Dr. Lasater is Assistant Professor and Ms. Nielsen is Instructor, Oregon Health & Science University, School of Nursing, Portland, Oregon.
This study was presented in part at the Sigma Theta Tau Biennial Convention, Baltimore, Maryland, November 2007. This study was funded in part by a research grant from the Beta Psi Chapter of Sigma Theta Tau International.
Address correspondence to Kathie Lasater, EdD, RN, ANEF, Assistant Professor, Oregon Health & Science University, School of Nursing, 3455 SW Veterans Hospital Road, Portland, OR 97239; e-mail: firstname.lastname@example.org.
In nursing education’s efforts to graduate more nurses, there is unprecedented competition for acute care clinical sites and experiences. In urban and rural settings, the health care reimbursement system is trying to keep admissions and lengths of stay shorter to reduce costs, leading to situations in which hospitalized patients have, in general, much more complex care needs than in the past. In addition, related to short stays and early discharges, the availability of patients for student study on subsequent clinical days is less predictable.
In the traditional clinical education model, nursing students are assigned a patient before their clinical experience, prepare themselves prior to contact with the patient (often the day before), and then provide total patient care for the entirety of the clinical day and often a second day. This strategy is becoming increasingly impractical given the random availability of appropriate patients for student care. In addition, the complexity of high-acuity patient care challenges students to track so many significant aspects of total patient care simultaneously that they may become task-focused. Students may not be able to think deeply enough to learn about any one aspect of care in a way that promotes the development of clinical judgment. This may be especially true for students early in their programs.
The total patient care approach to study also leaves specific clinical learning experiences to chance (Gubrud-Howe & Schoessler, 2008). Because of high patient acuity, faculty time with students may be dominated by discussions related to patient safety issues, rather than dialogue focused on deep understanding of a given patient care situation. Nursing resources are continually stretched thinner as nurses care for sicker patients and precept new staff as well as students. Preceptors may be too overloaded to provide the full measure of clinical education and may be unable to work with students to improve their clinical judgment.
In view of the complex nature of clinical education today, the National Council of State Boards of Nursing recently recommended that prelicensure nursing education include clinical experiences with actual patients and that supervision of students include provision of feedback and facilitation of reflection by faculty (National Council of State Boards of Nursing, 2005). The National Council of State Boards of Nursing acknowledged that one role of faculty is facilitation of clinical judgment development. Many educators are considering new clinical education models to meet the growing need and produce excellent clinical thinkers (Gubrud-Howe & Schoessler, 2008).
In 1990, Heims and Boyd introduced a different type of clinical learning activity, the concept-based learning activity, which offers students a way to learn about foundational concepts, such as fluid and electrolyte balance, as a strategy to increase clinical knowledge and in-depth thinking. In our program, concept-based learning activities, described by Heims and Boyd, were adapted to incorporate components of the Clinical Judgment Model, a research-based conceptual framework (Nielsen, 2009; Tanner, 2006).
The aim of the mixed-methods study reported in this article was to compare the development of clinical judgment between two groups of students at the same level: those exposed to concept-based learning activities and those who were not. Little is available in the literature specifically about concept-based learning activities; however, the literature focusing on clinical judgment and development of learners seems to support the use of concept-based learning activities.
Benner, Tanner, and Chesla (1996) defined clinical judgment as “the ways in which nurses come to understand the problems, issues, or concerns of clients/patients, to attend to salient information, and to respond in concerned and involved ways” (p. 2). Through an integrative literature review and three decades of research, Tanner (2006) developed a model of clinical judgment in nursing practice. The model includes the phases of noticing, interpreting, responding, and reflecting and acknowledges the influence of the nurse’s background (theoretical and practical knowledge, biases, blinders, and vision) on clinical judgment.
Although the clinical education environment is changing and presenting new challenges, the development of student thinking and clinical judgment remains fundamental and a critically important aspect of nursing education. That development progresses along a continuum (Lasater, 2007). Whereas novices rely on context-free rules for understanding clinical situations (Benner, 2001; Paul & Heaslip, 1995; Tanner, 2006), experts have a depth of knowledge that allows them to consider a situation comprehensively, notice patterns, and then organize knowledge around core concepts (Bransford, Brown, & Cocking, 2000). The challenge for educators is how best to give students learning experiences that move students’ thinking and clinical judgment along the developmental continuum.
Concept-based learning activities provide students with opportunities to study basic nursing and physiological concepts in depth without assuming responsibility for total patient care (Heims & Boyd, 1990; Nielsen, 2009). This supports learners’ need for dependence early on, preparing them for more self-directed learning as they move through the program (Grow, 1991). Subsequently, students should be able to apply conceptual learning in more complex total care clinical experiences, providing the sequential building on concepts so that new ideas can be integrated with previous learning to promote student learning (Fink, 2003).
Concept-based learning activities are a structured approach to study one discrete aspect of patient care, such as oxygenation or pain management (Heims & Boyd, 1990; Nielsen, 2009). Concept-based learning activities follow a study guide, using the Tanner (2006) Clinical Judgment Model as a framework.
Structure and Integration of Concept-Based Learning Activities
In the concept-based learning activity study guide, students are directed to prepare for clinical study. The expected learning outcomes are clearly stated, preparatory readings are assigned, and students are asked to consider and describe their previous learning (in theory classes or through previous life experiences) about the concept they are studying. This provides student background, an integral part of thinking in the Clinical Judgment Model. Questions in the study guide direct students to notice and interpret, identify an appropriate response, and reflect in and on action—all components of the model.
Meeting the Patients
After students arrive at the clinical site, they or their faculty choose patients for study. Students then follow prompts in the study guide to access information about their patients and the medical diagnoses from the written chart, reference, and electronic sources. Students follow with focused physical assessments pertinent to the concept. The guide then prompts students to consider the findings and interpret what is happening in their patients relative to the concept being explored, make decisions about appropriate nursing responses to patient findings, and identify outcomes that will provide evidence that the nursing responses have been effective. Finally, students reflect on the experience and describe what was learned. Students finish the study guide by documenting their findings in writing.
Later in the day, after students have completed study of an individual patient (focused on the same concept), the entire group performs rounds and visits all of the students’ patients. Students present their own patient and learning to the group. They describe the patient’s history and how the concept presents in the patient studied, and then demonstrate pertinent physical assessment findings, if appropriate. This allows students to gain additional experience with the concept by observing how a particular patient problem or concept manifested itself in a variety of patients. Faculty provide expert perspectives on observations, for instance, pointing out what is expected and what is unusual or unexpected in the patient situations observed and asking relevant questions that encourage deep learning. This exposure to several different patients can add greatly to student understanding of a given concept.
For example, students learning about the concept of fluid and electrolyte balance in a pediatric setting might study a 2-month-old patient with rotavirus and dehydration. Students will access the patient’s history, laboratory values, and information about how this particular medical diagnosis and this patient’s developmental stage might influence fluid and electrolyte balance. Students will do physical examinations and assessments of patient data focused specifically on fluid and electrolyte status. Later in the day during nursing rounds, students in the clinical group describe their patient findings and meet each other’s patients, if appropriate. Thus, in addition to learning about fluid and electrolyte status in the 2-month-old patient with rotavirus, students in the group may see how fluid and electrolyte issues present in an 8-month-old patient with congestive heart failure, a 4-year-old patient being treated for leukemia, an 8-year-old patient with Crohn’s disease, and a 16-year-old patient with pancreatitis.
In their original description of student use of concept-based learning activities, Heims and Boyd (1990) reported using ongoing, nongraded feedback to formatively and informally evaluate student thinking about patient care. Criteria used for evaluation included observation of student verbal interactions, both with other students and with faculty, and evidence of inclusion of new knowledge in subsequent verbal and written activities. They reported students learned to select and apply knowledge, organize data, integrate readings, and present findings to others. In addition, they reported students seemed to use all phases of the nursing process, rather than focusing only on the assessment phase. Students described perceptions of enhanced learning and reported appreciation of focusing on “learning to do,” not simply “doing.”
In adapting concept-based learning activities to include the framework of the Tanner (2006) Clinical Judgment Model, a tool for the formative evaluation of student learning was incorporated (Nielsen, 2009). The Lasater (2007) Clinical Judgment Rubric offers levels of clinical judgment development as well as language to facilitate discussion among faculty, preceptors, and students and to formulate goals and a trajectory for learning.
Study Context and Design
For this study, concept-based learning activities were used in pediatric and maternal-child (postpartum) settings with third-quarter baccalaureate nursing students studying nursing care of the child and family. This is a time in student development when students may benefit from more structured guidance of student learning (Craft, 2005; Grow, 1991). Early in the course, students used concept-based learning activities to study the essential learning concepts of fluid and electrolyte balance, nutrition, growth and development, and oxygen-carbon dioxide exchange (one concept on one clinical day). For the balance of the term, students progressed to the total patient care model, integrating their learning from concept-based learning activities.
The design for this study was quasi-experimental, with the treatment being an exposure to two, three, or four concept-based learning activities for students in the treatment group, whereas students in the control group had never been exposed to concept-based learning activities. Following the measurement of clinical judgment in both groups, a focus group consisting of treatment group members was held to collect the qualitative data for this mixed-methods study.
During their third term in a baccalaureate nursing program, half of the junior students were enrolled in the Adult Acute Care Nursing course with no concept-based learning activities (control group). The remaining students were registered in the Nursing Care of the Child and Family course, a combined pediatrics and maternal-child nursing course (treatment group), with students participating in two or more concept-based learning activities. The individual clinical faculty members determined the number of concept-based learning activities, as well as which specific concept-based learning activities were used in the treatment group participants; there was no set requirement.
Both courses used high-fidelity simulation cases to augment the students’ clinical experiences but in different numbers. Simulation at our institution focuses on clinical judgment. We controlled for simulation exposure as an intervening variable by measuring clinical judgment during students’ first simulation experience for the term; however, we could not always control for the timing of that experience. At the end of the term, invitations were sent via e-mail to the entire treatment group, asking students to voluntarily participate in a videotaped focus group to discover their impressions of concept-based learning activities and their thoughts about the effects of concept-based learning activities on the development of their clinical judgment.
For the quantitative part of this study, students in both groups signed a standard consent form to participate. Students who did not sign or those repeating the course were excluded from the sample. The sample for both groups was a convenience sample, based on who was assigned as the primary nurse in the first round of simulation scenarios for the term. This procedure limited the sample, as not every student could be the primary nurse in the first round of simulation. In one or two situations, there was no rater available to evaluate students’ clinical judgment; therefore, those students also were excluded from the sample. In the end, the control group consisted of 13 students (3 men and 10 women), and the treatment group included 15 students (4 men and 11 women).
For the end-of-term focus group, 5 of the 15 treatment group students volunteered and signed consent forms to participate. After the focus group was scheduled, 2 of the 5 students had other commitments; institutional review board modification was obtained to allow these 2 students to address the same questions via e-mail. Those who met as a group convened over a provided lunch of pizza. All 5 participants received a coffee card as an incentive and thanks for their participation.
Data Collection and Analysis
The Lasater Clinical Judgment Rubric (Lasater, 2007), a theoretically and empirically grounded instrument, derived from the Tanner (2006) model and validated by Sideras (2008) and Gubrud-Howe (2008), was used to rate the simulations. One primary and one backup rater collected the quantitative data in the simulation laboratory. Both raters had reached 90% inter-rater reliability using the rubric.
There are 4 points for each of the rubric’s 11 dimensions, representing the four phases of clinical judgment: noticing (12 points possible), interpreting (8 points possible), responding (16 points possible), and reflecting (8 points possible), for a total of 44 possible points. Although students worked in dyads or triads in the simulation theater, the raters focused on the student designated as the primary nurse. Data were analyzed using SPSS version 15.0.
For the focus group, the primary author (K.L.) used the following semistructured prompts to elicit responses:
- What concept-based learning activities did you participate in during this term?
- What was most helpful about your participation in concept-based learning activities?
- What was least helpful about your participation in concept-based learning activities?
- How did your participation in concept-based learning activities help you develop your clinical judgment skills?
- How did concept-based learning activities compare to clinical practicum or to simulation in helping you to develop your clinical judgment skills?
During the study time frame and remainder of the academic year, the primary author (K.L.) had no responsibility for student evaluation and little knowledge of the individual students. Both researchers viewed the video, using traditional qualitative data manipulation and hand coding of emerging themes for analysis.
Univariate Analysis. A one-way analysis of variance indicated the treatment group scored statistically significantly higher in all four phases of clinical judgment, as well as total clinical judgment (Table). In the noticing subscale, the mean was 6.80 (SD = 1.20) for the treatment group compared with 5.15 (SD = 1.41) for the control group, F(1, 26) = 11.13, p < 0.01. In the interpreting subscale, the mean was 4.33 (SD = 0.98) for the treatment group compared with 3.46 (SD = 0.97) for the control group, F(1, 26) = 5.60, p < 0.05. In the responding subscale, the mean was 9.77 (SD = 1.68) for the treatment group and 8.00 (SD = 2.05) for the control group, F(1, 26) = 6.28, p < 0.05). In the reflecting subscale, the mean was 4.77 (SD = 1.14) for the treatment group and 3.85 (SD = 0.38) for the control group, F(1, 26) = 7.62, p < 0.01. Finally, for total clinical judgment, the mean was 25.67 (SD = 4.02) for the treatment group and 20.46 (SD = 4.29) for the control group, F(1, 26) = 10.99, p < 0.01.
Table: Univariate Statistics by Clinical Judgment Phase for the Treatment and Control Groups
The researchers viewed the video from the focus group several times, separately and then together. Hand transcription and coding were used to identify several themes, including:
- Importance of the study guide structure.
- Use of concept-based learning activities to clinical learning.
- Bridge between theory and practice.
- Development of students’ thinking and clinical judgment.
Importance of the Study Guide Structure. Focus group participants used the guides to determine potential patient problems and consider risk factors for potential patient problems. One participant noted, “I may not have delved as deeply into this problem if I had not been working within the structure of the concept-based learning activity.”
The study guide helped students identify the assessment data they needed for a given concept. For example, one participant said, “After doing this activity, I now have [assessment] check boxes in my mind.” Another participant commented that concept-based learning activities made her think “in a way that made the potential problems associated with these altered conditions clear and understandable.” Another participant commented that completing the concept-based learning activity was like “pulling teeth,” but expressed appreciation for the depth of study with regard to the concept.
Use of Concept-Based Learning Activities to Enhance Clinical Learning. Focus group participants identified that concept-based learning activities allowed for enhanced development of their thinking. One important factor that emerged was time with faculty discussing the concepts in depth, guiding their learning. This helped “fill in the gaps” to fully grasp the concepts.
The participants described appreciation for cooperative learning, especially when working with a peer on a patient assessment and completion of the concept-based learning activity. One student valued the active learning, commenting that book learning was mundane but assessment findings and specific patient application promoted his understanding. Another participant noted the use of the concept-based learning activity gave her the “freedom to focus on one area rather than becoming overwhelmed or sidetracked by the other aspects of patient care.”
However, the purpose and intent of patient nursing rounds was less clear for some of the participants. Significantly, participants found more difficulty in applying the concept to patients with risk factors but no overt abnormal findings. Students struggled to use the activity to “rule out” problems. Participants from different clinical groups reported some disparate faculty approaches, and for some students, the purpose and intent of the concept-based learning activities may have been less clear.
Bridge Between Theory and Practice. Consistently, participants described the concept-based learning activity as helpful to relate pathophysiology directly to patient care. Reading about the specific concept immediately before their clinical experiences kept theory fresh in mind and ready as students began working with patients. Participants reported they actively assessed patient status, remembering the concept in later patient experiences; however, some also asked that the application of learning be made more explicit at the time of the concept-based learning activity for use in subsequent terms.
Development of Students’ Thinking and Clinical Judgment. Interestingly, and not surprisingly, participants identified the preparatory process as slow, tedious, and frustrating. Students used their reading (background information) to identify what to look for and expectations about what they would see in the patient assessments. The readings examining the concept and related pathophysiology helped students consider how what they actually noticed in patients differed from the expected, what the cause might be, and how to interpret the findings. Understanding potential causes of the problem seemed to influence formulating responses. One participant stated, “My interpreting skills have been sharpened as well as my responding through a better knowledge of what symptoms might reflect certain health alterations and also what certain symptoms occurring at the same time might reflect.” Another participant stated, “I can better respond to altered fluid and electrolyte situations because I understand the causative agents and therefore can explore certain pathways to treatment.” Working in pairs was especially helpful in interpreting and responding to patient findings; however, in general, knowing how to respond to the patient situation seemed more challenging for participants. Participants found that being guided to reflect on the patient care situation after the fact was helpful.
Related to the development of clinical judgment was the depth of study in which the participants were engaged. One participant noted the guide “helped me…to get a whole picture view of the patient but also to key in on certain features that might be indicative of an altered health state.” Faculty involvement in concept-based learning activities was considered crucial to exploring the concept in depth; in fact, several focus group participants indicated that without faculty discussion, their learning would have been much more superficial. Studying a single concept for the clinical day supported in-depth learning. Finally, participants expressed the desire to have opportunities to apply learning to other patients soon after completing the concept-based learning activities to reinforce the learning.
The purpose of concept-based learning activities is to expand students’ clinical experiences to allow more intentional, in-depth learning about a single concept rather than leaving specific learning experiences to chance (Gubrud-Howe & Schoessler, 2008). This study suggests some of that meaningful learning from the concept-based learning activity may be related to students’ development of clinical judgment.
From a faculty perspective, there are many benefits to using concept-based learning activities, especially in less experienced learners. For example, the structured study guide helps students use their preparatory reading to identify what they needed to notice about the concept in the patients, as well as how to interpret the findings. Learning can be reinforced further by faculty questioning during the clinical experience, written and verbal feedback, and guidance, pointing out the expected and unexpected. Students affirmed that completing the concept-based learning activity with a peer facilitated their learning because of each other’s unique approaches and perspectives; however, faculty remain key to enhancing the depth of student learning. These features of interactive learning served to expand student thinking about the concept.
Focusing on one concept in a clinical day allowed students to see the concept lived out in various ways with multiple patients and provided students with deeper learning. Although students identified patients who had actual manifestations of abnormal findings associated with the concept afforded clearer learning experiences, concept-based learning activities can be enhanced by the way in which faculty frame the activity and the learning potential. In addition, the value of patient rounds must be similarly framed to facilitate student learning.
Perhaps the most important feature of concept-based learning activities is that the activities address the theory-practice gap that exists in almost any kind of practice-based learning (Schön, 1987). Review of pathophysiology and other background information just prior to encountering the concept in the clinical setting integrated learning, focused assessment, and aided students’ ability to apply the four phases of Tanner’s (2006) Clinical Judgment Model.
Recommendations for improvement of learning from concept-based learning activities include that faculty develop their own understanding about the use of concept-based learning activities, be clear and consistent about the purpose and application of concept-based learning activities, and further enhance and guide patient rounds. The importance of patient selection for meaningful learning experiences was underscored by students in the focus group. Students sometimes had difficulty applying learning about the concept in situations in which there were no overt abnormalities. Student learning may be enhanced when patients actually display symptoms of the concept being studied or when faculty provide a framework for studying patients without overt symptoms.
The student-stated ambiguity about the worth of rounds requires careful consideration. The potential value of patient nursing rounds is notable in that the experience can facilitate students having face-to-face experiences with patients of clinical classmates and therefore has the potential to significantly expand their exposure to a given concept or problem.
This mixed-methods study examined the influence of concept-based learning activities on the development of students’ clinical judgment. Although this is a relatively small sample in one baccalaureate nursing program, the data suggest concept-based learning activities have a positive influence and guide students’ clinical thinking, especially when students have minimal experience with a given concept. Connecting the theory with patient findings in the concept-based learning activity was recognized as beneficial, although challenging, by students. Students suggested concept-based learning activities offered a bridge between theory and practice and transformed their concept-based learning activity learning for future patient care experiences.
Interestingly, since concept-based learning activities were introduced in 1990, no subsequent articles were found in an extensive database search. Perhaps total patient care that has been the primary clinical model for recent decades distracted educators from this alternative innovative clinical strategy. However, in the current nursing education climate, faculty need to use a wider repertoire of clinical models and strategies to foster the depth of student learning and their development of clinical judgment.
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Univariate Statistics by Clinical Judgment Phase for the Treatment and Control Groups
|Phase||Treatment Group, Mean (SD)||Control Group, Mean (SD)||Effect Size|
|Noticing||6.80 (1.20)||5.15 (1.41)||0.300|
|Interpreting||4.33 (0.98)||3.46 (0.97)||0.177|
|Responding||9.77 (1.68)||8.00 (2.05)||0.195|
|Reflecting||4.77 (1.14)||3.85 (0.38)||0.227|
|Total clinical judgment||25.67 (4.02)||20.46 (4.29)||0.297|