A developmental approach to evaluating competence in clinical reasoning

Competence perceptions of veterinary nursing students and registered veterinary nurses in Ireland: a mixed methods explanatory study

Background

Veterinary regulators require veterinary nursing students to demonstrate clinical competence prior to registration and practice as a veterinary nurse. However, in common with other medical professions, there is no one broadly accepted definition of competence. Studies in nursing have revealed that practicing nurses may view newly qualified colleagues as lacking competence, leading to disillusionment with nursing training programmes. Similar studies are lacking in veterinary nursing, despite the profession having recently undergone a similar transition from workplace-based training to undergraduate education.

Methods

A mixed methods explanatory study surveyed 66 Irish registered veterinary nurses and 31 first year veterinary nursing students at two Irish third level institutions to obtain their views on what constitutes veterinary nursing competence and when veterinary nurses develop it. The surveys were followed by student focus groups and semi-structured one-on-one interviews with registered veterinary nurses. Content analysis was employed to analyse the surveys, while the focus groups and interview transcripts underwent thematic analysis.

Results

Students perceived competence primarily as the ability to provide patient care, and they expected it to develop close to the time of graduation. RVNs held a broader definition of competence, incorporating leadership skills and confidence as well as patient care provision. RVNs expected it to take approximately two years of workplace-based experience post-graduation for a veterinary nurse to develop competence. In addition, RVNs recognised that anxiety felt by many newly qualified veterinary nurses during this period could be attenuated by mentorship from more experienced colleagues.

Conclusions

Irish RVNs and veterinary nursing students perceive competence differently, similar to previous findings from the nursing profession. Educators and regulators should provide explicit descriptions of terms such as ‘competence’ to avoid confusion and possible disillusionment amongst veterinary nursing stakeholders.

Second Life and Classroom Environments: Comparing Small Group Teaching and Learning in Developing Clinical Reasoning Process Skills

Medical education and clinical practice support the development of clinical reasoning competency. Traditionally, the process of clinical reasoning is taught through small group discussions in pre-clinical and clinical medical training, and the need exists to explore further teaching and learning approaches that develop clinical reasoning. This study compared teaching and learning the clinical reasoning process through the virtual platform of Second Life (SL) with the traditional classroom setting. Participants were first semester veterinary students; 34 participated virtually through SL, and 41 experienced traditional classroom interactions. Students and one facilitator engaged in three small group meetings to process a clinical case. A seven-item clinical reasoning rubric guided the teaching, learning, and assessment. Clinical reasoning assignments were scored on a grading scale from 0 to 4 with a maximum result of 28. Descriptive statistics for clinical reasoning assignment scores were (m = 14.0; SD = 2.6) and (m = 12.2; SD = 2.6) in SL and classroom interaction, respectively. Results indicated positive associations for all participants between the rubric item score of gathering historical information with (1) gathering physical examination information (p < 0.01) and (2) prioritizing patient's problems (p = 0.003). Additionally, the rubric item score of gathering physical examination information was positively associated with the rubric item score for prioritizing patient's problems (p = 0.02). Specifically for the SL cohort, results demonstrated that rubric item scores were significantly higher for gathering historical information (p = 0.03), gathering physical examination information (p < 0.01), and prioritizing patient's problems (p = 0.02). Small group interaction using SL and traditional classroom environments offers a comparable educational platform for developing clinical reasoning process skills.

Integrating clinical communication with clinical reasoning and the broader medical curriculum

OBJECTIVE

The objectives of this paper are to discuss the results of a workshop conducted at EACH 2012. Specifically, we will (1) examine the link between communication, clinical reasoning, and medical problem solving, (2) explore strategies for (a) integrating clinical reasoning, medical problem solving, and content from the broader curriculum into clinical communication teaching and (b) integrating communication into the broader curriculum, and (3) discuss benefits gained from such integration.

METHODS

Salient features from the workshop were recorded and will be presented here, as well as a case example to illustrate important connections between clinical communication and clinical reasoning.

RESULTS

Potential links between clinical communication, clinical reasoning, and medical problem solving as well as strategies to integrate clinical communication teaching and the broader curricula in human and veterinary medicine are enumerated.

CONCLUSION

Participants expressed enthusiasm and keen interest in integration of clinical communication teaching and clinical reasoning during this workshop, came to the idea of the interdependence of these skills easily, and embraced the rationale immediately.

PRACTICE IMPLICATIONS

Valuing the importance of communication as clinical skill and embracing the interdependence between communication and thought processes related to clinical reasoning and medical problem solving will be beneficial in teaching programs.

Impact of outcome-based assessment on student learning and faculty instructional practices

Increased accountability has been a catalyst for the reformation of curriculum and assessment practices in postsecondary schools throughout North America, including veterinary schools. There is a call for a shift in assessment practices in clinical rotations, from a focus on content to a focus on assessing student performance. Learning is subsequently articulated in terms of observable outcomes and indicators that describe what the learner can do after engaging in a learning experience. The purpose of this study was to examine the ways in which a competency-based program in an early phase of implementation impacted student learning and faculty instructional practices. Findings revealed that negative student perceptions of the assessment instrument's reliability had a detrimental effect on the face validity of the instrument and, subsequently, on students' engagement with competency-based assessment and promotion of student-centered learning. While the examination of faculty practices echoed findings from other studies that cited the need for faculty development to improve rater reliability and for a better data management system, our study found that faculty members' instructional practices improved through the alignment of instruction and curriculum. This snap-shot of the early stages of implementing a competency-based program has been instrumental in refining and advancing the program.

Understanding veterinary practitioners' decision-making process: implications for veterinary medical education

Understanding how veterinary practitioners make clinical decisions, and how they use scientific information to inform their decisions, is important to optimize animal care, client satisfaction, and veterinary education. We aimed to develop an understanding of private practitioners' process of decision making. On the basis of a grounded-theory qualitative approach, we conducted a telephone survey and semi-structured face-to-face interviews. We identified a decision-making framework consisting of two possible processes to make decisions, five steps in the management of a clinical case, and three influencing factors. To inform their decision, veterinary surgeons rarely take the evidence-based medicine (EBM) approach. They consult first-opinion colleagues, specialists, laboratories, and the Internet rather than scientific databases and peer-reviewed literature, mainly because of limited time. Most interviewees suggested the development of educational interventions to better develop decision-making skills in veterinary schools. Adequate information and EBM tools are needed to optimize the time spent in query and assessment of scientific information, and practitioners need to be trained in their use.

Use of the script concordance approach to evaluate clinical reasoning in food-ruminant practitioners

A script concordance test (SCT) was developed measuring clinical reasoning of food-ruminant practitioners for whom potential clinical competence difficulties were identified by their provincial professional organization. The SCT was designed to be used as part of a broader evaluation procedure. A scoring key was developed based on answers from a reference panel of 12 experts and using the modified aggregate method commonly used for SCTs. A convenient sample of 29 food-ruminant practitioners was constituted to assess the reliability and precision of the SCT and to determine a fair threshold value for success. Cronbach's α coefficients were computed to evaluate internal reliability. To evaluate SCT precision, a test-retest methodology was used and measures of agreement beyond chance were computed at question and test levels. After optimization, the 36-question SCT yielded acceptable internal reliability (Cronbach's α=0.70). Precision of the SCT at question level was excellent with 33 questions (92%) yielding moderate to almost perfect agreement between administrations. At test level, fair agreement (concordance correlation coefficient=0.32) was observed between administrations. A slight SCT score improvement (M=+2.8 points) on the second administration was in part responsible for some of the disagreement and was potentially a result of an adaptation to the SCT format. Scores distribution was used to determine a fair threshold value for success, while considering the underlying objectives of the examination. The data suggest that the developed SCT can be used as a reliable and precise measurement of clinical reasoning of food-ruminant practitioners.

New graduates' conceptions of and approaches to veterinary professional practice, and relationships to achievement during an undergraduate internship programme

New graduate veterinarians report differing experiences of the transition to practice. Some make a rapid transition to professional autonomy while others require prolonged and extensive support from their colleagues. Factors contributing to this variation are unclear. This study used phenomenography to analyse the conceptions of and approaches to veterinary professional practice (VPP) reported by new graduates in semi-structured interviews (n = 22). Quantitative statistical analysis was used to investigate links between the quality of graduates' experiences and their achievement during a comprehensive final year internship programme. Strong associations were identified between the quality of graduates' conceptions of and approaches to VPP. Links were also established between the quality of graduates' conceptions of VPP and their performance in practice prior to graduation. The outcomes of this research can be used to improve teaching and assessment during final year internships and enhance graduate attribute statements for professional degree programmes. The results also indicate that student learning research methodologies can be used to evaluate the quality of graduates' experiences in the workplace. This has implications for career outcomes research in a range of healthcare professions.