Preceptor Questioning and Student Critical Thinking

FLORENCE MYRICK, RN, PHD,* AND OLIVE YONGE, CPSYCH, RN, PHD†

Questioning is fundamental to student learning. Notonly does it enable students to elevate their level ofthinking, but in the process it also affords them theopportunity to deal with their world intelligently. Thepractice setting is an environment rich in opportunityfor enabling critical thinking through the use of ques-tioning. In the preceptorship experience, preceptorsare in a prime position to use questioning behaviorsthat can challenge the way preceptees think, encour-age them to justify or clarify their assertions, promotethe generation of original ideas, explanations, or so-lutions to patient problems, provide mental and emo-tional tools to help resolve dilemmas, promote dis-cussion, and evaluate learning. This article discussesthe importance of preceptor questioning for the de-velopment and promotion of student critical thinking.Contextually, the authors draw on the findings of arecent study in which preceptor questioning of theknowledge base, decision making, and actions of thepreceptee were found to directly bring about or trig-ger their critical thinking. This article allows for somefurther reflection on that process and its contributionto the enhancement of the preceptorship experience.(Index words: Preceptor; Preceptee; Questioning;Critical thinking) J Prof Nurs 18:176-181, 2002. Copy-right 2002, Elsevier Science (USA). All rights reserved.

ACCORDING TO Hunkins (1974), “the questionis central to learning” (p. 1). Since the Greek

philosopher Socrates used a method of questioning toderive a definition, the question has been an integralcomponent of the teaching-learning process and hascome to be recognized as a powerful device to promotethinking (Hunkins, 1989). Questioning is fundamen-tal to student learning. It not only enables students toelevate their level of thinking, but in the process it alsoenables them to deal intelligently with their world(Hunkins, 1974). The most widely renowned exem-plar of teacher questioning is the dialogue of Socrates

in “The Meno,” in which he elicits the Pythagoreantheorem from an untutored slave boy; the implicationof this dialogue being that perceptive teachers who useskilful questioning techniques can promote high levelsof thinking in their students (Scholdra & Quiring,1973).

Questions can be used to direct the thinking pro-cess, provoke interest, stimulate and challenge the stu-dent, influence the social and emotional milieu of theteaching/learning environment, form the basis of re-search, promote discussion, and evaluate learning(House, Chassie, & Spohn, 1990; Schell, 1998;Thompson, 1999). Although the focus of this article ison the questioning behaviors of preceptors and pre-ceptees, it needs to be recognized that data were con-sidered through the framework of critical thinking.Numerous investigators have critiqued critical think-ing theory and have acknowledged the role of ques-tioning in that literature (Boychuk, 1999; Coluciello,1997; Conger & Mezza, 1996; May, Butell, Doughty,& Langford, 1999; O’Neill & Dluhy, 1997; Rossig-nol, 1997).

The practice setting is an environment rich in op-portunity for enabling critical thinking through the useof questions. Indeed, preceptors are in a prime positionto challenge the way preceptees think, encourage themto justify or clarify their assertions, promote the gener-ation of original ideas, explanations, or solutions topatient problems, provide mental and emotional toolsto help resolve dilemmas, and provide a more personalenvironment with the one-to-one relationship (Con-ger & Mezza, 1996).

Recently, a study was completed in which key in-sights were gleaned into the process used in the precep-torship experience to develop and promote the criticalthinking ability of basic baccalaureate nursing students(Myrick, 1998). One of these insights related specifi-cally to enabling students to think critically by theprocess of preceptor questioning. The original studywas conducted with fourth-year basic baccalaureatenursing students and their staff nurse preceptors in atertiary care setting. The grounded theory approachwas adhered to for data collection and constant com-parative analysis, with saturation of the data determin-ing the eventual sample size. A total of 33 interviews

*Associate Dean, Graduate Programs, Faculty of Nursing, Uni-versity of Calgary, Calgary, Alberta, Canada.

†Professor, Faculty of Nursing, University of Alberta, Edmon-ton, Alberta, Canada.

Address correspondence and reprint requests to Dr. Myrick:Associate Dean, Graduate Programs, Faculty of Nursing, Univer-sity of Calgary, Calgary, Alberta, Canada.

Copyright 2002, Elsevier Science (USA). All rights reserved.8755-7223/02/1803-0012$35.00/0doi:10.1053/jpnu.2002.124485

176 Journal of Professional Nursing, Vol 18, No 3 (May–June), 2002: pp 176-181

were completed with six nursing students and six pre-ceptors and observations were performed in the prac-tice setting as they worked together in performing theirnursing care.

This article does not discuss the study per se, butrather draws specifically on a particular aspect of itsfindings as a rich backdrop and reflection regarding thereality of the preceptorship experience pertaining tothe process of promoting student critical thinking. In-deed, this study has brought to light the process inher-ent in the preceptorship experience that contributes tothe critical thinking ability of baccalaureate nursingstudents in the practice setting. Of major significance isthe finding that preceptors do openly question the pre-ceptees’ knowledge base, decision making, and actions,and in doing so they directly bring about or trigger thepreceptees’ critical thinking. This article allows forsome further reflection on that particular process andits contribution to enhance the preceptorship experi-ence.

Review of the Questioning Literature

Although the act of questioning is significant, thelevel of the question asked is also essential to enablecritical thinking. For example, it is essential that ques-tioning include not only low-level or factual questions,but that clarifying and higher-level questions be usedalso (Oermann, 1997). Factual or low-level questionsrequire that the preceptee recall specific informationand facts. Higher-level questions, on the other hand,cannot be answered by memory alone. They requireevaluation or judgment of the clinical situation, andmay require comparisons across patients or clinical sit-uations (deTornyay & Thompson, 1987; Oermann,1997).

Although there are numerous classification systemswith regard to questions, nurse educators are most fa-miliar with Bloom’s “Taxonomy of Educational Ob-jectives” (Bloom, 1956). This taxonomy delineatescognitive function in six areas: knowledge, compre-hension, application, analysis, synthesis, and evalua-tion. Categories are hierarchical because each level sub-sumes the use of the thinking processes of all lowerlevels. Moreover, the various levels of the taxonomyserve as building blocks (Hunkins, 1974). Because thetop four categories require higher-order thinking skills,the hierarchy is usually divided into high (application,analysis, synthesis, and evaluation) and low (knowl-edge and comprehension) cognitive levels (Wink,1993). Regardless of the level of questioning, however,

the questioner needs to establish an appropriate learn-ing climate, use wait time, probe after a question isasked, and ask questions at a pertinent level (Sachdeva1996).

Questions can also be classified as convergent ordivergent (Wink, 1993). Convergent questions requirelow-level thinking. Responses are predictable and typ-ically specific, succinct, and factual (House, Chassie,& Spohn, 1990). Convergent questions require thelearner to answer yes or no, compare, contrast, define,specify, name, or indicate relationships (House, Chas-sie, & Spohn). Divergent questions, on the other hand,are more thought provoking than convergent ques-tions and necessitate a higher level of thinking. An-swers to divergent questions are unpredictable and re-quire the learner to “defend, hypothesize, infer, judge,justify choice, predict, reconstruct, and value” (p.196). As with Bloom’s (1956) taxonomy, the differ-ence between convergent and divergent questioningalso addresses the category of questions according to ahierarchy of levels. For example, the more complex thequestion, the higher the thinking level required. Thecontext and framing of the question signifies the levelof thought processing required for appropriate studentresponse (House, Chassie, & Spohn).

Questions can also be derived from the perspectiveof a three-tier hierarchy, each level requiring incremen-tally higher levels and complexity in thinking (House,Chassie, & Spohn, 1990). The three levels of question-ing are described by Bowling (1979) as knowledgequestioning, application questioning, and problem-solving questioning. Knowledge questioning, the firstlevel, requires memory or recall and is designed to ob-tain specific information or concrete responses thathave right or wrong answers. Application questioningis the second level and requires students to use theinformation recalled at the knowledge level within aspecific context. Problem-solving questioning is thethird level of questioning and is designed to promotethinking at the highest mental capacity. All three levelsof questioning can be appropriate with all studentsregardless of the learning setting (House, Chassie, &Spohn).

Use of Questioning in the PreceptorshipExperience

In the preceptorship experience, skilful questioninghas many positive implications. For example, pre-ceptees questioned by their preceptors must show whatthey know regarding their knowledge base, discuss

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their individual perspectives, and reflect on critical is-sues or personal values that they may not have exam-ined previously. When questioned, they also must ap-ply theoretical knowledge to patient situations andprovide the rationale underlying their comprehensionof circumstances inherent in the particular situations(Wink, 1993). As well, questioning provides the op-portunity for preceptees to correct any misconceptionsshown by the question itself or by their own responseto the question (Wink, 1993).

The ability to ask stimulating, challenging questionsis perhaps the most important skill that a clinical nurs-ing instructor or preceptor can display (Craig & Page,1981). At best, effective questioning can trigger pre-ceptees to think critically and thus enhance their prob-lem-solving and clinical decision-making abilities bystimulating the highest level of thought processing(House, Chassie, & Spohn, 1990). When we thinkcritically, we judge the correctness of statements andthe soundness of the reasoning that leads to conclu-sions. Critical thinking assists preceptees to interpretcomplex ideas, assess, and analyze information that isprovided about individual patient situations, and dis-tinguish between that which is reasonable and thatwhich is unreasonable. Indeed, preceptees’ problem-solving and clinical decision-making skills hinge di-rectly on their ability to think critically (Ruggiero,1990). Integral to the critical thinking process is a the-oretical knowledge base or a fundamental grasp of thesubstantive knowledge of the discipline.

THEORETICAL KNOWLEDGE

Theoretical knowledge is the medium that renderspractice more efficient and more effective (Meleis,1991). Being able to practice by scientific principlesthrough a sound knowledge base permits precepteesthe opportunity to be able to accurately determine theconsequences of their nursing care and the potentialrange of patient responses. Theoretical knowledge pro-vides them with a perspective with which to considerpatient situations, and a way to organize, analyze, andinterpret the information that they encounter (Raudo-nis, 1997). A theoretical knowledge base permits thepreceptees to plan and implement care purposefullyand proactively. When they practice purposefully andsystematically, they are more efficient, have better con-trol over the outcomes of their actions, and are betterable to communicate to others (Raudonis). A soundknowledge base serves to guide the preceptees’ clinicaldecision making and their actions and, ultimately, en-sures a foundation for safe and competent nursing care.

Once they understand why a particular situation oc-curs, it becomes possible to identify what effect a spe-cific action will have on the situation or, conversely,what actions will prevent the situation from arising inthe first place (Dale, 1994). Moreover, an understand-ing of the theory underlying a given situation results inpreceptees being able to make informed decisions thatresult in purposeful actions.

CLINICAL DECISION MAKING

Clinical decision making and the ability to make aclinical judgment requires relevant knowledge for ap-plication to the clinical situation, skill in data collec-tion, and knowledge of appropriate strategies for effec-tive problem solving with patients (Reilly & Oermann,1992; Whiteside, 1997). Clinical decision making re-quires the ability to think critically. When preceptorsquestion their preceptees, they directly bring abouttheir critical thinking. For example, when confrontedwith questions concerning patient situations, if pre-ceptees are to make effective clinical decisions, theymust be able to recall relevant knowledge and in turntranslate and interpret that knowledge in light of par-ticular situations (Wink, 1993; Oermann, 1998).Clinical decision making requires an adequate knowl-edge base for analyzing patient situations, generatingpossible alternatives, and making judgments as towhich are the best alternatives to select (Reilly & Oer-mann; Whiteside). The following excerpt reflects apreceptor questioning a preceptee’s knowledge base re-garding a particular patient situation:

If we have a cardiac patient, okay, what are the threemain arteries, what is the problem, what can you antic-ipate? I want you to come back tomorrow and tell mewhat medications will work for this or not. If we have atrauma, okay, what are your ABC’s? Tell me about theairway, the lungs, what do you see? So she tells me andI see how far her knowledge has come and then I tryand expand on it or we research it together (Myrick,1998, p. 102).

One preceptor stated, “I go through the Kardex withher and we talk about the diagnosis and I ask her whatthat entails and try to determine her knowledge of thesituation” (Myrick, p. 102). Questions that are wellframed, timed, and formulated not only stimulate crit-ical thinking, but also enhance the breadth and depthof the answers and help preceptees to draw on andapply acquired knowledge in new and unique situa-tions for the purpose of problem solving and makingclinical decisions. Questions also trigger the pre-ceptees’ ability to critically evaluate their own knowl-

178 MYRICK AND YONGE

edge base, level of comprehension, ability to apply the-oretical principles, accuracy of their assessments, andanalysis of the data (Haffer & Raingruber, 1998;Wink, 1993).

In the quest for effective clinical decision making,preceptors’ use of questioning assists their preceptees toignore unnecessary and irrelevant information and tofocus on cues that elucidate significant patterns in theoverall situation (Wink, 1993). One preceptee re-counted:

She [preceptor] cues me and things that I don’t knowshe’ll give me little points and if I can’t answer she’llwait for me to put it together and if I can’t she’ll give mea little something else. She gives me little bits and piecesand allows me to put it together (Myrick, 1998,p. 103).

One preceptor, referring to a particular patient sit-uation, described how she questioned her preceptee:

Okay, when is it [patient’s condition] acutely urgent?And she [preceptee] stopped and thought. Okay, nowyou’re assuming you see a man arriving with back painand you see that he’s got renal colic. Well, we walkedthrough the process, for example when it’s urgent itcould be an aneurysm. You can’t assume. You’ve seenthis man, you’ve seen five patients with renal colic. Youtake his vital signs, his blood pressure is low. If he’s gotpain it usually increases. Stop and think about it. Don’tassume that this patient has renal colic. He’s grey, he’ssweaty and he’s got a low blood pressure. Change youropinion. Now tell me what else could we be workingwith here (Myrick, 1998, p. 103)?

When preceptors assist their preceptees to identifywhich cues lead them to draw a conclusion, the pre-ceptees become more aware of their own thinking pro-cesses. This awareness in turn affords the precepteesthe opportunity to be able to examine their approachto patient situations and thus become enabled and con-fident to make the necessary changes that are in the bestinterests of the patient. Preceptees thus become en-abled to make clinical judgments based on effectivedecision making and sound critical thinking. “To lis-ten and question at just the right place and degreedelimits the truly brilliant instructor from the average. . . Clearly, the questions a teacher asks can make thedifference between an antiquated wasteland and an ex-citing learning experience” (Cairn, 1975, p. 2).

Preceptees must continually make decisions regard-ing nursing diagnoses and the course of action to betaken for their nursing care (Reilly & Oermann,1992). As preceptees interpret situations, they simul-

taneously analyze the data available to them for thepurpose of developing nursing diagnoses and plans foraction. By questioning their clinical decision making,preceptors assist their preceptees to decide on the datathat need to be collected about the patient, to makeappropriate interpretations of the data, and to identifythe necessary nursing actions that need to be taken inthe situation (Reilly & Oermann). One preceptor de-scribed it thus:

I’ve been doing that [questioning] with her [preceptee]all along. That’s how I determine whether she knowsthe diagnosis and what that entails and what kind ofnursing care that she’s going to do for that type ofpatient. You have to have some idea of the diagnosisbefore you can determine what kind of nursing carethey need. What does this mean? What do I have to dofor this patient (Myrick, 1998, p. 105)?

When preceptors question their preceptees’ decisionmaking, they assist them in eliciting aspects of the sit-uation that are significant in identifying the problem,whether patient or setting oriented (Reilly & Oer-mann, 1992). Because of their limited practical knowl-edge and relative inexperience in the practice setting,preceptees require this kind of assistance in identifyingand delimiting patient problems. As one preceptor ex-plained:

I will point out certain things like now look at A, B andC and tell me what you find or tell me what you think.And I like her [preceptee] to think things out. Like,why do you think we’re looking at this? And she’spretty right on her answers. And if she’s not, then bythe time I’ve explained why, she can understand therationale (Myrick, 1998, p. 105).

One preceptee reflected:

If I get a patient, I go do the history and I’ll come backto her [preceptor] and she goes, ‘okay well what do youthink you know is going on with that person? What doyou think you need to do?’ And then I’ll mention thethings and she goes ‘okay what’s your first priority withthat person?’ With her asking me well what do youthink, what do you think is priority, it gets me thinkingnot just sitting there. And you learn by thinking andproblem-solving it on your own (Myrick, 1998,p. 105).

In affording preceptees the opportunity with whichto discuss their clinical decision making, preceptorsagain provide a means for them to assess the thoughtprocesses that they use to arrive at their decisions and toimprove their understanding of the alternatives that

179PRECEPTOR QUESTIONING

they might have considered (Daly, 1998; Haffer &Raingruber, 1998; Reilly & Oermann, 1992). As onepreceptor recounted:

I try to debrief any critical situations that occur andhave them [preceptee] think through what they wouldhave done had they been in charge of the situation. Ialways ask them what’s the worst possible thing thatcould have happened in the situation because they’realways terrified that they’ve done something wrong(Myrick, 1998, p. 106).

One preceptee stated:

We talk about the things you can do and it’s not a thisis what you do, these are the steps, but it’s an interac-tion. It’s a what would you do and why would you doit? It’s almost like a puzzle. You fit it all together andyou can have a holistic picture of what’s going on. Andthat happens when she [preceptor] and I are interacting(Myrick, 1998, p. 106).

ACTIONS

Ultimately, preceptees’ knowledge base and deci-sion making are directed toward actions designed toprovide competent nursing care. Creative problemsolving, sound decision making, adeptness in copingwith the unanticipated, and mastery of daily routineare fundamental components of that nursing care(May, 1980). Inherently, preceptees’ actions demandnot only skill in performance, but also the ability to beable to continuously evaluate their own actions as theyoccur (Reilly & Oermann, 1992). It requires critiquingtheir actions within the context of the goals they wishto achieve. As one preceptor indicated:

Every hour or so I’m saying have you done this, haveyou done that? Where are you with the care? That wayI can determine her [preceptee] prioritizing. If some-thing happens, I’ll say to her so what would you do, orwhat do you want to do about that (Myrick, 1998,p. 107)?

Another stated, “I try to step back and ask her to tellme about your [preceptee] patient. What should yoube doing for the day. And if she’s wrong well I’ll just saywell why would you do that (Myrick, 1998, p. 107)?”Careful questioning and the one-to-one discussionwith preceptees about their patient care are importantfactors in enabling critical thinking (Oermann, 1997).Preceptors question their preceptees about their ac-tions and the rationale underlying each action, alterna-tives contemplated, and different perspectives to pon-der about their care. By questioning the preceptees’

actions, preceptors not only spark intellectual curios-ity, but promote recognition of inconsistencies in nurs-ing care, and foster awareness of irregularities and dif-ferences between patient situations. Preceptees thusbecome enabled to deal confidently and competentlywith the day-to-day complexities of nursing care.

Implications

Fundamentally, there is a theoretical basis for ask-ing questions. Sellappah, Hussey, Blackmore, andMcMurray (1998) studied 1,085 questions generatedby 26 clinical teachers and found that more than 90percent asked low-level questions. In this study (Myr-ick, 1998), clearly the preceptors recognized the im-portance of asking questions to determine theoreticalknowledge, decisions, and actions. In light of suchfindings, the authors would suggest that faculty andpreceptors work together on an ongoing basis to ex-plore various ways in which to enhance the preceptor-ship experience through the process of effective ques-tioning. Bailin, Case, Coombs, and Daniels (1999)argue that questioning should be part of an environ-ment that fosters a spirit of inquiry. To move towardsuch an environment, nurse educators also need to as-sess the questions that they themselves use when inter-acting with preceptors.

Students also must be taught how to ask questions(Tanenbaum, Tilson, Cross, & Rodgers, 1997). Sed-lack and O’Bryan Doheny (1998) used student-lednursing rounds taught by themselves and by othernursing students to learn how to engage in criticalthinking and to ask high-level questions. Of interestwas the observation that to ask a question one had toengage in active listening. In preparation for the pre-ceptorship experience then it would seem appropriatefor faculty to consider providing student preparationthat would include the art of questioning and activelistening.

Summary

The importance of the use of questions and howthey form the basis of knowledge, decision making,and actions is integral to the promotion of criticalthinking. (Myrick, 1998). Also important is an under-standing of how the level of questions can serve tosupport and enable preceptors to better structure theirquestions from low to high, by using factual questionsto ascertain their preceptees’ knowledge base and fromthere progress toward questions that require explana-

180 MYRICK AND YONGE

tions, descriptions, evaluations, and judgments aboutpatient situations (Oermann, 1997). Essential to thatprocess as well is the invaluable role that nurse educa-tors need to assume in teaching both preceptors and

preceptees the theory and skills underlying effectivequestioning techniques that ultimately contribute tothe enabling of student critical thinking in the practicesetting.

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