties transferring theoretical knowledge to clinical practice may stem from limited opportunities to actively practice EBP processes. In fact, in medicine, deliberate practice has been shown to be effective in the acquisition of clinical skills (Duvivier et al., 2011). Students must therefore be provided with ample opportunities to actively learn and practice EBP theory within the clinical setting. Providing more clinical opportunities for application and practice of EBP knowledge may not only improve incidence of implementation but may also improve the speed at which the student implements an EBP framework. Historically, one of the largest criticisms for implementing EBP is time constraints (Cheung, Trembath, Arciuli, & Togher, 2013; Heiwe et al., 2001). Clinical educators must teach students how to effectively locate quality external evidence and complete an EBP framework in a reasonable amount of time to maintain with realistic productivity standards.
If there is growing evidence to suggest that novice learners are more likely to demonstrate skill competency and efficiency by repeated exposure to systematically and comprehensively completing a task, then perhaps teaching methods should focus on methodically scaffolding clinical skills. Teaching methods may be comprehensive and systematic initially, then gradually more efficient and automatic as experience level increases. For example, a student may be required to initially write a comprehensive three part EBP rationale for each of the selected goals for his/her assigned clinical case and then asked write a short paragraph to an insurance company validating the EBP rationale for services. Similarly, a student may be asked to present a 15 to 20-minute case presentation verbalizing a three part EBP rationale for the selected treatment goals and then asked to verbalize this three-part rationale to his/her client's physician in under 5 minutes.
Abiding by some of the same principles that guide generalization of a skill, the student should be provided with multiple opportunities and contexts to write and verbalize an EBP framework. As such, clinical educators may wish to ensure that teaching methods require students to learn evidence-based processes when (a) teaching clinical writing and (b) when guiding clinical communicative interactions. Providing isolated opportunities within one domain may prevent the student from generalizing the skill across all clinical contexts. Written contexts may not include just implementing an EBP framework within clinical documentation of services, but also written correspondence with insurance companies and outside professionals. Communicative contexts may include formal conferences with clinical educators, clients/families, peers, academic faculty, and outside professionals. Providing more formal and scheduled communicative interactions, particularly with clients, may also assist the student in placing higher value on the significance of client-centered treatment (one of the three parts to EBP).
Last, given that evidence suggests that clinicians tend to rely more heavily on clinical expertise rather than external evidence (Hart & Kleinhans, 2014; Manns, Norton, & Darrah, 2015; McCurtin & Clifford, 2015; O'Connor & Pettigrew, 2009), clinical educators may wish to implement teaching methods that encourage the student to use objective data rather than anecdotal to guide clinical expertise. For example, within the university setting, clinical educators should emphasize teaching methods for evaluating reliability and validity of data collection and using data collection to make objective assessment statements. These same principles should be translated to off-site externships such that the student can generalize these concepts across clinical settings. There is growing evidence to suggest that clinical supervision training and close partnerships with externships may assist with facilitating a richer clinical experience for the student (Hart & Kleinhans, 2014). Evidence-based practice (EBP) teaching methods may be one of the core principles included in clinical supervision training for off-site supervisors.
Metacognitive Models of Self-Reflection
Self- reflective practice involves evaluation of “… what one is doing versus what one is observing” (Geller, 2002, p. 195). Self-reflective practice is frequently cited in the literature as a learning method which strives to improve an individual's clinical independence and overall competency by improving one's self-awareness (Hill, Davidson, & Theodoros, 2012; Lewis, 2013; Mann, Gordon, & Macleod, 2009). Logically speaking, one might argue that the precursor to accurate self-reflective practice is well-developed metacognitive knowledge. Flavell (1979)  was one of the first psychologists to describe metacognitive knowledge as the ability to possess knowledge about one's own capabilities. Furthermore, individuals must be able to tap into their own higher level thinking processes in order to critically appraise the self.
How can an individual develop strong metacognitive knowledge such that accurate self-reflection is also well developed? There is growing research suggesting that efficacy for the use of self-reflective practice in clinical education may be stronger if learners are trained to engage in self-reflective practice (Aronson, Niehaus, Hill-Sakurai, Lai, & O'Sullivan, 2012; McCarthy, 2010). In other words, learners, especially, novice learners, may need more structured and transparent approaches which focus on developing self-awareness such that self-reflective practices are more effective. To further support this theory, research conducted by Kruger and Dunning (1999)  argued that “… less competent individuals overestimate their abilities because they lack the metacognitive skills to recognize error in their own decisions” (p. 1130). Additional studies following Kruger and Dunning (1999)  also recognized that the unskilled performers often lack awareness of their skill limitations (Ehrlington, Johnson, Banner, Dunning, & Kruger, 2008). Therefore, metacognition and metacognitive teaching methods may play a significant role in developing self-reflective practice, particularly for novice clinicians.
If novice learners need more formalized self-reflective training, clinical educators may wish to consider various metacognitive teaching methods to develop the skill of self-reflection. Metacognitive aspects of learning are not novel concepts. In fact, social cognitive theories, self-regulated learning, and other metacognitive aspects of learning have been cited in the literature for over 30 years (Bandura, 1986; Dignath & Buttner, 2008; Flavell, 1979; Williams & Hellman, 2004). Bloom and colleagues (1956)  and Anderson et al. (2001)  also emphasized the significance of metacognition in learning. Although journaling and blogging have been cited in the literature as viable options for self-reflection (Hill et al., 2012), it may not be sufficient to require students to journal without systematically developing the skill of self-reflection prior to being assigned reflective journaling activities (Chabon & Lee-Wilkerson, 2006). For example, a student may lack the self-awareness to be able to reflect on his/her clinical performance if self-reflective opportunities are not paired with metacognitive instruction methods that teach the student how to self-reflect. In turn, the student may be more likely to reflect on what he/she is observing versus what he/she is doing. Some literature has suggested that watching behavior of others may assist individuals with improving self-awareness (Kruger & Dunning, 1999; Williams & Hellman, 2004). Video-recording a student's performance, engaging the student in 1:1 or group facilitated discussion, and then engaging the student in self-evaluation may assist with more accurate self-reflective practice. Written self-reflections may require that the clinical educator provide more specificity in instruction methods. For example, the student may be asked to comment on a specific clinical competency area, such as his/her data collection techniques and to provide a written rationale for why the techniques were effective or ineffective (see Appendix A).
Conclusion
Critical thinking in the clinical setting is necessary to ensure that patients and clients are receiving the best possible services. Clinical educators carry the great responsibility of effectively stimulating students to think critically in the clinical setting. Therefore, clinical educators must also think critically about the selection and implementation of the clinical teaching methods used with students. Common across all of the clinical teaching methods discussed in this article is the significance of tapping into students' higher level cognitive and metacognitive abilities. Integrating teaching methods that are rooted in higher level cognitive and metacognitive learning principles may assist students with reaching a greater level of critical thinking. Given the diverse learning styles and skill levels of students, hybrid clinical teaching approaches that incorporate inquiry-based and other higher order teaching methods may be best suited for clinical and academic curricula. Further research is needed to explore the effect of both homogenous and hybrid clinical teaching approaches on critical thinking in student clinicians. Despite the need for more research, current evidence is promising regarding the effectiveness of clinical teaching methods that are intended to specifically challenge students to reach higher order levels of cognitive and metacognitive functions. These teaching methods stimulate critical thinking in students, as well as their clinical educators, and aid in the development of clinical skills that will result in improved client outcomes throughout their careers.
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Appendix A.
Clinical Teaching Methods for Developing Critical Thinking
Method Definition Pros Cons How to Effectively Implement?
Inquiry-Based Instruction
Problem- Based Learning Learning activities focus on developing viable solutions to problems. Promotes deeper learning, enhancement of self-directed learning skills, and collaboration between students and educators. Requires increased demands related to cost due to smaller class sizes and staff time; May not provide sufficient scaffolding of learning for the student. Most effective with smaller numbers of students who are closely supervised by the course facilitator.
Case- Based Learning Learning activities focus on authentic cases. Provides students with the opportunity to develop deeper learning which may lead to increased competency in the clinical setting. Difficulty incorporating content from didactic courses into a smaller number of meaningful cases; students who are accustomed to traditional teaching methods have reported difficulties transitioning to the collaborative teaching format. Used effectively with small working groups of 3 to 4 students.
Concept Mapping Graphic technique to understand connections of concepts within students' knowledge base or conceptual schemata. Provides visual “mental maps” to organize learning that include evaluation and synthesis of knowledge. May be better suited in the classroom vs. the clinical setting due to the overall complexity of implementation. Hybrid approaches which incorporate visual outlining and graphic organizers may be a viable alternative in the clinical setting.
Guided Discovery Learning by doing through a sequenced series of self-directed tasks. May be better suited to low knowledge learners who have a limited background in or experience with a particular concept. Generating hypotheses and strategies for learning may be difficult for students, requiring coaching from the instructor. May be better utilized as a prerequisite to the use of more learner-centered approaches.
Feedback & Strategic Questioning Information given to confirm, correct, guide, or improve performance; intentionally structuring questions to help the student reach higher levels of critical thinking. Provides the clinical educator with a more structured approach to assisting the student with reaching higher levels of critical thinking Clinical educators likely need formal clinical education training and self-reflective practice in order to access the necessary metacognitive skills to be able to ask higher level questions and provide specific feedback. Instructor-oriented, self-reflective practice and clinical education training in order to assist the student with achieving higher levels of critical thinking.
Evidence-Based Practice Effectively integrating external evidence, clinical expertise, and patient/family wishes. If executed appropriately, ensures highest quality of clinical services. Difficulty translating to real clinical decisions. More opportunities to actively learn and practice in the clinical setting; use a systematic approach to clinical implementation, first comprehensively and later with more brevity and automaticity.
Metacognitive Models of Self-Reflection Transparent training approaches that develop metacognitive knowledge and teach how to effectively self-reflect. Improves clinical independence and overall competence by improving one's self-awareness. Likely is a skill that needs to be developed through training. Formalized self-reflective training such as evaluating the self through video recording, followed by 1:1 or group discussion.
Method Definition Pros Cons How to Effectively Implement?
Inquiry-Based Instruction
Problem- Based Learning Learning activities focus on developing viable solutions to problems. Promotes deeper learning, enhancement of self-directed learning skills, and collaboration between students and educators. Requires increased demands related to cost due to smaller class sizes and staff time; May not provide sufficient scaffolding of learning for the student. Most effective with smaller numbers of students who are closely supervised by the course facilitator.
Case- Based Learning Learning activities focus on authentic cases. Provides students with the opportunity to develop deeper learning which may lead to increased competency in the clinical setting. Difficulty incorporating content from didactic courses into a smaller number of meaningful cases; students who are accustomed to traditional teaching methods have reported difficulties transitioning to the collaborative teaching format. Used effectively with small working groups of 3 to 4 students.
Concept Mapping Graphic technique to understand connections of concepts within students' knowledge base or conceptual schemata. Provides visual “mental maps” to organize learning that include evaluation and synthesis of knowledge. May be better suited in the classroom vs. the clinical setting due to the overall complexity of implementation. Hybrid approaches which incorporate visual outlining and graphic organizers may be a viable alternative in the clinical setting.
Guided Discovery Learning by doing through a sequenced series of self-directed tasks. May be better suited to low knowledge learners who have a limited background in or experience with a particular concept. Generating hypotheses and strategies for learning may be difficult for students, requiring coaching from the instructor. May be better utilized as a prerequisite to the use of more learner-centered approaches.
Feedback & Strategic Questioning Information given to confirm, correct, guide, or improve performance; intentionally structuring questions to help the student reach higher levels of critical thinking. Provides the clinical educator with a more structured approach to assisting the student with reaching higher levels of critical thinking Clinical educators likely need formal clinical education training and self-reflective practice in order to access the necessary metacognitive skills to be able to ask higher level questions and provide specific feedback. Instructor-oriented, self-reflective practice and clinical education training in order to assist the student with achieving higher levels of critical thinking.
Evidence-Based Practice Effectively integrating external evidence, clinical expertise, and patient/family wishes. If executed appropriately, ensures highest quality of clinical services. Difficulty translating to real clinical decisions. More opportunities to actively learn and practice in the clinical setting; use a systematic approach to clinical implementation, first comprehensively and later with more brevity and automaticity.
Metacognitive Models of Self-Reflection Transparent training approaches that develop metacognitive knowledge and teach how to effectively self-reflect. Improves clinical independence and overall competence by improving one's self-awareness. Likely is a skill that needs to be developed through training. Formalized self-reflective training such as evaluating the self through video recording, followed by 1:1 or group discussion.
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Method Definition Pros Cons How to Effectively Implement?
Inquiry-Based Instruction
Problem- Based Learning Learning activities focus on developing viable solutions to problems. Promotes deeper learning, enhancement of self-directed learning skills, and collaboration between students and educators. Requires increased demands related to cost due to smaller class sizes and staff time; May not provide sufficient scaffolding of learning for the student. Most effective with smaller numbers of students who are closely supervised by the course facilitator.
Case- Based Learning Learning activities focus on authentic cases. Provides students with the opportunity to develop deeper learning which may lead to increased competency in the clinical setting. Difficulty incorporating content from didactic courses into a smaller number of meaningful cases; students who are accustomed to traditional teaching methods have reported difficulties transitioning to the collaborative teaching format. Used effectively with small working groups of 3 to 4 students.
Concept Mapping Graphic technique to understand connections of concepts within students' knowledge base or conceptual schemata. Provides visual “mental maps” to organize learning that include evaluation and synthesis of knowledge. May be better suited in the classroom vs. the clinical setting due to the overall complexity of implementation. Hybrid approaches which incorporate visual outlining and graphic organizers may be a viable alternative in the clinical setting.
Guided Discovery Learning by doing through a sequenced series of self-directed tasks. May be better suited to low knowledge learners who have a limited background in or experience with a particular concept. Generating hypotheses and strategies for learning may be difficult for students, requiring coaching from the instructor. May be better utilized as a prerequisite to the use of more learner-centered approaches.
Feedback & Strategic Questioning Information given to confirm, correct, guide, or improve performance; intentionally structuring questions to help the student reach higher levels of critical thinking. Provides the clinical educator with a more structured approach to assisting the student with reaching higher levels of critical thinking Clinical educators likely need formal clinical education training and self-reflective practice in order to access the necessary metacognitive skills to be able to ask higher level questions and provide specific feedback. Instructor-oriented, self-reflective practice and clinical education training in order to assist the student with achieving higher levels of critical thinking.
Evidence-Based Practice Effectively integrating external evidence, clinical expertise, and patient/family wishes. If executed appropriately, ensures highest quality of clinical services. Difficulty translating to real clinical decisions. More opportunities to actively learn and practice in the clinical setting; use a systematic approach to clinical implementation, first comprehensively and later with more brevity and automaticity.
Metacognitive Models of Self-Reflection Transparent training approaches that develop metacognitive knowledge and teach how to effectively self-reflect. Improves clinical independence and overall competence by improving one's self-awareness. Likely is a skill that needs to be developed through training. Formalized self-reflective training such as evaluating the self through video recording, followed by 1:1 or group discussion.
Method Definition Pros Cons How to Effectively Implement?
Inquiry-Based Instruction
Problem- Based Learning Learning activities focus on developing viable solutions to problems. Promotes deeper learning, enhancement of self-directed learning skills, and collaboration between students and educators. Requires increased demands related to cost due to smaller class sizes and staff time; May not provide sufficient scaffolding of learning for the student. Most effective with smaller numbers of students who are closely supervised by the course facilitator.
Case- Based Learning Learning activities focus on authentic cases. Provides students with the opportunity to develop deeper learning which may lead to increased competency in the clinical setting. Difficulty incorporating content from didactic courses into a smaller number of meaningful cases; students who are accustomed to traditional teaching methods have reported difficulties transitioning to the collaborative teaching format. Used effectively with small working groups of 3 to 4 students.
Concept Mapping Graphic technique to understand connections of concepts within students' knowledge base or conceptual schemata. Provides visual “mental maps” to organize learning that include evaluation and synthesis of knowledge. May be better suited in the classroom vs. the clinical setting due to the overall complexity of implementation. Hybrid approaches which incorporate visual outlining and graphic organizers may be a viable alternative in the clinical setting.
Guided Discovery Learning by doing through a sequenced series of self-directed tasks. May be better suited to low knowledge learners who have a limited background in or experience with a particular concept. Generating hypotheses and strategies for learning may be difficult for students, requiring coaching from the instructor. May be better utilized as a prerequisite to the use of more learner-centered approaches.
Feedback & Strategic Questioning Information given to confirm, correct, guide, or improve performance; intentionally structuring questions to help the student reach higher levels of critical thinking. Provides the clinical educator with a more structured approach to assisting the student with reaching higher levels of critical thinking Clinical educators likely need formal clinical education training and self-reflective practice in order to access the necessary metacognitive skills to be able to ask higher level questions and provide specific feedback. Instructor-oriented, self-reflective practice and clinical education training in order to assist the student with achieving higher levels of critical thinking.
Evidence-Based Practice Effectively integrating external evidence, clinical expertise, and patient/family wishes. If executed appropriately, ensures highest quality of clinical services. Difficulty translating to real clinical decisions. More opportunities to actively learn and practice in the clinical setting; use a systematic approach to clinical implementation, first comprehensively and later with more brevity and automaticity.
Metacognitive Models of Self-Reflection Transparent training approaches that develop metacognitive knowledge and teach how to effectively self-reflect. Improves clinical independence and overall competence by improving one's self-awareness. Likely is a skill that needs to be developed through training. Formalized self-reflective training such as evaluating the self through video recording, followed by 1:1 or group discussion.
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The 19 individual SIG Perspectives publications have been relaunched as the new, all-in-one Perspectives of the ASHA Special Interest Groups.