Health care providers are increasingly caring for clients who are acutely ill and more complex. Therefore, it is imperative for RNs to be able to perform thorough and comprehensive client assessments in a timely manner. Accurate assessments optimize early detection of symptoms that can result in improved client outcomes (Jarvis, 2014). Nursing students lack confidence performing physical assessment skills during their initial clinical placements (Cowen, Hubbard, & Hancock, 2016; Douglas, Windsor, & Lewis, 2015). Health assessment courses in nursing programs are foundational in enabling students to learn how to perform accurate physical assessments in clinical practice.
The Think Aloud (TA) learning strategy was introduced in a health assessment course to develop nursing students' capacity and confidence to perform physical assessment techniques. When using TA, students verbalize everything they are thinking, seeing, and doing while performing a skill (Burbach, Barnason, & Thompson, 2015; Koro-Ljungberg, Douglas, Therriault, Malcolm, & McNeill, 2013). There is little literature describing TA in nursing education; however, this learning strategy has been widely used in psychology (Koro-Ljungberg et al., 2013). Studies have explored the use of TA with nurses and nursing students to assess cognitive processes, problem solving, decision making, and clinical reasoning (Burbach et al., 2015; Forsberg, Ziegert, Hult, & Fors, 2014; Lee, Lee, Bae, & Seo, 2016). Burbach et al. (2015) suggested that using TA in nursing education can potentially assist faculty to identify gaps in knowledge, clarify concepts, reinforce techniques, and facilitate students' learning and self-efficacy when performing physical assessment skills.
Zurmehly, Lynd, and Leadingham (2004) studied the effects of TA and critical dialogue on nursing students' assessment skills. Thirty-one students completed a pre–postknowledge test; knowledge gains were reported and increased student confidence was identified in both the teachers' and students' reflections (Zurmehly et al., 2004). Lee et al. (2016) examined the use of TA on RNs' assessment skills in complex clinical situations and found that assessing clients' health problems was the basis for their clinical reasoning.
The aim of this study was to build on those earlier studies and examine nursing students' experiences using TA in a health assessment course and to measure the affect of TA on students' ability and self-efficacy when performing physical assessment skills.
Study Design and Sample
The institutional research ethics board approved this study and participants gave informed consent. A quasi-experimental, mixed-methods study using surveys, participants' evaluation grades, and a focus group was conducted to examine their experiences using TA over a 12-week period. Participants were a convenience sample of baccalaureate nursing students enrolled in a first-year health assessment course.
Students were assigned by class sections into a control or an intervention group. Students in the control group were taught physical assessment skills using the traditional method where faculty demonstrated a physical assessment technique and then practiced their skills with their peers. Faculty working with students in the intervention group demonstrated physical assessment skills using TA in which they verbalized observations, health findings, and assessment interventions. Students practiced the physical assessment skills in a laboratory using the TA method. They voiced their thoughts out loud as they performed their physical assessments. If the professor or peers noticed a student had stopped talking for longer than 5 seconds during an assessment, they were instructed to continue verbalizing their thoughts.
Pretest data were collected using a demographic survey and a Student Self-Efficacy Scale (SSES) survey that was administered at the start of the course. Self-efficacy is the belief that one has the knowledge, skills, and capability to undertake and complete those actions required to manage a given situation (Bandura, 1977). The SSES assesses users' perceptions of being successful, ability to maintain a positive attitude, confidence in their capabilities, and motivation. The survey was developed and validated by Rowbotham and Schmitz (2013) and has a strong correlation to the well-established General Self-Efficacy Scale (r = .70). Permission was obtained to use the instrument, which was minimally modified for this study. Participants responded to Likert-type items using a 4-point rating scale where 1 = not at all true, 2 = barely true, 3 = moderately true, and 4 = exactly true. Participants completed the SSES a second time at the end of the 12-week health assessment course. The Cronbach's alpha for the SSES was .77 in this study, providing further evidence for the reliability of the scale.
Students' evaluation grades were collected from two sources: a 1-minute practical test and practical focused examination. The 1-minute practical test evaluates students' performance on one of 20 different physical assessments, such as the cranial nerves. The practical focused examination is a 20-minute health assessment evaluation on one of four systems: cardiac, abdominal, respiratory, or musculoskeletal system.
A 1-hour focus group involving students from the intervention group was also conducted to examine participants' experiences using TA, the effect of TA on their physical assessment skills, challenges using TA, and recommendations for future use of TA in the nursing curriculum. Burns and Grove (2005) recommended six to 10 participants within a focus group session.
Quantitative data were analyzed using SPSS® version 22.0. Descriptive statistics were calculated for the demographic and SSES items. Differences in the demographic variables between the two groups was tested with the chi-square test. The dependent t test was conducted to measure pre–post-SSES changes within each group and the independent t test was used to compare mean SSES scores between groups.
The focus group interview was audiotaped and transcribed. Three faculty members reviewed and coded the data, then categorized the codes to identify major themes (Braun & Clarke, 2006).
Thirty-six (46%) of a possible 78 eligible students participated in the study; 20 in the control group and 16 in the intervention group. The mean age was 19.2 (SD = 2) years, ranging from 17 to 24 years, with six males and 30 females. It was the first postsecondary education experience for most (72%) participants. There was no statistically significant difference between the control and intervention groups regarding age, sex, language, previous health assessment course, or postsecondary experience.
The total mean score on the pre-SSES for the control group was 22.3 (SD = 2.1) and 23 (SD = 3.2) for the intervention group; the difference between groups was not statistically significant. The total score on the post-SSES for the control group was 22.8 (SD = 2.8) and 24.8 (SD = 1.7) for the intervention group; the difference between groups was statistically significant, with the intervention group having the higher self-efficacy mean score, t(34) = 2.3, p = .02. There were no significant score gains in pre–post-SSES scores with the control group. The intervention group did make significant pre–post-SSES score gains, t(15) = 2.3, p = .031.
The 1-minute practical skill test mean score was 3.7 of 5 (SD = .98) for the control group and 4 of 5 (SD = .63) for the intervention group; the difference between groups was not significant. The practical focused examination mean score was 23 of 35 (SD = 2.9) or 65.7 of 100 for the control group and 27 of 35 (SD = 4.7) or 77.1 of 100 for the intervention group. The intervention group had a significantly higher score, t(31) = 2.9, p = .006.
Eight students from the intervention group (n = 16) participated in the focus group. The analysis yielded the following themes: benefits of TA, student challenges, and transferring of physical assessment skills to clinical practice.
Participants described several benefits of using TA. One participant explained, “It prepares you for lecture, because you know if you don't prepare…you are not going to do well in laboratory, because you know you will not have anything to say.” Participants reported TA helped prepare and organize their thoughts as they worked though their physical assessments. Participants processed their observations by verbalizing each step. They were able to recall their assessments and identify knowledge gaps. A participant voiced that TA “helps you look at what you are forgetting or what your weaknesses and strengths are.” When knowledge gaps were identified with TA, a participant said it was “good because you can just ask for help because you have to since they [professors] are standing right there.” There were challenges using TA. Participants felt uneasy verbalizing their assessments or became silent when faculty observed them. One participant stated feeling “really awkward at first but with practice it was easy to transition into.”
Participants commented that using TA helped them with transferring physical assessment skills to clinical practice. Experience gained through TA helped participants to support their peers and collaborate with health care staff during clinical. One participant shared, “We supported each other…coached each other” during the clinical experience using the TA approach. Participants felt that the TA process strengthened their communication skills and helped them build therapeutic relationships with clients. A participant commented, “Patients were more relieved that I was able to say what I'm doing and [describing] every single step rather than just doing the tasks without them knowing.” Positive feedback from clients increased students' confidence in their physical assessment skills and ability to connect with their clients.
The results of this study suggest that TA has a role in nursing education to develop student self-efficacy and increased physical assessment knowledge. Students used the TA approach in the clinical setting and found it helped them to make that transition to practice by improving their communication skills. A study had similar findings to support increased students' self-confidence when using TA (Zurmehly et al., 2004). Another study identified an increase in self-efficacy can facilitate students' to successfully transition into the nursing profession (George, Locasto, Pyo, & Cline, 2017). Although it can be awkward initially for students, incorporating this approach into health assessment courses is relatively simple, easy to use, and adaptable to other practice courses. TA has the potential to support student competency in their physical assessment skills and increase perceptions of self-efficacy.
This study consisted of a small convenience sample size from one nursing school, which markedly limits generalizability. Surveys were completed outside of class time, resulting in lower participant numbers. Results suggest that there is value to the TA method. A larger sample size and multisite using random sampling to measure the effect of TA on learning outcomes is recommended.
The TA approach encourages students to focus on the critical steps in physical assessment skills aiding memory, knowledge gains, and preparation for practical testing and transition to clinical practice. Implementing TA has the potential to improve student's self-efficacy and physical assessment skills. TA is a feasible teaching strategy for health assessment courses and potentially other practice courses to improve learning outcomes.
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