The health care environment is constantly evolving with new technology and new challenges for professional nurses and nurse educators (Ebright, Patterson, Chalko, & Render, 2003). Nurse educators must incorporate the necessary knowledge and skill acquisition into the curriculum so students will develop the tools required to assess and treat complex patient situations. The need to educate students in the necessary skills and knowledge has led to a theory–practice gap (Corlett, 2000; Gott, 1984). Because nursing students in a clinical setting are entering a high-stakes experience, the theory–practice gap must be eliminated so that students can actively think, reflect, and apply classroom knowledge to the particular clinical situations (Benner, Sutphen, Leonard, & Day, 2010).
The theory–practice gap is conceptually defined as the discrepancy between the theoretical content that nursing students are taught in the classroom and a lack of ability for the students to apply the knowledge to specific patient situations (Corlett, 2000). Nurse educators, clinicians, and students believe there is a theory–practice gap in which the theory that is taught in the classroom is not easily applied in the clinical setting (Corlett, 2000). The challenge for nurse educators is to bridge the gap between the academic setting and the clinical setting to enable the application of nursing knowledge to the clinical encounters. A curriculum that is successful in overcoming the theory–practice gap will assist students in the development of clinical judgment and prepare them to provide high-quality patient care in their professional practice.
The purpose of this research was to explore the perceptions of the development of clinical judgment and clinical confidence among Bachelor of Science in Nursing (BSN) students who experience structured classroom reflective practice. The following research questions were addressed in the study:
- How will BSN students describe a structured, reflective classroom experience that incorporates reflection-on-action, based on Tanner’s (2006) Clinical Judgment Model, on their perceived development of clinical judgment?
- How will BSN students describe a structured reflective classroom experience that incorporates reflection-on-action, based on Tanner’s (2006) Clinical Judgment Model, on their perceived development of clinical confidence?
The students were asked to describe their experiences using reflection on actual patient care situations and their perceptions of clinical judgment and clinical confidence development. This research attempts to provide a vehicle to unite the educational experiences the student receives at both academic and clinical settings.
The development of clinical judgment and the use of reflective practice have been identified as key components in bridging the theory–practice gap (Johns, 2007; Ruth-Sahd, 2003; Tanner, 2006). According to DiVito-Thomas (2005), a successful nursing curriculum would comprise teaching–learning strategies that help develop the students’ clinical judgment. Reflective practice was identified as a critical component in the development of clinical judgment (Tanner, 2006).
The Clinical Judgment Model (Tanner, 2006) was developed as a framework to incorporate reflective practice to guide students through patient situations in an effort to develop and expand nursing clinical judgment. Tanner (2006) stated that reflecting on nursing students’ actual patient experiences contributes to the development of clinical knowledge and clinical judgment in future clinical situations. Johns (2007) stated that reflection empowers a practitioner to be mindful of oneself and an experience in order to empower the practitioner to respond more effectively and confidently in future situations. Tanner (2006) encouraged educators to incorporate reflective practice, but little evidence was documented that it actually improved the development of clinical judgment and professional growth.
Tanner (2006) reviewed nearly 200 studies related to clinical judgment in the development of the Clinical Judgment Model. The Model provided a framework for faculty to guide students through patient situations, to identify areas of knowledge gaps, to identify emotional outcomes of patient situations, and to determine additional learning needs. Reflection-in-action and reflection-on-action were significant components of the Model. However, Tanner (2006) stated there was limited research regarding classroom or clinical educational approaches to improve the clinical judgment of nursing students using the Model. She called for research related to pedagogies of integration of facts with experience to develop clinical reasoning and judgment (Tanner, 2006).
On the basis of the results of the Carnegie Foundation for the Advancement of Teaching, Benner et al. (2010) reported that nursing students learned from increased clinical experience and that every classroom encounter should have contributed to their “clinical imagination” (p. 129). The authors added that a separation of clinical and classroom teaching does not integrate the knowledge and necessary skills that nursing students require. They also stated that nursing education must address the practice–education gap and develop new approaches to classroom teaching (Benner et al., 2010).
Benner et al. (2010) reported that students experienced a separation of classroom and clinical teaching and that it is imperative for nurse educators to eliminate the extreme divide between classroom teaching and clinical experiences. Benner et al. (2010) stated that classroom time should be used to teach nursing students what is important and unimportant in clinical situations, and they encouraged an integration of classroom and clinical teaching. These authors added that a separation of clinical and classroom teaching does not integrate the knowledge and necessary skills that nursing students require. They called for a revision in the current “pedagogies of inquiry” to enable nursing students to develop the skills necessary to work through complex clinical situations (Benner et al., 2010, p. 31).
Does the nursing literature support the effects of reflection and reflective practice on the development of clinical judgment in nursing students? Little research currently exists to evaluate the most effective method or framework to guide students in the practice of reflection and the shaping of effective curriculum reform.
Using Tanner’s (2006) Clinical Judgment Model, Nielsen, Stragnell, and Jester (2007) developed the Guide for Reflection as a tool for faculty to structure student thinking by providing a structured reflective process for clinical experiences. The format of the educational activity was to provide questions to encourage critical thinking and knowledge transfer through reflective writing assignments. The Guide served as a tool to help students evaluate their current knowledge base and to reflect on their actions in a particular patient situation. The authors supported the use of the Guide in a variety of learning settings at different academic levels to enhance critical thinking and analysis through a repetitive process to improve clinical judgments.
Murphy (2004) researched the question of whether the use of focused reflection and articulation enhanced clinical reasoning development using journals and postconference sessions. The results evaluated test scores and interviews. Results indicated there were no significant differences between groups in the composite test scores related to clinical reasoning. However, the interviews provided support for the value of focused reflection and articulation to promote clinical reasoning. The study concluded that the use of structured reflection and articulation enhanced the practice of clinical reasoning and that nurse educators should encourage students to use reflection in both journals and postconference dialogues.
Walker, Tilley, Lockwood, and Walker (2008) evaluated the use of a reflective practice framework in accelerated nursing programs for second-degree students. The reflective model required deliberate actions of the faculty and students to reflect on actions, to assess outcomes, and to seek improvement in both classroom and clinical sites. By using the reflective model, the faculty reported they were able to integrate clinical course work and encourage synthesis of major principles and concepts effectively and efficiently. The authors reported that the Reflective Practice Model placed the responsibility for learning on students and enhanced the development of critical thinking.
Many qualitative studies have supported the use of reflection, but conflict persists regarding a concise definition of reflection, framework for implementation, and benefit to professional practice, as well as the development of clinical judgment (Haffner, 2001; Page & Meerabeau, 2000; Ruth-Sahd, 2003; Walker, Tilley, Lockwood, & Walker, 2008; Walker, 1995; Wilding, 2008). This study used the definition of reflection by Johns (2007): reflection occurs when the practitioner is mindful of self in regards to a particular experience. The practitioner can view oneself within the experience to confront, to understand, and to identify contradiction between one’s vision and actual practice (Johns, 2007).
This study was conducted at a private, nonsectarian institution for undergraduate women and graduate women and men located in the northeastern United States. This qualitative study was an attempt to explore the perceptions of the development of clinical judgment in BSN students who experience structured reflective practice. After institutional review board approval, students were invited to participate, and the investigator provided a detailed description of the study to all potential participants. The study was conducted in an early nursing course in the curriculum, when the students are asked to begin the process of developing clinical judgment and clinical confidence. During the course, students have the opportunity within their clinical experience to care for patients with increased complexity, and they are required to apply theoretical knowledge to the patient care experience. The course has traditionally used a lecture format based on assigned readings in the text.
A structured reflective classroom component was incorporated into one of the lecture sessions by the primary investigator (D.M.G.). During the first 90 minutes of each weekly session, the participating students received a PowerPoint® presentation related to the weekly topics and assigned readings consistent with the traditional lecture format for all students enrolled in the course. On completion of the traditional lecture, the participants were asked to prepare and present actual patient care situations from their clinical experience for class discussion. The students were asked to follow the Structured Reflective Practice Guide (Table), which is based on Tanner’s (2006) Clinical Judgment Model.
Table: Structured Reflective Practice Guide
After an introduction of the patient, the students discussed formal knowledge, pathophysiology, and emotional and ethical issues related to the patient situation. The students were encouraged to discuss their first impressions, initial interpretations, nursing interventions, outcomes, goals for the patient and family members, and any conflicts that may have occurred. The class was encouraged to ask questions related to the patient presentation. At the conclusion of the patient presentation, students were asked to “Reflect-on Action” and, as a group, to discuss the nursing interventions, outcomes, and the implications for future patient care situations.
After random selection, 15 of the 34 students participating in the reflective sessions were interviewed at the beginning of the semester and at the end of the semester. The interviewed students were asked to describe clinical judgment and reflective practice and to evaluate their current perception of their clinical abilities, skills, and judgment at the beginning of the course and at the completion of the course. In addition, at the completion of the structured reflective practice, students were asked to describe situations in which structured reflective practice affected their clinical confidence and clinical judgment.
The primary researcher reviewed the results of the study in consultation with colleagues who are expert in qualitative analysis. The research questions were evaluated using qualitative content analysis. The interviews were transcribed verbatim and data analysis began after the completion of the preintervention and postintervention components. The research questions served as an initial organizing framework. The researcher, by using qualitative content analysis, began with a coding system that was frequently modified based on data collection. During this phase, all interview transcripts were coded line by line, and keywords, phrases, patterns, and regularities in responses were identified and confirmed by counting. Substantive categories, which included a description of participants’ concepts and beliefs, were developed based on the interview content. As codes began to overlap, they were collapsed into more definitive codes and multiple categories began to develop.
The sample included 34 female students, with a mean age of 21.63 years. The group comprised 81.3% students enrolled in the traditional BSN program, and 31.3% of respondents reported prior work experience in health care. The remainder of the participants were nontraditional students enrolled in the Dix Scholars program. The Dix Scholars program is a 2-year or 3-year option for individuals with or without a previous baccalaureate degree who re-enter the academic setting to obtain a BSN degree.
The preintervention interviews were an attempt to identify the participant perceptions of clinical judgment, reflective practice, and clinical confidence. The responses were limited, and the participants struggled with descriptions of clinical judgment and clinical confidence and had minimal exposure to reflective practice. As compared with the preintervention data, the postintervention data were rich with perceptions of clinical judgment and clinical confidence related to reflective practice.
The major finding of this research is that the participants reported a perceived improvement related to the development of clinical judgment and clinical confidence. The themes that emerged related to clinical judgment development were (a) application of acquired knowledge, (b) perceived increased patient care experiences, and (c) situated teaching and prioritizing. The themes that emerged related to clinical confidence development were (a) reassurance, (b) improved communication with the health care team, and (c) realization of the depth of the science of nursing.
Clinical Judgment Themes
Application of Acquired Knowledge. The participants in the interview component of the study discussed the importance of a merger of classroom knowledge with clinical experience in the definition and development of clinical judgment. One student stated that the development of clinical judgment is “the common sense factor of being able to take your knowledge and apply it to the patient situation.” A majority of the respondents commented that clinical judgment involves the application of knowledge to the clinical situation. Another student stated:
Clinical judgment is using the skills that you learned in class and lecture and applying them to clinical situations and being able to have the prowess to make decisions and be able to handle a patient situation.
Another student was specific in regard to the benefits of the reflective sessions and their ability to bridge the theory–practice gap; she stated:
In class, we would discuss the pathophysiology, subjective and objective data, interventions and outcomes. It was a way to link the information in our textbook to actual patients and apply our knowledge.… It was like combining everything from our books and lectures with our actual clinical experiences. The presentations provided a bridge to allow us to improve the clinical judgment as opposed to going straight from books to clinical.
Perceived Increased Patient Care Experiences. The respondents reported that reflecting on specific patient encounters in the classroom setting provided them with an opportunity for increased overall patient experiences. The students reported that by hearing presentations from their peers of actual patient experiences, they were able to gain insight and apply other students’ acquired knowledge to their own development of clinical judgment.
As a result of the structured reflective narrative sessions, one student stated:
Instead of just having one patient a week at my clinical, it was like having eight patients a week and you could hear the whole story behind each of these patients and what the nursing students did to help them.
Another student said:
Just hearing other students’ experiences in the class discussion and actively participating in another patient encounter was really helpful because then our brains are actively working.
Situated Teaching and Prioritizing. The students reported that the reflective sessions on actual patient experiences were critical in their development of clinical judgment as they provided a situated teaching strategy. Benner et al. (2010) described situated teaching as the coaching of students regarding specific clinical situations to evaluate the actions taken to improve clinical reasoning skills (p. 225). The students reported that being able to reflect on patient situations in the classroom provided the students with the opportunity to assess their actions, reflect on their experiences, and possibly improve future care.
One student stated:
The discussions gave different views, different ideas, and different ways of thinking so that we can pick the right one that works for the patient in the future.
Another student stated that she believed that the learning strategy was effective because it:
provided an environment where we all felt safe and were able to be active participants in the discussion of our patients, ask questions about what was happening with our patients and evaluate the patient outcomes for better or for worse.
Overall, the students reported that being able to identify the most important tasks and procedures based on a particular patient situation aided in the development of a sense of salience during the clinical encounter. A student reported that effective clinical judgment correlates to a nurse’s ability to be “able to prioritize all of your patient’s needs and treatments so that everything works together for the patient.” Many of the respondents believed that clinical judgment was closely linked to the successful completion of the necessary tasks related to patient care.
Clinical Confidence Themes
Reassurance. The students reported an overall sense of reassurance and camaraderie related to clinical confidence. Through the narrative accounts of patient encounters, many of the students reported that it was helpful to know that the majority of the group possessed the same worries, lack of comfort, and lack of confidence related to the discussed clinical situations.
The students reported a feeling of “being in the same boat” as it related to initial patient clinical encounters, a sense of being overwhelmed, and a lack of knowledge related to a variety of diagnoses; they also reported that the classroom reflective sessions provided a safe environment in which to discuss emotions and learn from each other. One student stated:
Everyone compares their [examination] grades and that becomes overwhelming sometimes, but the reflective practice is like all of us talking and putting our ideas together in a noncompetitive format.
The students reported that through the help of their peers, they were able to “start to piece the puzzle together and applying the theory and to know that other students were experiencing the same challenges.”
Improved Communication with the Health Care Team. A majority of the students who participated in the postintervention interviews reported an improved confidence in their ability to discuss and present patient situations to the health care team at the clinical sites. The students reported that through narrative reflection on real patient situations, they were more prepared for future clinical experiences, and they developed the ability to discuss patient care situations or concerns with the health care team.
Regarding the benefits of structured reflection and the ability to discuss patient situations, a student stated:
It gave me more confidence to talk to the nurses on the unit, to question certain medications and treatments and discuss different options for the patient.
Another student supported these findings when she added:
During the classroom patient presentations, we learned what was appropriate to ask and learned a variety of options that helped me suggest things to the doctors and nurses related to my patients’ plan of care. At clinical I could now talk about what would benefit my patient.
Realization of the Depth of the Science of Nursing. During this research, the participants were asked to rate their perceived confidence in clinical abilities, skills, and judgment on a scale of 1 to 10, with 1 equaling no confidence and 10 equaling very confident. The participants were encouraged to discuss their self-rating prior to the intervention and at the end of the research.
Prior to the intervention, the average rating for the students was a 6.5. The students reported a sense of confidence related to patient interactions, including the assessment of vital signs, interviews, and personal patient care. During the postintervention assessment of perceived confidence related to clinical abilities, skills, and judgment, the student reported an average rating of 6.0. Many students reported a realization of the amount of knowledge that they needed to learn and the vastness of patient situations, conditions, treatments, and outcomes. One student stated:
I have learned a lot, but I still feel that there is so very much for me to learn. So I am just trying to keep building by experience. The more patients that I have and the more situations that I am in, the more my clinical judgment will grow.
The purpose of this research was to explore perceptions of the development of clinical judgment and clinical confidence in BSN students who experienced structured reflective practice, based on Tanner’s (2006) Clinical Judgment Model in the classroom setting. This research was an effort to contribute to nursing knowledge that will narrow the theory–practice gap and attempts to provide a vehicle to unite the educational experiences the student receives at both academic and clinical settings. The students reported that their participation in the structured reflective sessions improved their perceptions of their ability to apply acquired theoretical knowledge to patient situations, to process important objective data, to identify issues specifically related to the individual patient, and to recognize patient outcomes. The participants agreed that the weekly presentations and the evaluation of actual patient care encounters had a positive outcome on their development of clinical judgment and clinical confidence.
An important finding in the analysis of the research question was that prioritizing was a necessary factor in the students’ perceptions of their development of clinical confidence. The participants identified prioritizing patient needs as the initial strategy in the development of clinical confidence. As novices, the students reported that the reflective sessions provided an opportunity to interpret the coordination of patient care and develop strategies to prioritize the necessary tasks. The participants stated that the reflection sessions of patient care experiences supported their need to identify priority tasks related to patient care; they also stated that the skill of prioritization was an important initial component in the development of clinical judgment and confidence.
Several limitations of this research study were noted. These included a small sample size, time constraints, and the students’ ability to present patient encounters in the classroom setting. The reflective practice sessions occurred during the final 30 minutes of the weekly class. The students reported that more time was needed to discuss and review their patient presentations, and some students did not have an opportunity to present patient encounters. The final limitation was the students’ ability to present their patient care experiences in a group setting. Several students reported a lack of self-confidence presenting patient situations to their peers. The students reported feeling uncomfortable when they lacked knowledge during their presentations or when they admitted mistakes or reported poor patient outcomes to the group. Therefore, several students reported an overall reluctance to participate in the presentations.
The results of this study may have important implications for nursing education, nursing practice, and future research. The educational implications from this study include:
- The incorporation of structured reflective sessions throughout the nursing curriculum.
- The development of a curriculum focusing on situated teaching that includes narrative, structured, reflective practice.
- Consideration of the benefit of actual patient presentations, compared with case study exercises.
- Instructional benefits for nursing faculty.
- Organizational and national support for faculty development regarding reflective practice.
Through the inclusion of reflective sessions into the curriculum, students have an opportunity to recognize, prioritize, and delineate important clinical situations and gain a sense of salience to potentially apply this learning experience to future patient care encounters. Through reflective sessions, the sharp separation of classroom and clinical teaching may be eliminated, and the students may develop improved clinical reasoning and the ability to integrate classroom and clinical knowledge. Therefore, nurse educators should consider the incorporation of structured reflective sessions throughout the nursing curriculum.
Several unexpected instructional benefits of the reflective sessions occurred that may have important implications for nursing education. These benefits included (a) providing the opportunity to review the types of patients assigned to the students at the clinical settings, (b) providing an evaluation of the students’ knowledge of patient conditions, (c) identifying current treatment options employed at the clinical facilities, and (d) providing the opportunity to assess the effectiveness of the education and application of nursing theory.
For an educational approach that incorporates reflective practice to be successful, nurse educators must be open to the benefits of reflection. Nurse educators need to be educated in reflective practice to become effective coaches for the students. Educational institutions should consider the development of a faculty and a pedagogy that uses reflection and reflective techniques.
The purpose of this study was to explore the perceptions of the development of clinical judgment in BSN students who experienced structured, reflective practice in the classroom. Although the generalizability of the findings from this study is limited, the qualitative results provide support for the incorporation and continued evaluation of reflection-on-action in a structured classroom format, as defined by the Clinical Judgment Model (Tanner, 2006). Future research focusing on the benefits of reflection on perceived clinical judgment and clinical conference is warranted. Through new pedagogies that incorporate structured reflection of patient care situations in the classroom, nurse educators may narrow the theory–practice gap and improve the educational outcomes and preparedness of nursing students.
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Structured Reflective Practice Guide
|At Clinical Site||Structured Reflective Classroom Sessions|
| Obtain the formal knowledge needed to care for the patient assignment (classroom lectures, readings, textbooks).|| Student will present their patients (in accordance with HIPAA) to the group and will include the following information:|
| Identify the relationship with the patient and family.|| History of present illness|
| Identify any emotional or ethical issues related to the care of the patient.|| Chief complaint|
| Past medical history|
| Family history and social history|
| Diagnostic studies|
| Vital signs|
| Physical examination findings|
|Noticing||Reflection-on-action and clinical learning|
| What additional information was required to care for the patient and how was it obtained?|| Review and present the pathophysiology related to the patient situation.|
| Identify your first impression of the patient and family.|| Discuss the specific intervention in the patient care and the impact on the outcomes.|
| Identify any patient situations previously encountered and include similarities and differences in regard to the current situation.|
| Discuss and review diagnostic studies, laboratory results, medication intervention.|
| Discuss evidence-based nursing care and the patient outcomes.|
| Describe what interventions you would perform differently if faced with a similar situation in the future.|
| Describe emotional and ethical issues that occurred during the care of the patient.|
| What is your initial interpretation of the data, and what priorities of care were identified?|
| List the nursing interventions that were performed.|
| Identify your goals for the patient and family members.|
| Identify collaborative efforts and any conflicts.|
| Identify what happened during the clinical experience.|
| Identify the patient and family response to the situation, and document your immediate interventions|