Background

Generating critical thinking and facilitating a group discussion can be a challenging task in Higher Education. This challenge is further compounded where bioethics is the intended focus as this requires a shared abstract conceptualisation about concrete and dilemmatic experiences. Critical care nurses face several sources of bioethical conflict with multiple perspectives in their practice; if unresolved, these conflicts may lead to job dissatisfaction and can trigger burnout syndrome (Park et al. 2015). The use of innovative methods in nursing education has the potential to prepare these nurses to solve bioethical conflicts in clinical practice (Hoskins, Grady & Ulrich, 2018).

Previous practices have shown that the use of a PowerPoint slide with written information about a specific case scenario is not effective per se as a means of promoting critical thinking nor of generating group discussion amongst students attending a postgraduate course in critical care nursing.​ Based on key messages found in the literature and on reflections on teaching practice, a pedagogical intervention was developed to promote critical reflection and group discussion amongst critical care nursing students. This pedagogical intervention used documentary film as an educational tool for a case-based exercise with a view to improving student engagement and satisfaction in the proposed learning activities during a postgraduate course in critical care nursing.​ This pedagogical intervention encompassed four main stages: a review of key literature, the formulation of a detailed plan, an implementation stage, and final evaluation of the intervention.

Literature review

A literature review was conducted – asserting the use of videos within the context of active learning. It has been proposed that videos can be a highly effective educational tool in Higher Education (Brame, 2016; Castellanos, Haya & Urquiza-Fuentes, 2017). In fact, videos (e.g. documentary film) have the potential to illustrate abstract phenomena instigating both visual and auditory learning (Brame, 2016; Lee, 2018). Moreover, videos encourage student reflection and discussion about scenarios (in this instance the videos were of clinical scenarios, but the concept is generalisable to other disciplines). Videos can also be a cost-effective option, they can be used in a safe learning environment, and they can reduce the teacher’s workload (Castellanos, Haya & Urquiza-Fuentes, 2017; Wirihana et al., 2017). It can be seen from this analysis that the integration of a documentary film instead of a PowerPoint slide with written information has the capacity to promote a richer perception of a given case scenario; this contributes to a more realistic reflection and discussion amongst different students with multiple backgrounds (Wirihana et al., 2017).

To maximise the identified benefits of documentary film as an educational tool, it is important to embed the chosen video in a context of active learning; this can be done by using guiding questions in order to generate group discussion (Brame, 2016). Group discussion is one such effective active learning tool (Hattie, 2015) and evidence shows an improvement in the learning experience when using group discussion in Higher Education, either online or in the classroom (Bender, 2012; Davis & Murrell, 1993). Subsequently, active learning promotes the development of critical thinking skills (Nelson & Crow, 2014; Samson, 2015).

Planning

A detailed lesson plan was drawn up at the second stage of this pedagogical intervention where the main principles suggested by the findings from the literature review were applied. A search through different documentary films available and related to bioethical issues in critical care nursing practice was also performed at this stage. The chosen documentary was a production by Netflix in 2016 entitled ‘Extremis’. Following a detailed and critical analysis of this documentary film, three bioethical issues in critical care nursing were identified: 1) consent to treatment (e.g. capacity to decide; refusing treatments/procedures; patient’s vs relatives’ wishes); 2) the vulnerable adult (e.g. deprivation of liberty; physical restraint); 3) end of life care (e.g. sanctity vs quality of life; withdrawal/withhold treatments; family support). It has been shown that these topics are related to the main bioethical concerns raised by nurses on their clinical practice (Dimond, 2015), strengthening the suitability of this documentary film to this module and population.

The findings from this literature review, and more specifically those presented and proposed by Brame (2016) suggest the inclusion of pre-viewing, while-viewing and post-viewing tasks to foster the effective use of the chosen documentary film as an educational tool. The inclusion of these tasks is essential to promote: 1) cognitive load; 2) student engagement; 3) active learning (Brame, 2016). Therefore, such tasks have been designed and contemplated on the lesson plan through a dynamic process with three main stages (see Figure 1). To promote cognitive load, pre-viewing tasks are introduced and explained to students. At this stage, the lecturer will enumerate the bioethical issues to be identified by the students in the different case scenarios from the documentary film. While-viewing tasks are then implemented to foster student engagement. The film screening will then be interrupted on three different occasions. This will enable group discussion about the bioethical issues that were enumerated in the pre-viewing task. Lastly, active learning will be promoted through post-viewing tasks. To accomplish this, students will be asked to apply the principles taught in the first part of the session when discussing the bioethical issues that were identified in the pre- and post- viewing tasks.

Figure 1 . Pre-viewing, while-viewing and post-viewing tasks embedded on Brame (2016) framework.

Meetings with the module leader and module tutors also take place during this second stage to discuss the appropriateness of the proposed changes, i.e. the inclusion of the chosen documentary video and its associated learning activities. The analysis and discussion emerging from these meetings consolidated the fact that this pedagogical intervention was aligned with the learning outcomes and assessment forms of this particular module; therefore, the principles of constructive alignment when planning a session have been secured.

Implementation

This pedagogical intervention was initially implemented in March 2019 as part of one of the sessions for a postgraduate course in critical care nursing at the University of West London. The session lasted a total of four hours and was comprised of two main parts: 1) a seminar covering the main theoretical aspects of bioethics and its principles applied in critical care nursing to provide students with the essential tools for a bioethical reflection and discussion; 2) the pedagogical intervention per se , where the pre-, while- and post- viewing tasks took place to promote critical thinking and group discussion (see Figure 1). The first part took approximately 1.5 hours and the second part almost 2 hours. A total of 18 students (mixed genders; age range 26-41; multiple nationalities) attended the session; all of them were part-time students working in different adult intensive care units as registered staff nurses.

Evaluation

To evaluate this pedagogical intervention, a triangulation of different methods and sources was performed in order to facilitate and promote the validation of the feedback obtained. Formal feedback was obtained through the application of a post-session questionnaire; the module evaluation survey was also considered to collect data about this session / pedagogical intervention. Informal feedback was obtained from the students in the classroom and by the module leader/mentor.​ The students’ participation in this evaluation process was voluntary and anonymous.

Overall, students were positively satisfied with this pedagogical intervention, suggesting that more time be given up for similar activities in the future. This was particularly evident from the results of the post-session questionnaire. In fact, the documentary film was reported as helping them to reflect and discuss their clinical practice from a bioethical perspective (see Figure 2). Moreover, the topics and discussion that emerged from the case scenarios on the documentary film were realistic and appropriate for their clinical practice (see Figure 3). On the module evaluation survey, it was also noted that this session was well received by this group of students. There were also specific mentions of the use of this documentary video (and its pre-, while- and after- viewing tasks) as one of the strongest elements of the module.

Figure 2. Post-session questionnaire – ‘The documentary film has helped me to reflect and discuss about my clinical practice from a bioethical perspective.’ (n=18)

Figure 3. Post-session questionnaire – ‘The topics and discussion emerged from the case scenarios on the documentary film are realistic and appropriate for my clinical practice.’ (n=18)

At the personal level, drawing on informal feedback received, this experience was enjoyable to both parties: lecturer and students. Students’ engagement in the group discussion clearly demonstrated appropriate levels of critical thinking on the nature of the main topic – bioethical issues in critical care nursing; therefore, the intended aim and outcomes of the intervention were satisfactorily achieved. ​

Final considerations

This pedagogical intervention aimed to promote critical thinking and group discussion through the integration of a documentary film instead of the previous method of using a PowerPoint slide with written information about specific cases / clinical scenarios. Its effectiveness as an educational tool has been confirmed by the level of student engagement and the level of satisfaction in this learning activity, strengthening previous evidence provided by Brame (2016), Castellanos, Haya and Urquiza-Fuentes (2017), Lee (2018) and Wirihana et al. (2017).

To ensure an appropriate and effective use of documentary films / videos in Higher Education, pre-, while- and post- viewing tasks should be planned and implemented through a dynamic process. This dynamic process, comprising three main stages, will enable: 1) cognitive load; 2) student engagement; 3) active learning (Brame, 2016). Further research should be performed in the specific field of bioethics; ideally comparing different educational tools/methods in postgraduate courses.​ In future sessions, other strategies could also be implemented given its proven effectiveness, e.g. simulation practice and expert-patient as a teacher (Hoskins, Grady & Ulrich, 2018). However, required resources such as time and staff must be considered to determine its cost-effectiveness.

References

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Brame, C.J. (2016) Effective educational videos: principles and guidelines for maximizing student learning from video content, CBE – Life Sciences Education , 15(6): 1-6

Castellanos, J., Haya, P.A. & Urquiza-Fuentes, J. (2017) A novel group engagement score for virtual learning environments, IEEE Transactions on Learning Technologies , 10(3): 306-317

Davis, T.M. & Murrell, P.H. (1993) Turning teaching into learning: the role of student responsibility in the collegiate experience , ASHE-ERIC Higher Education Report , 8. Washington, D.C.: The George Washington University, School of Education and Human Development

Dimond, B. (2015) Legal aspects of nursing . 7 ^th ed. Boston: Pearson

Hattie, J. (2015) The applicability of visible learning to higher education, Scholarship of Teaching and Learning in Psychology , 1(1): 79-91

Hoskins, K., Grady, C. & Ulrich, C. (2018) Ethics education in nursing: instruction for future generations of nurses. The Online Journal of Issues in Nursing , 23(1): 1-4

Lee, S.H.M., Hoffman, K.D., Chowdhury, S.A. & Sergueeva, K. (2018) Creating a video documentary as a tool for reflection and assessment: capturing guerrilla marketing in action. Marketing Education Review , 28(2): 126-130

Nelson, L.P. & Crow, M.L. (2014) Do active-learning strategies improve students’ critical thinking?, Higher Education Studies , 4(2): 77-90

Park, D., et al. (2015) Ethical issues recognized by critical care nurses in the intensive care units of a tertiary hospital during two separate periods, Journal of Korean Medical Science , 30(4): 495-501

Samson, P.L. (2015) Fostering student engagement: creative problem-solving in small group facilitations, Collected Essays on Learning and Teaching , 8: 153-164

Wirihana, L., Craft, J., Christensen, M. & Bakon, S. (2017) A nursing education perspective on the integration of video learning: a review of the literature. Singapore Nursing Journal , 44(1): 24-32