Journal of Nursing Education

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Discovering Confidence in Clinical Reasoning and Critical Thinking Development in Baccalaureate Nursing Students

Ann G Haffer, RN, EdD; Bonnie J Raingruber, RN, PhD

Abstract

ABSTRACT

The purpose of this preliminary investigation was to discover students' experiences of clinical reasoning and critical thinking development. Findings are reported from one group of baccalaureate nursing students participating in a clinical reasoning course. Narrative approaches were used to reveal how students experience their developing reasoning skills. Class videotapes and reflective logs in which students described their reasoning and responses to others' reasoning provided data. An interpretive phenomenological approach was used to derive a beginning understanding of the experiences of students' developing clinical reasoning and critical thinking. Confidence emerged as a significant aspect of students' experiences. This report of the investigation focuses on only one aspect of clinical reasoning and critical thinking, namely, students' perceptions of threats to confidence and ways of building confidence.

Abstract

ABSTRACT

The purpose of this preliminary investigation was to discover students' experiences of clinical reasoning and critical thinking development. Findings are reported from one group of baccalaureate nursing students participating in a clinical reasoning course. Narrative approaches were used to reveal how students experience their developing reasoning skills. Class videotapes and reflective logs in which students described their reasoning and responses to others' reasoning provided data. An interpretive phenomenological approach was used to derive a beginning understanding of the experiences of students' developing clinical reasoning and critical thinking. Confidence emerged as a significant aspect of students' experiences. This report of the investigation focuses on only one aspect of clinical reasoning and critical thinking, namely, students' perceptions of threats to confidence and ways of building confidence.

Clinical reasoning and critical thinking are related skills basic to nursing practice (Baker, 1996; KataokaYahiro & Saylor, 1994; Maynard, 1996; Píese & Clayton, 1993; Tanner, 1993, 1997). Advancing clinical reasoning and critical thinking skills is of great interest and concern to nurse educators. It is no longer acceptable to assure that graduates have sufficient formal knowledge (Polanyi, 1962). Educators must establish that new nurses can use knowledge in uncertain, rapidly changing, complex clinical situations. The reform agendas of the Department of Education's National Education Goals 2000 Panel (1992a), and its post-secondary task force recommendations for achieving these goals (1992b) and the National League for Nursing's (NLN) outcome accreditation requirements (NLN, 1992) all reflect this necessity and mandate that nursing graduates be able to think critically and use sound clinical reasoning. Responding to these imperatives is problematic because there are many elemente fundamental to addressing this challenge that are not understood well yet. Therefore, it is difficult for educators to adequately assess and promote students' developing clinical reasoning and critical thinking skills.

There is considerable diversity in critical thinking descriptions. Ennis (1990), Facione (1990), McPeck (1990), Siegel (1988), and Watson & Glaser (1980) each offer differing ways of approaching the meaning of critical thinking. Their approaches differ according to essential characteristics, goals, skills, processes, and importance of the discipline or domain in which critical thinking is occurring (Bandman & Bandman, 1995; Kataoka-Yahiro & Saylor, 1994; Kintgen-Andrews, 1991). Additionally, there is disagreement regarding whether clinical reasoning and critical thiTiki^g are primarily cognitive activities or skülbased practices incorporating social, affective, and embodied ways of knowing (Benner, 1984; Tanner, 1997). No unifying guidance to nurse educators teaching in a practicebased discipline can be found in these variant approaches to describing critical thinking.

CLINICAL REASONING COURSE DEVELOPMENT

Purpose

After a period of several semesters, the faculty teaching the last two semesters of a 5-semester baccalaureate program noted persistent concerns expressed by students of feeling unready to practice nursing or make decisions on an independent basis. This was further observed by one faculty member in research exploring beginning nurses' diagnostic reasoning (Haffer, 1990). These beginning baccalaureate graduate nurses all had significant problems with independent clinical reasoning. With the exception of Benner (1984; Benner, Tanner, & Chesla, 1996), little research has either targeted the beginning nurse or involved identification of nurses' reasoning behaviors as seen in actual clinical practice (Haffer, 1990). Because beginning and experienced nurses approach clinical reasoning and critical thinking differently (Benner, Tanner, & Chesla, 1996), there is a need for educators to be better grounded in the ways that students experience their developing clinical reasoning and critical thinking skills. Understanding students' experiences should be a first step in finding ways to facilitate skill development.

Meager guidance for means of promoting critical thinking skills, observations of students, and desire to address the challenge of graduating sound clinical reasoners led faculty to design a clinical reasoning course to begin to explore a way to facilitate students' developing skills. Because the authors assume that clinical reasoning and critical thinking are not solely cognitive but also affective and grounded in practice, a narrative approach, which allowed holistic access to students' understandings, was used both as a learning approach and a way of examining students' developing experiences. Throughout the semester, the authors conducted a preliminary investigation using interpretive phenomenology. The purpose of the investigation was to derive a beginning understanding of students' developing reasoning experiences as seen in their actual clinical stories and in their log responses.

COURSE DESCRIPTION

The class was an elective two-unit course, meeting once a week for 2 hours. There were 15 students, ranging in age from 24 to 49 years. One student was male. Twelve students were enrolled in their last two semesters, one was in the third, and two were in the second semester of a five-semester baccalaureate program. Twelve students had never worked in an acute health-care setting outside of their nursing program. Three students had limited part-time health-care employment experiences.

Learning activities consisted of scenario presentations by students and by experienced nurses who had been invited to class. During presentations, both students and faculty questioned the presenter to clarify understandings and explicate some of the reasoning behaviors embedded in the scenarios. To demonstrate the detail needed in narratives, the faculty first illustrated the process by presenting their own scenarios. In addition to the faculty examples, students and experienced nurses were instructed to think of their scenario description as if telling a story or painting a picture. They were to imagine it with enough detail and clarity that everyone in the class could imagine it. They were to unfold the story as it occurred over time, including many contextual details. For approximately the last 30 minutes of each class, students wrote logs in which they described scenario standouts and discussed reasoning processes used by the presenter as well as their own reasoning processes. All classes were videotaped, allowing the faculty team to interpret the tapes and the students who missed class to review the tapes. Both faculty members independently read the logs and wrote weekly feedback to each student, asking questions and offering comments to help students extend their understandings. Students received this feedback at the beginning of the next class.

Rationale for Class Learning Experiences

Although clinical reasoning and critical thinking are ambiguously understood, there is some agreement in the literature on approaches to facilitating these skills based on the following assumptions:

* Skill development is an evolving process (Brookfield, 1987; Schon, 1987).

* Processes and skills are domain specific (Ennis, 1990; McPeck, 1990; Paul, 1993; Siegel, 1988).

* Learning experiences that help to develop the process need to be dialectic and dialogic rather than didactic (Baker & Diekelman, 1994; Porter, 1995).

* Students should be involved in authentic problem-solving activities (Benner, Tanner, & Chesla, 1996).

* Involvement needs to be real, include complex contextual elements, and be sufficiently engaging to enable students to become imaginatively involved (Benner, 1984; Schon, 1987).

* Processes should empower thoughtful self-reflection in students (Paul, 1993; Schon, 1987; Siegel, 1988). Siegel (1985) additionally suggests three essential critical thinking teaching goals: facilitating students' perceptions of their ability to use reasoned appraisal; encouraging inquisitiveness; and promoting a habit of seeking and providing rationale for decisions.

Because the authors accept the foregoing assumptions, the reasoning course incorporated approaches mentioned above by: using dialectic and dialogic processes with a focus on authentic, contextual, engaging situations; stimulating appraisal of self and others' reasoning approaches; and encouraging self-reflection. To foster reasoningskill development in the nursing domain, learning experiences were designed to stimulate students' awareness of their own reasoning processes as well as the processes of other students and those of more experienced nurses. Benner (1984) suggests that learning occurs when students actively listen to and are engaged by actual paradigm cases. She asserts that, "In order for students to learn from another person's paradigm case, they must actively rehearse or imagine the situation" (p. 9).

Narratives of actual clinical cases were the primary learning activity in the course because they provide experiential learning crucial to developing expertise in a skillbased practice such as nursing (Benner, 1984; Benner, Tanner, & Chesla, 1996; Boykin & Schoenhofer, 1991). Narrative, along with group discussion, was used both to promote clinical reasoning and to access students' understandings of decision making (Benner, 1984; Benner, Tanner, & Chesla, 1996; Nehls, 1995). Narrative accounts offer the closest possible access to practice because decision making cannot be directly viewed (Benner, 1994). "Narrative pedagogy is both an approach to teaching and learning and a way of thinking," according to Nehls (1995, p. 204). Narratives incorporate all the domains of knowing by "integrating feelings, thoughts, perceptual recognition, and memory" (Benner, Tanner, & Chesla, 1996, p. 314). Clinical narratives facilitate reasoning-skill development by bringing students into the experience of others, thus building on the students' views of their place in the world of nursing. Vezeau (1993) suggests that narratives parallel reality to the extent that they are contextual, complex, and dynamic. Narratives unfold as they are told so that one is not certain what will happen, or what is important in the situation. Listeners can experience and discover the story from unique personal perspectives in ways that build on previous experiences. Similar and dissimilar narratives discussed together help students begin to build a repertoire of understandings in a given area (Benner, 1984).

INVESTIGATIVE APPROACH

A preliminary interpretive phénoménologie investigation was undertaken to begin to explore how students perceive and experience their developing clinical reasoning and critical thinking skills revealed in narratives. Phenomenology was chosen because this approach is suited to the study of experience, meaning, and significance. Narrative accounts

allow the speaker to give more details and include concerns and considerations that shape the person's experience and perception of the event. A story of an event is remembered in terms of the participant's concerns and understanding of the situation (Benner, 1994, p. 110;

Benner, Tanner, & Chesla, 1996; Heidegger, 1962/1926). Students and nurses in the class were asked to specificalIy detail their experiences by sharing scenarios in which they made clinical decisions that were significant and meaningful (Benner, 1985, 1994; Heidegger, 1962/1926). Stories told in a manner incorporating feelings, contextual aspects, and unfolding complexities reveal the quality and detail of data crucial for phenomenology.

Throughout the semester, data were gathered consisting of student logs, videotapes of students and experienced nurses relating clinical scenarios, and class discussions of scenarios. Student logs were submitted at the end of each of 15 classes. Videotapes of clinical scenarios which chronicled the voice tones and expressions of students and nurses dialoguing about presented cases, were used to access holistic understandings. Permission to use videotapes and logs was obtained with the stipulation that names would not be used. Multiple videotapes and multiple logs were used so that common meanings would be recognized and idiosyncratic information would be eliminated from the findings (Benner, 1984, 1994).

The process of interpretation consisted of identifying narrative themes, exemplars, and paradigm cases in the logs and videos. Independently visiting and revisiting the text, researchers identified narrative themes, compared each other's themes, and agreed upon those that were most significant. When wording used by both researchers to code the themes differed, the text was revisited to find quotes that accurately conveyed the meanings of narrative themes. Researchers agreed on exemplars and a paradigm case which illustrated the complexities of the themes. During this process of collaboration, researchers remained within the hermeneutic circle and revisited the data repeatedly. According to Benner, "[a] systematic moving from the parts back to the whole text allowed the interpreters to check for incongruities, puzzles, and unifying repeated concerns" (1994, p. 113). Revisiting the text forced researchers to support interpretations with solid textual evidence. A paradigm case and numerous exemplars are offered, allowing the reader to participate in consensual validation and follow the decision trail to evaluate if the presented conclusions are true to the text (Madison, 1988).

FINDINGS

The purpose of the investigation was achieved to the extent that faculty came to a greater understanding of how students experienced clinical reasoning and critical thinking. Because this was a preliminary investigation and qualitative approaches yield an abundance of data, researchers are not suggesting these findings are exhaustive. Much more remains to be understood about how students experience clinical reasoning and critical thinking. However, from the clinical narratives, class discussions, and reflections in logs, confidence emerged as a significant aspect of these processes. This report of the investigation focused on students' perceptions of threats to confidence and on ways of building confidence which are only limited aspects of clinical reasoning and critical thinking.

Initially, students revealed they were very apprehensive about entering nursing practice. It was clear that their reasoning was significantly colored by self-doubts and diminished confidence. During this reasoning course, students described six areas in which a shift occurred from confidence-diminishing to confidence-enhancing experiences and understandings. Students moved from being overwhelmed by inexperience to drawing strength from others' experiences. They shifted from perceiving others as more competent to learning that their own capabilities were comparable to their peers' capabilities. They went from lacking the confidence to question to discovering the power in questioning. Students moved from focusing excessively on potential harm to looking also for positive actions and from feeling total responsibility to experiencing comfort in shared responsibility. Students shifted from being disorganized and scattered in approaches to finding ways to focus under stress. The Table summarizes students' perceptions of threats to their confidence (column one) and the contrasting aspects of confidence building (column 2). Although the Table suggests a progressive, linear process, an uneven, modulating growth of confidence was observed in the students, which would be expected in experiential learning and in new skill acquisition. Even though the categories are presented in the Table as discrete, the separations between them are not clearly distinct because they are interrelated aspects of confidence. For example, drawing strength from others' experiences overlaps with discovering the power in questioning because questioning is one way to access another's experience.

Table

TABLEDiscovered Ways of Responding to Diminished Feelings of Confidence

TABLE

Discovered Ways of Responding to Diminished Feelings of Confidence

CASE EXAMPLES

Diminishing and Building Confidence

One paradigm case, presented by a student near the end of the semester, illustrates all the components of both diminishing and building confidence.

In my second semester, I had the idea there was absolutely no excuse for a med. error (focusing excessively on potential harm] because there are too many ways to cross check. Then I did it. I had a patient in her 70s from a board- and-care who was diabetic and could only grunt to communicate following a CVA. She had 14 meds., was in a lot of pain, and most of her meds. were CNS depressants. The primary nurse was busy and she kept asking me to help her. I kept mentioning I had to give my 8 o'clock meds. and she kept saying, "Relax. We have the window period" (lacking confidence to question]. So, I just kept on. Also, my patient's roommate was not good. 1 decided to check the orders and found she had a DNR (do not resuscitate). I might have been the first one to notice something, some change in her (finding ways to focus under stress]. It was 8:30 and the window (time-frame for administering the drug on time) was going; so, I went into the room [talking rapidly]· The roommate wasn't breathing [with a worried look]. She had no radial, no carotid, no apical pulse. I went for help. I got the nurse [drawing strength from others' experiences] who did the same checks I did. Then we closed her eyes [sighing]- Finally I told the nurse I had to give my meds. It was 8:45. I was really rattled. I double checked all of the meds. [fidgeting in seat], but I gave the patient the cup before I checked meds. off on the bedside table [being disorganized and scattered]. Then I noticed a 10 (o'clock) med. mixed in there [looking down at feet], I reached for the cup and the patient had taken them. I went to the drug book to look up the medication and see what it would do with the others. I told the RN and we filled out an incident report. 1 told my instructor. I thought, Tm gone, out of the nursing program [voice softening]. Nobody else would do this" [perceiving peers as more capable]. 1 went to assess vitals after talking with the nurse. There was a BP spike of 210 over 110. 1 thought, "I've killed her. She's dead" [sighing, looking down]. I retook the vítala and they were down (finding ways to focus under stress]. I went back to the nurse and told her. She said a spike like that could just be from pain [experiencing comfort in shared responsibility and drawing strength from others' experiences]. I looked up the 10 o'clock med. again in a better drug book and found out it was a muscle relaxant that acted peripherally and was not even a CNS depressant. When the nurse called the doctor he said it wouldn't even affect her. There was reassurance from the staff that it was no big deal. I felt better [looking also at positive actions and drawing strength from others' experiences]. The whole thing taught me a lesson [resolute voice]. My primary responsibility was for my patients, and their medications. I should have been more assertive, asked questions, and not got pushed into a corner where I reacted instead of being proactive [feeling total responsibility and discovering power in questioning]. I don't know enough about meds. to know what is or isn't OK. I didn't know what to do [being overwhelmed by inexperience]. It was everything at once. It wasn't the death so much, but that it piled on so many other things [being disorganized and scattered].

Another student inserted here, "You cared enough to check on the other patient, I don't think many other people would have done that. I wouldn't have." The narrator replied, while sitting up in her chair, That's good to hear" [learning capabilities are comparable to peers and looking also at positive actions].

Other quotes that further describe exemplars of each confidence category are included in the following section. These exemplars were either in the students' narratives or in their responses to narratives in their logs.

Being Overwhelmed By Inexperience and Drawing Strength from Others' Experiences

All students expressed some fear of being overwhelmed by a lack of experience as well as the feeling that they could build confidence by listening to nurses and taking parts of this shared experience as their own. One log entry read, "As I listened to scenarios I tried to put myself in the nurse's shoes, walking through the decisions she made. It was almost like getting hands-on experience."

When describing clinical challenges, students mentioned their own lack of experience and their ability to balance that feeling by drawing on the experience of other nurses. In one exemplar a student relates:

I was giving my patient some Demerol and she seemed to fade out. She began having facial tics and it progressed to a tonic-clonic seizure. I'd never seen a seizure before. My mind went blank and I froze. Luckily my preceptor was in the room working with the woman in the next bed. She told me what to do. The patient stopped breathing. I didn't know whether to wait 10 or 20 seconds or what, afterwards, for her breathing to start. The nurse set the suction up and told me to go verify that my patient was a code and then to call one. Having an experienced nurse there helped me be able to do something.

Studies of novice nurses have shown that they are not able to focus on salient aspects of a clinical situation because they lack experience. In contrast, the tendency of expert nurses is to clump similar situations together and use their experience to make salient qualitative distinctions between individual cases (Benner, 1984; Benner, Tanner, and Chesla, 1992). Though not exposed to these studies, students commented that:

Experience is a net which allows you to catch things and to relate and recall previous similar information. I have noticed that we (students) have limited experience in clinical situations, we feel unsure of ourselves, and due to our inexperience we are unable to quickly process all the information we are receiving at the time. It appears that after the situation is over and we have time to think about it, we have better understanding of what was happening and a hindsight view that gives us some amount of experience.

Students benefited from being exposed to experienced nurses' stories, from having access to experts whose experience they relied on, and from reflecting on their own clinical experience. Experienced nurses' stories were described by the students as a way of adding to their collage of clinical experience.

Perceiving Peers as More Capable and Learning One's Capabilities are Comparable to Peers

During the first weeks of the course, students repeatedly expressed fear that other students were more competent than themselves. This was true even of students who had a high achievement record in the nursing program. Commenting on something another student shared in class, a student wrote, "She feels as if everyone else is better at making decisions. I feel the same way. I look at people around me and think that other students are smarter or better than I am." One of the strongest gains students reported during the course was recognizing that other students shared similar fears and were at a comparable competence level. One student captures ideas mentioned by all students, saying, "This class has been a very comfortable place because I realize that I am not the only student who feels insecure and uncertain about my clinical judgments." Another student summarized:

Listening to other studente makes me feel that I am at the relatively same level of skill that they are. The stories remind me that we are all human and that perhaps my opinions, insights, and knowledge base are no less valuable than anyone else's regardless of my student nurse status.

Lacking Confidence to Question and Discovering Power in Questioning

Students shared their reluctance to ask questions, saying, "I feel that questioning reveals a lack of knowledge that I should have and don't."Another indicated, "You prepare for clinical and the instructors expect you to know the answers, and we don't have all the answers, but it's not okay to say we don't know." Another problem was that students did not feel they could challenge others' opinions about their patients. One student described an exemplar where she noticed a change in her patient and felt strongly that something needed to be done, but her concerns were initially dismissed by more experienced nurses:

In the report they described my patient as "waning in and out." Being inexperienced, I never did ask what that meant. She would be alert only after you called her name. Toward the end of the shift she started getting more lethargic. I had a float nurse to work with and it was like being on my own. I kept asking her and my instructor about the way my patient was and they kept saying "That's how she is." The nurse who was assuming care at shift change arrived and went down to eee the patient. She came running back yelling, "How long has she been like this? I want the doctor here now!" He came by and we found out it was because of her high calcium level. She was getting medications to lower that. I learned I didn't present myself to people so that they would take me seriously when I was asking questions. I should have gone to the charge nurse if the float nurse didn't listen. The p.m. nurse was able to get something done.

It was empowering when experienced nurses described the importance of questioning in their presentations of clinical situations. One student commented in her log:

The presenter helped me see that questioning is a positive step for even the most experienced nurses. It was reassuring to me that it's OK to ask questions; that we should never stop asking questions because it's never wrong to try to validate our thinking.

Another student related that, "I am now questioning more than I did in the beginning of the semester. I have a fierce inquisitiveness. It is difficult for me to leave questions unanswered." One realization was, "I have become aware that if I am not heard, I must be persistent and assertive with my coworkers and the physicians." One student captured this feeling by saying:

I feel more support for questioning problems, investigating, and acting on the information I gather. This course has given me a sense of personal power and confidence. I believe that even if I am the only one who doesn't understand or disagrees, or needs more information, I will be acting like a better nurse by questioning.

Focusing Excessively on Potential Harm and Looking Also at Positive Actions

Students consistently commented on their need to avoid mistakes and to try to be perfect in clinical settings. One student shared, "When you are a student starting out, the hospital can be intimidating. We beat ourselves up about mistakes. We don't realize that even experienced nurses can make mistakes." Because students cannot distinguish mistakes that could be truly harmful to patients from those that reflect noncritical imperfections which exist in actual practice, they make comments such as, "Every time I find myself not performing to perfection, I play with the idea of quitting nursing." Another student wrote:

Before you have a backlog of clinical success to draw from, it's important to not be hypersensitive to small mistakes and get so overwhelmed by them that you can't do anything.

After listening to an experienced nurse's narrative, another student wrote in her log, "Today I learned that I have to take some of my limitations into consideration so that I will not have unrealistic expectations of myself." Several students commented that it is also important to notice success saying, "Beginning nurses don't learn to give themselves pats on the back. They learn to identify their flaws. It's also important to look at positive actions."

Feeling Total Responsibility and Experiencing Comfort in Shared Responsibility

Another troublesome issue that diminished students' confidence was feeling totally alone in responsibility for the patient. One student wrote, "I am pleased to hear that I am not the only one who feels apprehensive about being completely responsible in clinical for my patients." Another student's apprehension was evident in the comment, "I am really concerned about going out there and being a real nurse, being totally responsible." Our students described what Benner, Tanner, & Chesla (1992) found with advanced beginners who feel "a remarkable sense of responsibility to perform. ..but are so dependent on others... they cannot decide what to do or even how to do it" (p. 19). The students seemed to be surprised listening to the experienced nurses by how much decision making involved collaborating with others. They seemed to draw comfort and confidence from seeing the team as a kind of support or as sharing in the responsibility of appropriate decisions. One student describes this in her log, "Listening to the nurses, I've learned the great extent to which nurses have worked as a team in making decisions. That has helped me ask for help." Another echoed the same feelings by commenting:

Collaborative effort allows for input from a variety of perspectives. I cannot expect to be able to make decisions like an expert nurse at this point in my nursing career. What I can do is avail myself of other nurses' experience by asking for their input concerning decisions. Being able to do that makes me feel more confident.

One student's community health scenario serves as an exemplar of both the fear of being solely responsible and the comfort experienced by students in collaborating with more experienced nurses. The student said-.

Before I left, I had established what the referral parameters for BP were and what clinic to suggest. I thought to myself; I'm not going to be in a county where I dont know any of the facilities without knowing the parameters. The nurse had said to educate about high blood pressure. My first glimpse of my patient was a 5 foot 4 inch woman, 170 pounds, moving quickly in a walker, yelling "Who is here to take my blood pressure?" She was manicy [sic] and angry with the world. She kept saying her public health nurse got her BP as 150/90 so the doctor who got 220/110 had to be wrong. I got 210/104, and she kept refusing to go to urgent care. All I could do was to let her cry. I went back to the office feeling like I had accomplished nothing. It felt good to have the nurse to bounce things off of because it seemed to me the patient wasn't able to make decisions for herself

Being Disorganized and Scattered and Finding Ways to Focus Under Stress

Students regularly described how they became tered and overwhelmed for many hours whenever something unexpected or unplanned occurred in clinical. One student described this sense of being overwhelmed as 'dithering back and forth and feeling scattered-" Another student wrote:

I remember doing pointless, repetitive things. I was just able to do one task at a time. I had to break everything down to the simplest form to make it manageable, trying to control what felt like an uncontrollable situation.

Another student commented:

In clinical situations, maybe due to lack of experience, it seems to be that fear of the situation leaves me in a paralyzed state and I cannot sort out the steps involved to solve the problem.

As the course progressed, students described that they were finding better ways to focus which helped to avoid the immobilization associated with feeling scattered. One student wrote, "I've learned to pick one task, do it, do another, and finally the problem begins to resolve itself."

Another student explained:

It helped to take a break from charting the arrhythmias and feeling so confused. I know I'm focusing on myself when I get so anxious. The nurse's suggestion of focusing on the patient's face helped. It draws you away from selfabsorption.

One exemplar describes students' experiences with feeling scattered and developing a sense of focus:

The next day my patient was worse. She was incontinent and had trouble swallowing medications. I couldn't figure things out so I asked the charge nurse to do an assessment with me. She said, The patient is OK, she's just 80." I knew that wasn't a good answer, so my plan was to wait for my preceptor to have time to go with me. The preceptor agreed [something was wrong] after seeing the patient, so we went to look in the chart and didn't find much. We talked to the doctor who said, "I'm discharging her tomorrow." Next we talked to the chore worker and found out this woman usually dressed herself and did all her own cooking, bo this wasn't normal. Eventually, the patient had a grand mal seizure. I monitored her breathing, but I got so rattled I forgot about a p.r.n. order for Ativan for seizures. My preceptor was irritated, and I knew it was a dumb mistake. She called the doctor and an EEG tech ran a strip and verified the seizures. It's funny the doctor denied the patient was having seizures even though the strip proved it. Finally we decided to get an oncology doc to come by. It turned out her potassium was high at 6. Her oxygen sate, went from 96 to 59 and her BP kept fluctuating. We were giving her Dilantin and her IV had to be restarted. I was feeling really scattered. I had another patient who needed insulin and one to discharge. I asked my preceptor, "How do you do it?" She said, "Get used to it. We have 10 patients, so I turn the monitor toward the door and pass by every few minutes." For the rest of the shift, I tried thinking about and doing just one thing at a time and it helped.

Students described increasing confidence and a related growth in clinical reasoning and critical thinking as being shaped to some extent by the reasoning course. Students also exhibited more confident demeanors as seen in increasing class participation, assured voice tone, and more interactive eye contact throughout the course of the semester. When writing in their logs, dialoguing in class, and discussing what they got out of the course overall, students mentioned ways their confidence and clinical reasoning increased. One student's log comment obviates the connection between confidence, critical thinking, and reasoning, "Critical thinking and reasoning affects confidence, and confidence is important to critical thinking because it gives me faith that I can solve clinical problems." An example of the reported increasing confidence can be seen in another student's log, "This course has been a big step toward helping me feel more confident in my clinical decisions." An example of a shift in reasoning is evident in the following quote:

My reasoning processes have changed in that, before this class, I didn't realize the extent to which I tried to quickly categorize my patients' problems without thinking. I am now asking more thoughtful questions and looking at more clinical possibilities.

Yet another student commented:

I'm beginning to believe that decision making goes much deeper than assessment findings. I now feel that how I see myself in a given situation also affects my decision-making process.

Finally, a student offered:

I have noticed that my reasoning patterns have changed because I apply some of the strategies I learned from the class scenarios. Some strategies that expert nurses used were similar, so that over a period of time, after we listened to them over and over, they became engraved in our understanding.

However, one student shared the caveat, "Changes in my thinking are, of course, still very tentative and have never been tested under fire, so to speak."

DISCUSSION

The beginning growth in confidence associated with clinica] reasoning and critica] thinking was reported by studente in their reflective logs and class discussions. Additional studies in actual clinical settings, where skill level changes can be more directly observed, as well as investigation of more narrative accounts are needed to understand more completely students' experiences of clinical reasoning and critical thinking development. The sample size of this study was small and describes students in only one nursing program. For two subsequent semesters, students have also related similar experiences about confidence; however, further study is needed to explore more fully the large domain of clinical reasoning and critical thinking development.

While faculty observed developing student confidence, no class approaches purposely focused on attempts to build confidence. Many experiences may have shaped students' developing sense of confidence including the class, concurrent clinical practica, and other life situations. What facilitated growth in reasoning development cannot be understood separately from the emerging confidence because confidence and experience are reciprocally linked. In drafting this article, it was difficult to discuss the instructional approaches apart from the investigative approach and findings because involvement in narratives generated the interpreted data as well as shaped changes in student confidence and reasoning. Logstrup (1971/1956) describes confidence as deriving from an authentic grasp of situations. Perhaps becoming involved in narratives enabled students to experience a more authentic grasp of decision making as it exists in the world of nursing. Self-understanding and confidence significantly develop the sense of being at home in the world of nursing, including the ability to reason in a clinical setting (Benjamin, 1988).

Confidence and self-understanding evolve from the relationships, situations, and activities in which one is engaged on a daily basis. The familiar habits, practical activities, skills, and patterns of relating to the environment give people a sense of who they are and their place in the world (Heidegger, 1962/1926). When students first enter the practice of nursing, they must learn different habits, new traditions, new patterns of relating, and new skills. Part of how students learn to understand what it means to be a nurse is through interactions with others within the world of nursing. Benjamin (1988) describes this process as recognition, explaining it as, "That response from the other which makes meaningful the feelings, intentions, and actions of the self (p. 12). As students start acquiring a personal view of the nursing world, they try out new behaviors and ways of viewing themselves. She stresses that, "Recognition is reflexive. It includes not only the other's confirming response, but also how we find ourselves in that response" (Benjamin, 1988, p. 21). In contrast, students may embody previous self-understandings which differ from others' understandings. Benjamin describes this as self-assertion. Benjamin maintains that there is a tension or balance between self-assertion and mutual recognition. Therefore, it seems crucial for students to be given opportunities to assert themselves, to try out their evolving understandings, and to dialogue about their experiences and be recognized during the process. In the logs and class discussions, faculty saw how students used this process of asserting their views, dialoguing, and receiving feedback in building confidence.

Educational Implications

The six sources of diminished clinical-reasoning confidence revealed by these baccalaureate students suggest several implications for educational approaches. To help students feel recognized, they should be offered many opportunities to share clinical experiences with peers and with other more experienced nurses. This is recommended because of the consistency with which students exclaimed how unique it was and how supportive it was to be able to share being doubtful of skills. They also commented that understanding peers were at a comparable level helped them to learn.

During either actual clinical experiences or stories of actual experiences, approaches for facilitating clinical reasoning and critical thinking should avoid activities that unnecessarily add to students' already well-developed self-doubt. Consider the work of Belenky, Clinchy, Goldberger, and Tarale (1986), in which they describe the encouraging and nurturing practices of people who foster critical thinking. They note:

Because so many women are already consumed with selfdoubt, doubts imposed from outside seem at best redundant and at worst destructive, confirming the woman's own sense of themselves as inadequate k&owere (p. 288).

The students in our class, both men and women, made it eminently clear that they are already skilled selfdoubters. Instructors need to take great care not to reinforce students' positions of doubt. Efforts should be made to build confidence in students. Faculty should find "positive triggers" (Brookfield, 1987, p. 31) for advancing skilled practice by facilitating movement instead of blocking it by creating self-doubt. This approach is consistent with the findings of Oermann & Moffitt-Wolf (1997) that support is essential for new graduates to develop confidence in their practice.

Educators need to help students build on their improving clinical skills. Students can be given an assignment of keeping clinical logs in which they reflect on what they "did right" (Baker, 1996). To help students gain a greater sense of the appropriateness of their clinical progress, faculty can offer support for growth in log feedback. Also students can exchange their logs for peer feedback, which can be another information source about clinical progress. Without recognition of progression, a sense of developing confidence and skill may be impaired. Achieving recognition from patients, experienced nurses, and instructors is important to students who are just beginning to develop an awareness of their practices and of who they are within the world of nursing (Benjamin, 1988).

Offering many opportunities to share stories about clinical experience with peers and with more experienced nurses can assist students in developing realistic expectations of their skills. This is consistent with Loving's (1993) assertion that feedback colors students' perceptions of developing competence. Educators should help students identify and appropriately use their strengths and limitations, and thus help them learn from problematic experiences. Students can dialogue about clinical situations that were troublesome. They can analyze what went wrong and why, as well as propose better alternatives. It will be important for faculty to view this as a developing process and not as a time to evaluate mistakes or imperfections.

Educators should consider clinical placements on one unit per semester rather than moving students to several units. This type of placement allows students to develop familiarity with commonly recurring situations, build a collection of successes in solving problems, and form a stronger view of themselves in the nursing world. The situational stability may also help diminish some of the problems students have with getting out of focus when something disruptive happens (Benner, 1984). Students can be helped to anticipate the out-of-focus problems and to develop deliberate responses when this happens, such as taking a break to reorganize priorities.

CONCLUSION

Empowering students to ask questions seems to be an educational imperative for promoting sound clinical reasoning and critical thinking (Siegel, 1985). Nursing pedagogy should encourage students to develop the habit of asking questions and of challenging perceptions of the status quo. Rather than questioning students about what they should know, educators might ask students what they think they need to know and how they plan to seek answers to then* questions. Educators need to demonstrate the acceptability of questioning by demonstrating this skill in real situations. As clinical instructors approach a student the first thing in the morning, instead of asking for the patient's diagnosis, lab values, or procedural knowledge, they should ask, "What concerns do you have this morning? What questions can you ask to address these concerns? How can you find ways to answer them?" Such questions help guide students through learning how to practice in a given situation in contrast to questions which focus on "knowing that" or factual information (Benner, 1984). Instructors should demonstrate that no one knows all the answers, that questioning is the expected norm, and that they are willing to guide students through the process of finding answers. In any learning experience, use of measures that reinforce selfdoubt should be minimized. It should be safe for students to question, to be wrong, or to doubt or challenge ideas. Until it is safe, educators and clinicians may be blocking clinical reasoning and critical thinking development instead of facilitating its potential.

Because students are concerned about being solely responsible for their patients, by encouraging health team collaboration and intervening whenever students experience negative input from staff, educators can help students decrease self-doubt. Students need to be helped in identifying team resources and assisted in gaining experience in their appropriate use. Opportunities should be offered to dialogue about feelings and ways of dealing with negative encounters commonly described by students where staff, instructors, or physicians treat them like "idiots" or "children."

Clinical reasoning and critical thinking are often taught as linear processes, as in the classical nursing process. Assuming they are most likely not linear in real, complex, dynamic situations, using actual clinical scenarios seems to be an effective way to facilitate skill development as well as a way to understand beginners' developing experiences of clinical reasoning and critical thinking. Scenarios are a close approximation of clinical practice. Much of the information about how clinical reasoning and critical thinking develop in beginning nurses may be embedded in scenarios. They incorporate multifaceted, context-rich, particular information, allowing students to be exposed to the type of decision making which actually occurs in practice. Such a format provides students with opportunities to assert themselves confidently, to be recognized, and to come closer to finding their place within the world of nursing (Benjamin, 1988). While this investigation offered a view of only one aspect of students' developing clinical reasoning and critical thinking, much more needs to be understood.

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Discovered Ways of Responding to Diminished Feelings of Confidence

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