Developing Students' Clinical Reasoning Skills: A Faculty Guide

Psychometric Evaluation of the Nurse Clinical Reasoning Scale: A Validation Study Among Italian Nurses

Background and Purpose: Clinical reasoning for nurses is considered a valuable component of clinical nursing competencies, but there are few tools to ascertain this. This study tested the Italian Nurses Clinical Reasoning Scale (I-NCRS) psychometric properties based on Levett-Jones' theoretical clinical reasoning model. Methods: Content, face, and construct characteristics were ascertained for their validity. The study had a two-phase design: (a) content and face validity and (b) construct validity. Results: Three factors emerged from the factorial analysis of our reference sample: nursing problems of health, nursing information of health, and nursing assessment of health. Conclusions: The scale represents a valuable tool for the self-assessment of the clinical reasoning skills of nurses. I-NCRS showed evidence of validity and reliability, being also useful for assessing clinical reasoning for educational and research purposes among Italian nurses.

Using unfolding case studies to develop critical thinking for Graduate Entry Nursing students: an educational design research study

BACKGROUND

Graduate Entry Nursing (GEN) programmes have been introduced as another entry point to nurse registration. In the development of a new GEN programme, a problem-based approach to learning was used to develop critical thinking and clinical reasoning skills of motivated and academically capable students.

OBJECTIVE

To explore and evaluate the design and delivery of course material delivered to GEN students embedded in authentic learning pedagogy from the perspectives of both GEN students and academic staff using an unfolding case study approach.

METHODS

An educational design research approach was used to explore the learning experiences of GEN students using an unfolding case study approach situated in experiential pedagogy and the teaching experiences of the academics who designed it. Data were collected through semi-structured interviews with students once they had finished the course and weekly reflective diary recordings by academic staff throughout implementation. Thematic analysis was used to analyse the data.

FINDINGS

Student reflections highlighted that this cohort had insight into how they learned and were comfortable voicing their needs to academic staff. While the unfolding case studies were not liked by all participants, for some it offered a unique learning opportunity; particularly when scaffolded with podcasts, simulation labs, tutorials and clinical placements. Staff reflections primarily aligned with student experiences.

CONCLUSION

The gaps highlighted in the delivery of the course suggest that a blended pedagogical approach to graduate entry nurse education is required. Specifically, GEN students are aware of the learning needs and are happy to express these to academic staff, thus suggesting that engaging with a co-design curriculum approach will benefit future cohorts.

The Lasater Clinical Judgment Rubric: 17 Years Later

BACKGROUND

Nearly 17 years ago, the Lasater Clinical Judgment Rubric (LCJR) was published to provide a common language and trajectory of students' development to think like a nurse.

METHOD

This article traces the uses of the LCJR from creation to the present and cites lessons learned from its use.

RESULTS

During the intervening years, the LCJR has been used effectively as a debriefing guide in simulation and as a research instrument, as well as for formative assessment. The LCJR has been translated or is in process in 19 languages besides English.

CONCLUSION

This article provides evidence of the efficacy of the LCJR and discusses important lessons learned. [J Nurs Educ. 2024;63(3):149-155.].

Clinical Instruction in Nursing: A Leveraging Tool

BACKGROUND

Clinical educators influence the preparation of nursing students for complex professional roles. Although classroom instruction is well-structured and guided by an array of frameworks, clinical instruction remains vague. This study explored components of effective clinical instruction and the support needs of clinical educators.

METHOD

A qualitative multiple case study design was used to examine the teaching experiences of 14 clinical faculty and preceptors, guided by Danielson's teaching framework.

RESULTS

When teaching domains of "planning" and "instruction" were emphasized, assessment of students' needs, behavioral management, and reflective practice were understated. Findings identified events and concepts deemed essential for effective clinical instruction, and participants' needs for ongoing support and guidance concurred with teaching gaps.

CONCLUSION

This study attested to the complexity of clinical instruction, yet generated a clinical tool that may guide academia on designing professional programs to advance instruction in challenging clinical environments. [J Nurs Educ. 2024;63(3):163-170.].

Early Prelicensure Nursing Students' Perceptions of Case Studies Through the Lens of the Clinical Judgment Measurement Model

BACKGROUND

Research indicates new nursing graduates struggle with clinical reasoning, despite some related skill development throughout their education. The question remains, "Could an earlier focus on clinical reasoning in nursing programs enhance nursing students' clinical reasoning?"

PURPOSE

This pilot study investigated how first-semester nursing students perceive the use of case studies in clinical reasoning skill development and the perceived benefits of case studies related to the NCSBN Clinical Judgment Measurement Model (NCJMM).

METHODS

Case studies and written reflections were introduced to a convenience sample (n = 45) of first-semester nursing students. Qualitative analysis was conducted on written reflections.

RESULTS

Students found case studies enhanced their knowledge and prepared them for clinical practice as a nurse.

CONCLUSIONS

Findings suggest early introduction of case studies is a meaningful teaching strategy to develop clinical reasoning aligned with the NCJMM.

Transformation and Articulation of Clinical Data to Understand Students' and Health Professionals' Clinical Reasoning: Protocol for a Scoping Review

BACKGROUND

There are still unanswered questions regarding effective educational strategies to promote the transformation and articulation of clinical data while teaching and learning clinical reasoning. Additionally, understanding how this process can be analyzed and assessed is crucial, particularly considering the rapid growth of natural language processing in artificial intelligence.

OBJECTIVE

The aim of this study is to map educational strategies to promote the transformation and articulation of clinical data among students and health care professionals and to explore the methods used to assess these individuals' transformation and articulation of clinical data.

METHODS

This scoping review follows the Joanna Briggs Institute framework for scoping reviews and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) checklist for the analysis. A literature search was performed in November 2022 using 5 databases: CINAHL (EBSCOhost), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), and Web of Science (Clarivate). The protocol was registered on the Open Science Framework in November 2023. The scoping review will follow the 9-step framework proposed by Peters and colleagues of the Joanna Briggs Institute. A data extraction form has been developed using key themes from the research questions.

RESULTS

After removing duplicates, the initial search yielded 6656 results, and study selection is underway. The extracted data will be qualitatively analyzed and presented in a diagrammatic or tabular form alongside a narrative summary. The review will be completed by February 2024.

CONCLUSIONS

By synthesizing the evidence on semantic transformation and articulation of clinical data during clinical reasoning education, this review aims to contribute to the refinement of educational strategies and assessment methods used in academic and continuing education programs. The insights gained from this review will help educators develop more effective semantic approaches for teaching or learning clinical reasoning, as opposed to fragmented, purely symptom-based or probabilistic approaches. Besides, the results may suggest some ways to address challenges related to the assessment of clinical reasoning and ensure that the assessment tasks accurately reflect learners' developing competencies and educational progress.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/50797.

Undergraduate nurses' reflections on visual thinking learning to construct inductive reasoning through situated patient pictures: A mixed-method study

BACKGROUND/OBJECTIVE

Deductive logic has often been used to develop critical thinking. However, inductive logical thinking, essential to care decision-making, has yet to be emphasized. This study aimed to explore visual thinking learning among undergraduate nursing students by asking them to draw situated patient pictures in order to integrate theoretical knowledge and promote inductive logical thinking.

METHODS

A mixed-methods research design was used to obtain quantitative and qualitative data from a convenience sample of 100 students. The study was conducted in a Taiwanese university from September 2022 to January 2023. In the quantitative component, learners' views of situated patient pictures were captured based on 15 paired identifiers and two questions: (a) What word should be used in describing the situated patient's picture? (b) How strongly do you feel about the selection? Written feedback was analyzed using qualitative content analysis.

RESULTS

Quantitative analysis identified specific, unpretentious, humorous, harmonious, conservative, realistic, rational, entire, image performance, professional performance, understandable, expressive, static performance, rigorous, and profuse with a reasonable degree of choice. Qualitative analysis identified four stages in participants' development of inductive reasoning through situated patient pictures and visual thinking learning. These were: exploration, intuition, theme, and logic and creation.

CONCLUSIONS

The results suggest that visual thinking learning is a practical pedagogical approach to increasing learners' communication abilities, group cooperation, theoretical knowledge integration, and logical thinking. Neither educators nor learners required any artistic skills. Nonetheless, participants demonstrated creativity and innovation through continuous visual thinking learning.

Effects of electronic fetal monitoring simulation with problem-based learning on nursing students' performance confidence, clinical judgment, and knowledge

AIM

This study aimed to determine the effects of an electronic fetal monitoring simulation with problem-based learning (EFM SPBL) program based on the Clinical Judgment Model.

METHODS

Third-year nursing students were randomly allocated to the control (n = 46) or experimental groups (n = 46). The control group participated in the conventional clinical practice, while the experimental group participated in the EFM SPBL program. The students completed a structured questionnaire on Google surveys.

RESULTS

Nursing performance confidence (t = 10.72, p < .001) and clinical judgment (t = 2.53, p = .015) increased significantly in the experimental group.

CONCLUSIONS

This study recognized improvement in students' clinical judgment in the context of learning transfer. A standardized SPBL with various cases is recommended.

Learning Nursing Skills of Practice Virtually: The Rough Ground of Engagement

BACKGROUND

In spring 2020, nursing education programs abruptly transitioned the teaching and learning of nursing practice skills to virtual environments as the result of the coronavirus disease 2019 (COVID-19) pandemic.

METHOD

This study sought to describe ethnographically how faculty and students formed and integrated clinical judgment and other nursing practice skills within this quickly formed virtual subculture. Thirty-seven associate-degree nursing students participated in small group interviews, and four faculty participated in one-to-one interviews.

RESULTS

Two overarching themes were identified: (1) the pervading mood of learning through the pandemic; and (2) the primacy of the nursing traditions of direct care experience. Themes were nested further within the five essentials for human learning: curiosity, authenticity, emotion, sociality, and failure.

CONCLUSION

Virtual simulation cases with focused prebriefing and debriefing sessions provided experiences that were targeted, shared, guaranteed, and safe. Adequately supported virtual simulation platforms can enhance the learning of nursing skills. [J Nurs Educ. 2023;62(10):541-547.].

Scoring Methods in Script Concordance Tests: An Exploratory Psychometric Study

BACKGROUND

Despite the increasingly popular role of script concordance test (SCT) scoring methods in the evaluation of clinical reasoning, studies examining these methods in nursing are relatively scarce. This study explored the psychometric properties of five SCT scoring methods.

METHOD

An SCT was administered to 12 experts and 43 learners. Scores were calculated using five methods and descriptive statistics. Differences in scores were assessed with the Mann-Whitney U test, and Spearman correlation coefficients were calculated for the different methods.

RESULTS

The median scores of both experts and learners differed substantially according to the scoring method used. Learners' scores were statistically different from experts' scores (p < .01) for each method. Spearman coefficients (range, 0.44 to 0.95) were positive for the different methods.

CONCLUSION

Further research is needed to refine the influence of SCT scoring methods for use in certifying assessment of clinical reasoning in nursing. [J Nurs Educ. 2023;62(10):549-555.].

Effects of simulation with problem-based learning (S-PBL) on nursing students' clinical reasoning ability: based on Tanner's clinical judgment model

BACKGROUND

Clinical reasoning ability, a complex cognitive and metacognitive process, is a crucial core competency required in nursing practice. Therefore, undergraduate nursing students should be provided with nursing education to strengthen their clinical reasoning ability based on real-life nursing scenarios.

METHODS

This study was conducted using a quasi-experimental single-group pretest-posttest design. Three sessions (lasting three hours each) of Simulation with Problem-Based Learning (S-PBL) using high-risk obstetrics-gynecology scenarios were provided to 71 third-year nursing students of a university. The sessions were conducted from September to December 2022, and they aimed to strengthen their clinical reasoning ability. For data collection, an online survey was conducted using Rubric for Clinical Reasoning and learning satisfaction evaluation tool. Data were analyzed using descriptive statistics and repeated measures analysis of variance in SPSS.

RESULTS

The mean score of clinical reasoning ability significantly increased from 29.42 (standard deviation: 4.62) out of 40 points in the pre-test to 32.28 (4.36), 33.44 (5.35), and 33.80 (5.91) after the first, second, and third S-PBL sessions, respectively (F = 61.668, p < .001). The learning satisfaction score was as high as 107.04 (12.66) out of 120 points.

CONCLUSION

This S-PBL program is an effective nursing education strategy to strengthen nursing students' clinical reasoning ability. Future studies must examine learner variables and standardize the S-PBL design and operation process by comparison to a traditional teaching approach and a higher range of clincal reasoning ability.

Preparing for the Next Generation NCLEX Using a Virtual Simulation

BACKGROUND

Virtual clinical simulation is a digital innovation that augments clinical reasoning and clinical judgment, narrowing the theory-practice gap, preparing new graduates for the Next Generation NCLEX (National Council Licensure Examination), and mitigating the demand for clinical placement and clinical faculty.

METHOD

The purpose of this article is to describe an educational innovation employing a virtual clinical simulation using the tenets of Tanner's Clinical Judgment Model and a National League for Nursing Advancing Care Excellence for Seniors unfolding case.

RESULTS

A virtual clinical simulation successfully served to replace direct care clinical for 86 undergraduate nursing students enrolled in a foundation nursing course, augmenting the students' ability to transfer and apply theoretical knowledge to clinical practice.

CONCLUSION

This virtual clinical simulation served as a viable platform for teaching clinical reasoning and clinical judgment, mitigating the education-practice gap for new graduate registered nurses. [J Nurs Educ. 2023;62(X):XXX-XXX.].

Factors Influencing Nursing Student Learning During Clinical Placements: A Modified Delphi Study

BACKGROUND

Factors identified as important to nursing student clinical learning include the environment, the clinical facilitator, and student human factors.

METHOD

A modified Delphi study generated clinical nurse educators' expert consensus of the importance of factors that influence student learning during clinical placements. Short-answer questions exploring facilitation of learning were also provided.

RESULTS

Thirty-four nurse educators participated in the first round, and 17 nurse educators participated in the second round. Final consensus of at least 80% agreement was reached for all factors. Enablers of student learning included a positive workplace culture, student attitude, and clear communication between facilitator and student. Barriers to student learning included lack of time for teaching, short placement duration, and poor student and facilitator attitude.

CONCLUSION

Further investigation is needed on how these factors are addressed during placements including a review of the quality of resources provided to students and clinical facilitators for student learning. [J Nurs Educ. 2023;62(6):333-341.].

Nursing students' clinical judgment skills in simulation and clinical placement: a comparison of student self-assessment and evaluator assessment

BACKGROUND

Clinical judgment is an important and desirable learning outcome in nursing education. Students must be able to self-assess their clinical judgment in both the simulation and clinical settings to identify knowledge gaps and further improve and develop their skills. Further investigation is needed to determine the optimal conditions for and reliability of this self-assessment.

AIMS

This study aimed to compare the same group of students' self-assessment of clinical judgment with an evaluator's assessment in both simulation and clinical settings. The study further aimed to investigate whether the Dunning-Kruger effect is present in nursing students' self-assessment of clinical judgment.

METHODS

The study applied a quantitative comparative design. It was conducted in two learning settings: an academic simulation-based education course, and a clinical placement course in an acute care hospital. The sample consisted of 23 nursing students. The Lasater Clinical Judgment Rubric was used to collect data. The scores were compared using a t-test, intraclass correlation coefficient, Pearson's correlation coefficient, and Bland-Altman plots. The Dunning-Kruger effect was investigated using linear regression analysis and a scatter plot.

RESULTS

The results showed an inconsistency between student self-assessment and evaluator assessment of clinical judgment in both simulation-based education and clinical placement. Students overestimated their clinical judgment when compared to the more experienced evaluator's assessment. Differences between students' scores and the evaluator's scores were larger when the evaluator's scores were low, indicating the presence of the Dunning-Kruger effect.

CONCLUSION

It is vital to acknowledge that student self-assessment alone may not be a reliable predictor of a student's clinical judgment. Students who had a lower level of clinical judgment were likely to be less aware that this was the case. For future practice and research, we recommend a combination of student self-assessment and evaluator assessment to provide a more realistic view of students' clinical judgment skills.

Current Practices for Teaching Clinical Judgment: Results From a National Survey

BACKGROUND

Safe patient care is closely linked to clinical judgment. Concerns about inadequate practice readiness and the impending inclusion of clinical judgment items on the NextGen NCLEX have resulted in increasing interest and publications about teaching clinical judgment. However, little is known about actual current practices for teaching this skill.

PURPOSE

This research describes findings about current strategies to teach clinical judgment used in US prelicensure nursing programs.

METHODS

Cross-sectional methodology was used to survey program deans and directors across the United States.

RESULTS

Programs are using multiple strategies to teach clinical judgment. The most common strategies used include case studies and simulation. Participants believed strategies have a positive impact on student thinking, practice readiness, and program outcomes. They described insights into implementation of teaching for clinical judgment.

CONCLUSION

The results of this research provide foundational data to inform current teaching practices and further research for this essential skill.

A National Report on Clinical Judgment Model Use in Prelicensure Nursing Curricula

AIM

This study examined US prelicensure nursing program use of clinical judgment models and teaching strategies to promote students' clinical judgment.

BACKGROUND

Growing interest in teaching clinical judgment associated with upcoming changes in NCLEX-RN testing warrants exploration of how models and teaching strategies are currently used.

METHOD

A cross-sectional survey with multiple-choice and open-ended response items was used to examine programs' use of clinical judgment educational models.

RESULTS

Of 234 participants (9 percent response rate), 27 percent reported using a model; 51 percent intended and 20 percent did not intend to start using a model. Tanner's clinical judgment model was the most used, followed by the clinical reasoning cycle. Models were used to inform design of teaching/learning strategies and facilitate clinical teaching and evaluation.

CONCLUSION

Clinical judgment model use may increase as programs prepare for changes in NCLEX-RN. Research is needed to understand how model use contributes to measurable differences in clinical judgment skill.

Clinical learning opportunity in public academic hospitals: A concept analysis

BACKGROUND

Clinical learning opportunities (CLO) are vital educational encounters occurring in various clinical areas to provide the student nurses with clinical knowledge and experiences to develop their competencies for professional practice. However, CLO is a broad concept with varied characteristics that allow ambiguity, limiting its understanding and use. Its ambiguous nature leads to uncertainties and poor development of the required clinical attributes of successful theory to practice integration, higher-order thinking skills (HOTS) and clinical competencies.

AIM

The aim of the study was to explore and describe the conceptual meaning of CLO, have a clear understanding and insight into the concept and identify the antecedents and consequences for pragmatic purposes.

SETTING

The study took place in a public academic hospital in Gauteng.

METHODS

The eight steps of concept analysis by Walker and Avant were followed. Multiple data sources not limited to nursing were explored and critically analysed for the definitions, characteristics, nature and uses of CLO from different fields of study.

RESULTS

The defining attributes of CLO were identified, namely the context, antecedents, processes, consequences and outcomes. The context within which CLO occurs was dynamic, multidimensional, real-life healthcare settings; antecedents included planning of clinical placement, provision of learning outcomes and consideration of the cognitive level of the students. Engagement and active participation in collaborative, problem-based learning activities, community-based research and the use of emerging technologies were the processes identified. The outcomes were autonomous, confident, competent professional nurses with critical thinking, clinical reasoning, judgement, critical decision making and problem-solving skills.

CONCLUSION

A theoretical and operational definition of CLO was developed. The findings and results of concept analysis identified and specified the defining attributes of clinical learning opportunity. The findings can assist nurse educators, Clinical Education and Teaching Unit (CETU) personnel and operational managers to enhance CLO for student nurses to achieve their clinical learning goals and outcomes. The evaluation tools that may be adopted to assess the acquired clinical skills were also identified.

CONTRIBUTION

An increase in the existing body of knowledge in nursing education, considering that enhancing the CLO exposes students to various clinical experiences contributing to their development of clinical competencies to solve complex problems. The strategies to enhance the CLO will be developed, which may also provide vital information for policy development. Conceptualisation of the findings to nursing practice and quality patient care will be integrated into relevant literature.

Facilitating Development of Problem-Solving Skills in Veterinary Learners with Clinical Examples

Simple Summary

This review seeks to open discussion on the teaching of problem-solving skills in veterinary learners. Before a veterinary learn-er can solve a problem, they need to be able to recognize the problem. Then, information is gathered and economically viable solutions determined. To make problem-solving easier, we suggest a process with 5 elements: (1) define the problem list; (2) create an associated timeline; (3) describe the (anatomical) system involved or the pathophysiological principle applicable to the case; (4) propose management for the case; and (5) identify unique features of the case. In order to put the above into context, we end the review with an example case scenario showing the approach of teaching of problem-solving.

Abstract

This paper seeks to open discussion on the teaching of problem-solving skills in veterinary learners. We start by defining the term problem before discussing what constitutes problem-solving. For veterinary medical learners, problem-solving techniques are similar to those of decision-making and are integral to clinical reasoning. Problem-solving requires the veterinary learner to organize information logically to allow application of prior or new knowledge in arriving at a solution. The decision-making must encompass choices that provide the most beneficial and economical approach. In a modification of an existing protocol, we suggest the inclusion of the 5 elements: (1) define the problem list; (2) create an associated timeline; (3) describe the (anatomical) system involved or the pathophysiological principle applicable to the case; (4) propose management for the case; and (5) identify unique features of the case. During problem-solving activities, the instructor should take the role of facilitator rather than teacher. Skills utilized in the facilitation of problem-solving by learners include coaching, differential reinforcement, effective feedback, modelling and ‘think out loud’. Effective feedback must inform learners of their progress and performance, as this is fundamental to continued learning and motivation to succeed. In order to put the above into context, we end with an example case scenario showing how we would approach the teaching of problem-solving to veterinary learners.

Perspectives of Nursing Students on Promoting Reflection in the Clinical Setting: A Qualitative Study

Background: Reflection increases meta-cognitive capacities, promotes student-instructor relationships, overcomes the theory-practice gap, and enriches learning. This study aims at exploring nursing students’ perspectives on the facilitators of reflective practices in the clinical setting. Methods: Semi-structured interviews were conducted among 21 Saudi nursing students at one major university in Saudi Arabia. Results: Two major themes were prevalent upon thematic analysis, namely, “Personal Drivers of Reflection” which consisted of “Motivation to Learn”, “Desire to develop”, “Ethical Regard”, and “Responsibility towards patients” and “External Drivers of Reflection” which consisted of “Patient characteristics”, “Case complexity”, and “Competent Instructors”. Conclusion: As per the results of the study, nursing students perceived that they underwent reflection as a response to personal motivational and external educational aspects. According to the findings, instructors should assist students through clinical reflection, with a special focus on their interactions and motivation.