In order to teach nursing clinical judgment, we need to be exploring the highest levels of Bloom’s taxonomy in our classrooms.

It can be difficult to come up with activities that ask students to “create.”

I find developing classroom activities for the highest level of Bloom’s taxonomy the most difficult. As we move away from the expectation of having students memorize our lecture content, it can be challenging to think of what they can “create” when we are still building their foundational knowledge.

But don’t forget: we are also helping them to create decision-making frameworks. We are developing their ability to use nursing clinical judgment. We are responsible for training their brain to “create” a desired patient outcome based on their assessments and interventions.

Educational consultant Patti Drapeau (2014) reviewed the six criteria for students who are thinking creatively:

  • Express ideas that others haven’t thought of
  • Choose their own way to demonstrate their understanding
  • Ask questions without fear of sounding silly
  • Enjoy open-ended assignments
  • Prefer to discuss ideas rather than facts
  • Prefer to try new ways to solve a problem rather than the accepted way

This activity, called the Six Thinking Hats, developed by Edward de Bono in 1985, can help students practice decision-making, develop nursing clinical judgment and incorporate creative thinking when looking at a problem. The activity guides students through various viewpoints and creates a decision-making tree in their brains that can be referenced when faced with a tough decision that requires a creative solution.

How to start the six thinking hats activity.

To start, give students a problem. For this example, students are presented with an ethical dilemma related to nursing practice.

Scenario: A new graduate nurse was just hired into the float pool at your hospital. As a nurse on a busy oncology unit, you are assigned to orient the new nurse for the first four weeks before she moves to another hospital unit.  

During your first day, you are preparing to review the protocol for a blood transfusion when she tells you that her religious beliefs will not allow her to administer blood products. As the shift goes on, she refuses to read the policy, will not go down to the blood bank to pick up the unit of blood, and is not in the room when you administer the blood.

As an oncology nurse on this unit, blood product administration is a regular occurrence that could happen multiple times during a shift.

Ask students, “How should the nurse approach this issue?” I like to have students write down their initial responses to see their knee-jerk, instant reactions. Then, have students share their ideas in their group and why they chose this initial response.

Then, assign students the roles of the different hats.

Six Thinking Hats was developed by Edward de Bono (1985).

Have students analyze their problem or proposed solution from the viewpoint of their hat.  

  • The blue hat is the leader and is responsible for keeping the group focused, organizes the students’ thoughts, and gives a synopsis of the group’s work at the end of the activity.
  • The white hat looks at the available data. In this case, the white hat student may share facts about Jehovah’s Witness beliefs around blood product administration.
  • The green hat would look for an alternative, creative solution to solve the problem.  
  • The yellow hat would summarize the benefits of the proposed idea. Does the solution benefit both parties? Would both sides be happy with the resolution?
  • The black hat looks for potential negative impacts of the decision. Their job is to identify why it would not work and help the group eliminate or change aspects of the plan based on negative consequences.

Once all of the students had had time to analyze independently in their hat color, the blue hat should lead the discussion giving each hat a few minutes to share their thoughts.

Give time for reflection and debriefing following the group discussion.

Give the students time to reflect on the activity afterward.

  • Compare your initial idea to your group’s final idea. How did looking at the topic through the six hats change your initial opinion?  
  • How can analyzing a problem from different viewpoints help you approach a situation with confidence?
  • What new ideas emerged? Did you come up with a satisfactory solution?

Variations of the six thinking hats to further develop nursing clinical judgment.

You could easily modify this for online learning by using breakout rooms and assigning roles to students within each room. Students can take on more than one hat role if your groups do not count out perfectly to 6.

A safety case study could be an excellent way to introduce the six thinking hats to beginner students. For example, the scenario may be a patient who is confused, combative, and at risk for falls. Assign the students the different hat roles and then brainstorm which fall precautions would be most effective.

  • Blue hat – Clearly defines the problem.
  • White hat – What information do you have about the patient? Especially related to fall risk?
  • Green hat – What creative ideas are out there for fall prevention?
  • Yellow hat – Would the fall precautions proposed be a good fit for staffing? How would the patient’s family feel?
  • Black hat – What could go wrong with this plan? Is there additional staff, patient or family education involved? Is the necessary equipment/staff available?

For advanced students, you could use the six thinking hats activity to explore ethical dilemmas, review medication errors, or discuss prioritizing care. In addition, instructors could utilize this activity in community clinicals or in public health areas where resources are scarce.  

Also, nursing instructors could use the idea of hats to introduce students to the roles of the interdisciplinary team. For example, you could present a complex patient situation and have students put on the hat of a pharmacist, dietician, physical or occupational therapist, or case management nurse. Using the hats as interdisciplinary roles allows students to see the benefits of a team and how each specialty can enhance patient care outcomes.  

Consider other professional situations or current events that new graduate nurses will encounter. These may include hospital systems lacking PPE, addressing burnout and mandatory overtime, engaging nurses in professional councils, or workplace violence.  

In conclusion

  • The Six Thinking Hats exercise is useful to to develop creative problem solving and nursing clinical judgement.
  • Choose an existing case study, safety concern or ethical dilema that applies to the content in your class.
  • Use the Six Thinking Hats diagram to assign a hat to each student and have them view the problem from this vantage point.
  • Put on that blue hat yourself! Debrief the activity asking students to compare their initital response to their response after looking at the problem from multiple angles.

Looking for additional ideas to create an active learning classroom?

Check out the other posts at the Idea Bank for more activities to help you step away from lecture with confidence in your classroom!

Did you know we have a community?

Head over to the ACTIVE LEARNING STRATEGIES FOR NURSE EDUCATORS Facebook group for more ideas and inspiration!

Martha Johnson is the charge nurse over at BreakoutRN

Martha Johnson MSN, RN, CEN

Charge nurse over at BreakoutRN with a focus on helping other nursing educators transition from lecture to active learning.  She believes it does not have to be hard or overwhelming, just take it one activity at a time 💜

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