Journal of Nursing Education

Major Article 

Teaching Clinical Reasoning Piece by Piece: A Clinical Reasoning Concept-Based Learning Method

Lisa Gonzalez, MSN, RN, CNE, CCRN-K

Abstract

Background:

Recent discourse generates a more thorough understanding of what clinical reasoning entails. Although numerous strategies prioritize clinical reasoning development, teaching and evaluating the thinking involved in clinical reasoning remains a struggle for nurse educators, particularly regarding clinical education.

Method:

In response, the author developed a concept-based clinical reasoning teaching method with weekly themes, lessons, and learning activities adapted from Tanner's clinical judgment model and Lasater's Clinical Judgment Rubric.

Results:

The method offers an organized, consistent approach to teaching and learning clinical reasoning, with multiple opportunities for student reflection, instructor guidance, and discussing clinical reasoning concepts. Clinical education became transformed for both the nurse educator and nursing students as clinical reasoning became a visible part of students' budding nursing practice.

Conclusion:

Nurse faculty must ensure future nurses are prepared to think-inaction. The clinical reasoning teaching method offers one potential solution. [J Nurs Educ. 2018;57(12):727–735.]

Abstract

Background:

Recent discourse generates a more thorough understanding of what clinical reasoning entails. Although numerous strategies prioritize clinical reasoning development, teaching and evaluating the thinking involved in clinical reasoning remains a struggle for nurse educators, particularly regarding clinical education.

Method:

In response, the author developed a concept-based clinical reasoning teaching method with weekly themes, lessons, and learning activities adapted from Tanner's clinical judgment model and Lasater's Clinical Judgment Rubric.

Results:

The method offers an organized, consistent approach to teaching and learning clinical reasoning, with multiple opportunities for student reflection, instructor guidance, and discussing clinical reasoning concepts. Clinical education became transformed for both the nurse educator and nursing students as clinical reasoning became a visible part of students' budding nursing practice.

Conclusion:

Nurse faculty must ensure future nurses are prepared to think-inaction. The clinical reasoning teaching method offers one potential solution. [J Nurs Educ. 2018;57(12):727–735.]

Development of students' clinical reasoning skills remains a priority for nurse educators. Since the 1970s, nursing scholars have highlighted the need to develop not only nurses' hands-on skills but also their thinking processes (Benner, Sutphen, Leonard, & Day, 2010; Heims & Boyd, 1990; Levett-Jones, Sundin, et al., 2010; Tanner, 2006). Despite robust discourse regarding strategies that develop nursing students' clinical reasoning skills, there is growing concern about the preparation-practice gap among new nurse graduates, specifically in regard to their clinical reasoning skills (Del Bueno, 2005; Kavanagh & Szweda, 2017; Lasater, Nielsen, Stock, & Ostrogorsky, 2015; Maryland Nurse Residency Program Collaborate, 2018; Slaikeu, 2011). New nurse graduates are drastically underprepared to translate their knowledge into clinical decisions when working within fast-paced, complex practice settings (Benner, 2015; Kavanagh & Szweda, 2017; Lasater, 2017). In one study, researchers reported that only 28% of their new nurse graduate population met a safe or acceptable score for ability to recognize urgent changes in patient condition and ability to identify appropriate responses to manage these situations (Kavanagh & Szweda, 2017). Clinical reasoning matters, especially during times of acute deterioration.

Clinical reasoning is a skill that requires time, practice, and cognizance to develop (Lasater et al., 2015; Monagle, Lasater, Stoyles, & Dieckmann, 2018; Nielsen, Lasater, & Stock, 2016). Aspiring nurses need guidance and learning opportunities from educators willing to introduce, clarify, and help them to incorporate the skills they need to think like a nurse. Calls for transformation in nursing education continue as faculty are urged to revamp the curriculum and innovate teaching strategies that place more emphasis on clinical reasoning (Benner et al., 2010; Hunter & Arthur, 2016; Koharchik, Caputi, Robb, & Culleiton, 2015; Lasater, 2011; Tanner, 2006).

Nurse educators face specific barriers and challenges when considering prioritizing clinical reasoning skills. Too often, nurse educators teach how they were taught using content-saturated curriculum largely based on knowledge acquisition (Ironside, McNelis, & Ebright, 2014; Kavanagh & Szweda, 2017). Furthermore, a reliance on nursing process as a measure of nurse-thinking distracts both student and instructor away from time spent on more complex clinical reasoning concepts. Although nursing scholars have uncovered aspects of clinical reasoning and the skills required to make sound clinical judgments, transferring these skills to students can be challenging. Therefore, further discussion and refinement of strategies that promote students' clinical reasoning development, particularly ones that help students incorporate these skills within their budding nursing practice, is needed. (Benner, 2015; Cappelletti, Engel, & Prentice, 2014; Ironside et al., 2014; Tanner, 2010; Thompson, Airken, Doran, & Dowding, 2013).

A Day without Clinical Reasoning

Of particular concern is the area of clinical education. Although educators are more apt to include clinical reasoning content within theory courses, they do not consistently identify, facilitate, and evaluate their students' reasoning skills during clinical rotations (Burbach, Barnason, & Thompson, 2015; Hunter & Arthur, 2016; Ironside et al., 2014). Although educators verbalize the importance of teaching thinking, clinical education remains largely task-focused by missing key elements necessary for clinical reasoning development (Hunter & Arthur, 2016; Ironside et al., 2014; Kavanagh & Szweda, 2017; McNelis et al., 2014). Nurse educators must reconsider traditional clinical experiences to adequately prepare future nurses for practice.

The importance of clinical reasoning skills to nursing practice is well established. Nurses rely on clinical reasoning skills to manage patient care; they process significant amounts of information within a short time frame and make many decisions that directly impact patient care and outcomes (National Council of State Boards of Nursing, 2018; Thompson et al., 2013). Health care settings are practical areas where nursing students can develop clinical reasoning. Working with patients in real-life settings presents students with pragmatic opportunities to develop their abilities to think like a nurse. Exposure to clinical environments allows students opportunities to become part of the health care team, to appreciate the health care culture, and to witness nurses acting as first-line responders (Tanner, 2010). A clinical day without a focus on clinical reasoning results in missed opportunities.

Shifting From Nursing Process to Teaching Clinical Reasoning Concepts

During the past several decades, nurse education focused on developing skill with the nursing process, a linear approach to organize and plan patient care (Huckabay, 2009; Tanner, 2006). However, teaching the nursing process is not the same as teaching critical thinking or clinical reasoning and should not be viewed as equivalent (Huckabay, 2009; Tanner, 2006). The nursing process assists students through a sequence of steps in patient care (e.g., one must first assess before providing an intervention), but it does not adequately reveal the complexity of how nurses make decisions or think through patient care. One can superficially apply the nursing process by picking an intervention from the nursing care plan book, or one—typically a more experienced nurse—can more intentionally apply the nursing process by consciously thinking through which intervention may most effectively meet the patient's needs (Hawkins, Elder, & Paul, 2010).

Although the nursing process requires nurses to use critical thinking skills in planning care, it fails to account for the complex thought processes involved in clinical reasoning and decision making, such as analysis, intuition, and narrative thinking (Tanner, 2006). When nurses make clinical judgments, they rely on various forms of reasoning and unseen cognitive processes (Tanner, 2006). Additionally, clinical reasoning accounts for the nurse's background (personal) and professional experience, biases, relationship with the patient, and the context in which the care is occurring. Students need to understand the factors that go into thinking and decision making in real time.

To help students better understand decision making, a nurse educator could unpack the situation using a model of clinical thinking and decision making and assist students through the reasoning, occurring when they identify and consider alternate viewpoints when creating patient care goals (Banning, 2008). In this way, the nurse educator transforms formerly unseen cognitive processes into more visible thinking patterns that students can better grasp. Helping students become aware of their thought process and how they perceive enables them to be aware of their thinking. Important conversations such as this could focus on concepts regarding clinical reasoning and thinking beyond the nursing process model of care.

Literature Review

Clinical Reasoning

The literature provides numerous terms and descriptions for clinical reasoning and judgment—clinical judgment, critical thinking, problem solving, and thinking like a nurse, to name a few, as well as a clear distinction between them (Tanner, 2006; Thompson et al., 2013). Clinical reasoning relates to thinking processes, whereas clinical judgment describes the decisions made based on the clinical reasoning that can occur within a situation, such as during an acute decline in patient health status (Tanner, 2006). It can also materialize as nurses organize ideas and explore options to reach a conclusion about patient care (Banning, 2008), unfold throughout a shift, or adjust as a patient's story unfolds (Benner et al., 2010).

Tanner (2006) made great strides in uncovering and describing clinical reasoning and clinical judgment with her development of the clinical judgment model (CJM). Tanner (2006) defined clinical reasoning as “the process by which nurses make judgments” about patient care and clinical judgment as “an interpretation or conclusion about a patient's needs, concerns, or health problems, and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by patient's response” (p. 204). According to Tanner (2006), clinical reasoning involved four main aspects or phases: noticing, interpreting, responding, and reflecting— all of which occur during patient care in an iterative, nonlinear pattern. For example, a nurse treating a patient with acute respiratory compromise may consider oxygen as a priority intervention. In this situation, the nurse may need to make a decision about the amount and delivery method of oxygen. An experienced nurse will consider many factors: whether the patient has a preexisting disease process (chronic obstructive pulmonary disease), admitting diagnosis (pneumonia), assessment findings (early signs versus late signs of hypoxia), current treatments (whether the patient is already receiving oxygen), experience (how the nurse has handled similar situations and what the outcomes were), and available resources. What makes the CJM unique is that it accounts for the unique aspects of the situation (background, context, relationship with the patient) that help inform nurse reasoning and decision making (A. Nielsen, personal communication, June 11, 2018).

Lasater (2007) expanded upon the CJM with the addition of a rubric that describes dimensions of the four elements— noticing, interpreting, responding and reflecting—in her pivotal clinical judgment evaluation tool: the Lasater Clinical Judgment Rubric (LCJR; Table 1). LCJR dimensions such as focused observation, recognizing deviations from expected patterns, and information seeking further describe what nurses do when operating within the noticing phase of the CJM. Both model and tool help generate a more thorough understanding of what it means to think like a nurse and offer a common language for instructor and students when discussing clinical reasoning (Lasater, 2011).

Aspects and Dimensions from the CJM and LCJR

Table 1:

Aspects and Dimensions from the CJM and LCJR

Teaching Clinical Reasoning

The CJM and LCJR spearheaded a stronger focus on developing clinical reasoning skills through the use of reflective journaling (Bussard, 2015; Lasater & Nielsen, 2007), concept-based learning activities (Lasater & Nielsen, 2009; Nielsen, 2009, 2016), simulation (Dillard et al., 2009), and concept-mapping (Gerdeman, Lux, & Jacko, 2013). The LCJR is also used as a tool in many studies to evaluate nursing students' clinical reasoning skills during simulation (Adamson, Gubrud, Sideras, & Lasater, 2012; Ashcraft et al., 2013; Lasater, 2007).

Tanner's CJM and the LCJR offer an ideal framework for teaching clinical reasoning, as both provide insight regarding how nurses think when making clinical judgments and how that thinking develops. The LCJR includes 11 dimensions that are leveled from beginning to exemplary with accompanying descriptions on what constitutes performing at each level. Components of the LCJR such as focused assessment skills, recognizing deviations from expected patterns, and clear, concise communication offer separate and distinct skills that students must learn to practice sound clinical reasoning (Lasater, 2011). Although the LCJR offers clarity on describing clinical reasoning skills, nursing students may still be unclear on how to put these behaviors into action. For example, they may wonder how to clearly communicate with a family member or a physician. Communicating with a physician requires focusing on pertinent data versus nonrelevant data and may involve using medical terminology as opposed to communicating with family who may involve using laymen's terms and a therapeutic element. Tanner's model and the LCJR offer terminology to start these conversations, but a nurse educator would need to add additional structure and details (e.g., real-life examples) to help students develop their understanding.

The LCJR can be used as a tool when considering teaching and evaluating clinical reasoning skills. A recent study demonstrates the use of the LCJR and Tanner's CJM to provide a framework for preceptors and new nurse graduates to develop their clinical judgment (Nielsen et al., 2016). Preceptors applied the framework when training new graduates and evaluating clinical reasoning. Kavanagh and Szweda (2017) immersed new nurses into a 1-week training program that teaches them how to apply clinical reasoning concepts, such as recognizing changes in a patient's condition. Both studies demonstrate success with teaching clinical reasoning to new nurse graduates during their orientation program.

However, only a few publications explain strategies that formally teach clinical reasoning or demonstrate a direct approach to teaching thinking skills when students are in the clinical environment (Hunter & Arthur, 2016). One team of educators, Delany and Golding (2014), developed an effective method for teaching clinical reasoning by shedding light on instructors' thinking by sharing their thoughts out loud when analyzing clinical situations at the bedside. They further explained the types of knowledge and cognitive processes they used. This study documents a method that intentionally revealed the expert's thought processes to the students, but the method targeted allied health sciences, not nurse educators. Another study revealed the actions of expert nurses via a role-modeling approach. Students discovered clinical reasoning by observing their instructors' work through a simulation and then immediately applying what they learned by completing the same simulation (Lasater, Johnson, Ravert, & Rink; 2014).

These studies, along with recent literature, suggest that clinical reasoning and judgment are indeed skills that can and should be taught with intention. (Cappelletti et al., 2014; Kavanagh & Szweda, 2017; Monagle et al., 2018). Recent calls for transformation suggest exploring approaches such as teaching clinical reasoning within the context of practice settings (McNelis et al., 2014), using a structured framework or routines to assist thinking (Delany & Golding, 2014; Lasater & Nielsen, 2009; Nielsen et al., 2016), and/or providing guided learning opportunities (Kavanagh & Szweda, 2017) that focus on clinical reasoning. The project offers a potential solution to fill the identified gaps in clinical education and begin these crucial clinical reasoning conversations well before graduation.

The Project

The College of Southern Maryland's (CSM) nursing curriculum committee, with permission, adapted the LCJR to create a Clinical Evaluation Tool (CET) that evaluates students' clinical performance. CSM nursing faculty continue to utilize the CET to evaluate students' progress in clinical courses. Given that the LCJR is intended to evaluate clinical reasoning, components of CSM's CET also evaluate clinical reasoning; however, an essential piece, instruction in clinical reasoning, was missing. Subsequently, the developed clinical reasoning teaching method is intended to teach thinking prior to evaluation.

This project began as a brainstorm several years ago following a presentation by Caputi (2014) in which participants were encouraged to examine current teaching practices and to develop new strategies that place more emphasis on the teaching of thinking. The presenter suggested that educators should not just tell students to critically think but show them how. After all, educators teach their students the steps to successfully start an intravenous therapy. Could we also examine the intricate details of how nurses cognitively work through situations to make sound clinical judgments? Two main goals emerged during this initial brainstorm: (a) to teach clinical reasoning directly by breaking it down into simpler pieces, and (b) to help students to practice and develop confidence with their clinical judgments by working with patients in the clinical setting.

Concept-Based Approach

The developed concept-based clinical reasoning method utilizes the LCJR as a framework by adapting dimensions from the LCJR into individual concepts and daily themes (Table 2), and pilots the approach in the Medical-Surgical II clinical course. Every clinical day explores a daily theme. To unpack individual concepts, the author developed daily clinical lessons with assisted learning opportunities and activities. The lessons offer time in clinical to discuss practical ways that nurses implement clinical reasoning in health care settings and highlight the cognitive processes nurses use, and the learning activities give students real-life opportunities to practice and develop their thinking.

Clinical Reasoning Daily Themes by Week

Table 2:

Clinical Reasoning Daily Themes by Week

This method utilizes a concept-based approach. Concept-based learning offers students opportunities to dive into one topic at a time, which provides time for them to gain further insight and depth with specific concepts. Concept-based learning emphasizes critical thinking through patient care and less focus on completing tasks (Heims & Boyd, 1990; Nielsen, Noone, Voss, & Matthews, 2013). Studies demonstrate that concept-based learning activities help students focus on and make progress with regard to specific course objectives, as well as develop their clinical reasoning skills more so than traditional clinical experiences without a specific focus that leaves learning to chance (Lasater & Nielsen, 2009; Nielsen, 2009), so intentionally foregrounding concepts based in clinical reasoning may enhance students learning components of clinical reasoning.

Although many schools using a concept-based curriculum select traditional concept-based themes such as pain and comfort, fluid and electrolytes, and nutrition tissue integrity, educators can use creativity when selecting concepts, so long as concepts align with course objectives (Giddens, Wright, & Gray, 2012; Nielsen, 2017). Concept-based learning activities have also been developed to focus on other nonphysiologic concepts, such as transitional care settings (Mood, Nuenzert, & Tadesse, 2014) and aspects of an emergency department environment (e.g., triage) (Schumaker & Bergeron, 2016). In this article, Tanner's CJM (2006) and dimensions from the LCJR are adapted into clinical reasoning concepts (Gonzalez, 2015, 2016; Table 2)

A concept-based approach marries well with teaching clinical reasoning. Concept-based teaching helps simplify complicated material by showing how common threads piece together—like a jigsaw, as more pieces are added the clearer the whole photograph becomes. Clinical reasoning includes an array of skills and thinking patterns students do not overtly understand or use. Intentionally breaking down dimensions of clinical reasoning into individual concepts allows time for instructors to explain each component of clinical reasoning and to shape students' thinking in clinical. Students become aware of how nurses think while practicing these nursing skills.

Using the Clinical Reasoning Concept-Based Learning Method

In this project, clinical reasoning is taught by intentionally breaking down concepts of reasoning into manageable pieces. The semester begins with basic concepts, such as organization and focused assessment, and progresses to more advanced clinical reasoning themes, such as prioritization. During the first and second weeks of clinical, students are introduced to the culture of nursing in the unit and to an important organizational tool, the report sheet. Flow of a nursing shift and documentation are not explicit components of the CJM; however, they are essential skills nurses use every shift. To analyze data, one must maintain an organized process to access and gather data. For example, a nurse may need to evaluate specific data when caring for a patient with congestive heart failure. An experienced nurse would quickly identify priorities of care for a patient with congestive heart failure, know where to find and gather pertinent information, organize these data (either mentally or physically on their report sheet), evaluate the information to arrive at a set of conclusions (current status of the client), and then decide how to make effective use of their time (prioritize). In real-time these steps occur quickly, are complex, and require thought processes novice nurses and nursing students do not immediately possess. Thus, this article's author chose to teach these skills one at a time starting with how to gather and organize pertinent data, as well as how to determine what data were needed.

As the semester progresses, topics become more in depth. For example, during the week covering focused assessment, instructor and students discuss how to fine tune noticing skills, such as becoming acutely aware of any abnormal assessment findings, the care environment when walking into a patient's room, or even what should they notice based on the patient disease process. Students who are not aware of the difference between a head-to-toe assessment and a focused assessment may want to look at everything before arriving at a conclusion; however, doing so is not realistic for modern-day nurses, who must learn how to quickly gather and analyze data to respond to acute situations (Koharchik et al., 2015).

Daily Themes and Lessons. Daily themes are outlined in a posted handout that students access prior to attending clinical. Each day's theme has an associated lesson that covers a component of clinical reasoning. Lessons introduce the concept and process behind the clinical reasoning theme, both explaining how nurses implement reasoning in practice and demonstrating through practical examples. The conversation begins in preconference, continues at the midshift conference called the seventh inning stretch, and once again revisited during postconference (Table 3).

Examples of Clinical Reasoning Concepts Threaded With Daily Theme, Warm-up Activity, Lesson, and Learning Activity

Table 3:

Examples of Clinical Reasoning Concepts Threaded With Daily Theme, Warm-up Activity, Lesson, and Learning Activity

Step by step, day to day, students explore each component of clinical reasoning as they enact the roles nurses play within the health care setting. Clinical reasoning, a previously unfamiliar concept, becomes a familiar part of students' daily routine and thinking patterns as they incorporate each dimension into their nursing care routine. Thinking becomes instinctive to experienced nurses (Tanner, 2006). Teaching one component at a time helps to slow down the process so students could become familiar with each reasoning component, evaluate their thinking, and progress when being presented with invaluable opportunities to practice. Slowing down the process also helped this article's author to analyze her own thinking, to consider the most important aspects of thinking like a nurse, and then to prioritize teaching the identified components.

Preconference and Warm-Up. Each clinical day begins with a warm-up activity pertinent to that day's theme and lesson. The activity challenges the students' understanding of the current topic and encourages them to become of aware of their thinking throughout the shift. For example, the third week's warm-up activity emphasizes observation (Tanner's noticing phase) and focused assessment (dimension from the LCJR). During preconference, students are encouraged to identify what they notice when they walk into the patient's room and are asked to identify a priority focused assessment. The warm-up activity unfolds as students work with their patients. Early in the shift, after students have completed assessments, the instructor checks in with individual students to probe and help assist their reasoning. The instructor not only inquires about what they noticed and about their focused assessment, but also questions their reasoning that determines their focused assessment—to explain their thought process in arriving at their decisions. The instructor may also offer insight and role model noticing by accompanying the student into the patient's room and describing what they notice.

By highlighting components of clinical reasoning such as noticing, students become more aware of their thinking and ability to notice and, subsequently, have a better understanding of what and how to notice. Clinical reasoning relies on the development of metacognition, commonly referred to as thinking about thinking (Banning, 2008; Kuiper & Pesut, 2004). Becoming more aware of thinking facilitates the development of metacognition. Coaching students to become keen observers heightens their visual domain that can help them focus on what they need to see and not just what they expect to see (Bleakley, Farrow, Gould, & Marshall, 2003). Novices can be made aware of variations of normal and abnormal. These conversations help students identify if they are making sound clinical judgments. Additionally, they can more accurately identify his or her limitations and strengths for each component of clinical reasoning while practicing thinking in real time.

Midshift Conference.The teaching method also includes a conference in the middle of the shift, endearingly called the seventh inning stretch. Similar to pre- and postconference, the midshift conference offers opportunities to pause for reflection and debrief. Because the seventh inning stretch occur in the middle of their shift, students are able to reflect on the first part of the shift, receive guidance from the clinical instructor, and then implement new learning or make adjustments to their plan of care during the second part of the shift.

The seventh inning stretch also offers the instructor an opportunity to discuss the weekly lesson in more detail or to teach the clinical reasoning concept in a more formal lesson. For example, the seventh inning stretch for intervention week includes discussion on protocols. The instructor shows various protocols (e.g., alcohol withdrawal, stroke, myocardial infarction) that help assist patient care and include specific nursing interventions. The lesson for intervention week teaches students how to determine which interventions will have the greatest impact on the patient and how to prioritize interventions based on situations. For example, a situation where a patient may become unstable requires immediate intervention focusing on what will keep the patient alive. During these moments of urgency, interventions focus on stabilization, another point discussed during the midshift conference. This particular lesson builds on concepts discussed from previous weeks (e.g., week 3 and 4) when the significance of abnormal assessment findings and connecting focused assessment data was discussed. The scaffolding approach ensures that students are actively using newly learned skills from previous weeks. This helps solidify the knowledge pathways, gives them practice, helps them build their intuition, and develops their confidence. The midshift conference typically lasts 30 minutes, which, in addition, to a typical 15 minutes preconference and 1-hour postconference, increases the amount of time students spend reflecting during clinical. Reflection helps students develop their thinking skills (Khan, Ali, Vazir, Barolia, & Rehan, 2012; Tanner, 2006) and an appreciation for the complexity of nursing practice (Gould & Masters, 2004). Monagle et al. (2018) found that time for structured reflection helped new graduate nurses become more aware of clinical reasoning and judgment. Setting aside this time also trains them to evaluate their confidence and their ability to use learned skills in practice.

Learning Activities. Students arrive to clinical with a wealth of knowledge from previous experiences and theory classes, but they often do not know how to use the knowledge or put the pieces together when presented with clinical data (Kavanagh & Szweda, 2017; Levett-Jones, Hoffman, et al., 2010). Assisted learning opportunities for clinical reasoning provide needed practice (Benner et al., 2010; Kavanagh & Szweda, 2017). The activities also reduce potential downtime when the instructor is not available.

Each day, students practice the discussed clinical reasoning concepts via learning activities. Students print the activity prior to the clinical day; each activity includes written instructions or prompts. Some activities are individual tasks, whereas others promote collaborative learning. Completed activities are typically revisited during preconference so students can share what they learned or present the information. For example, one activity occurring during communication week assists students to develop recommendations based on their observations and understanding of the current situation. Students receive guidance during the midshift conference on how to use a Situation, Background, Assessment, Recommendation (SBAR) format, they practice writing recommendations during their downtime, and then they practice making recommendations to their peers using an SBAR format during postconference. Individuals pretending to be a primary provider (e.g., physician or nurse practitioner) listen and determine whether the presenting student made a case for his or her recommendations. Both presenting student and listening students are able to think through the situation and practice making clinical judgments. In this example, one can see how the theme for the day is revisited and integrated into the clinical day (see Table 3 for additional examples).

Another activity, one that facilitates making thinking visible, is rounding. During the final weeks of clinical, the instructor introduces the concept of traditional interdisciplinary rounding in hospitals, such as the presence of various disciplines like the physician, pharmacist, respiratory therapist, and/or physical therapists. Students begin rounding on their patients with instructor and fellow students as a means to practice narrative reasoning. Tanner (2006) described three types of thinking involved in clinical reasoning: (a) analytic processes, (b) intuition, and (c) narrative thinking or thinking through situations by telling a story. Narrative thinking is an important part of reflection. As the students share a narrative account, including a basic introduction to their patient (e.g., medical history, presenting diagnosis), priorities of care, and any recommendations ,their peers are able to critically evaluate and offer feedback.

The rounding activity tends to be the hallmark of the clinical semester as students become conscious of what they have learned during the past several weeks by making valuable connections. Simply arriving at the priorities of care requires them to use analytic skills by processing their patient's data, evaluating progress with treatment, examining the current status, and making recommendations. Rounding also gives students an opportunity to develop confidence with their clinical judgment given that they are able to practice verbalizing their thought processes by receiving instructor and fellow student affirmation and guidance. Burbach et al. (2015) described an effective metacognition strategy they used with their students during simulation. Students were asked to verbalize their thoughts as they reasoned through a simulation scenario. When students share their thoughts, they become aware of their own thinking, which helps them become more effective thinkers. Additionally, instructors can accurately identify and evaluate student thinking. The author often takes notes during these instructor–student interactions and requires reflective assignments for evaluation purposes. Students appreciate these assisted learning moments because they receive feedback regarding their progress with clinical reasoning skill development.

Discussion

Clinical instructors are often busy helping students with medication administration, skills, or decision making. A national survey by Ironside and McNelis (2010) revealed the difficulty instructors have balancing time with students during clinical and a need for innovative strategies that provide guidance and feedback while reducing downtime. Students need to be actively engaged in learning clinical reasoning throughout his or her clinical rotation, even when the instructor is not available. Clinical learning activities offered direction and guidance for the students which helped transform potential downtime into meaningful learning moments.

Novices initially think in black and white until later developing their clinical reasoning skills. They do not trust their instincts, and thus, need structure, guidance, and affirmation (Benner et al., 2010; Bleakley et al., 2003; Delany & Golding, 2014). The clinical reasoning concept-based teaching method and strategies offer an assisted, structured approach to teaching clinical reasoning within the clinical setting. Students know what to expect when coming to clinical with the themes and daily objectives posted before clinical begins.

Clinical faculty may be at a loss about how to assist students through thinking and how to explain aspects of clinical reasoning; however, the structured lessons and learning activities offers a starting point and can be adapted across the curriculum. Also, the developed learning activities provides clinical instructors with frequent opportunities for assessing their students' clinical reasoning skills.

Conclusion

Clinical education became transformed for this author and centered on teaching and learning clinical reasoning. Although the author noted improvement in her students' grasp of clinical reasoning and increased use of these skills as the clinical semester progressed, more research is needed to explore what about this method works and does not work in regard to developing students' clinical reasoning skills. Students are focused on skill acquisition; completing skills makes them feel like a nurse. However, teaching clinical reasoning concepts with frequent opportunities for students to incorporate these skills within their practice helped them begin to understand clinical reasoning and implement these skills in a practice setting.

Clinical reasoning is complex and includes knowledge in pathophysiology and diagnostics, skills such as prioritization, flexibility and analysis, and an awareness of patient baselines with subsequent changes. Teaching it requires a multifaceted approach. If nurse educators do not provide ample explanation and time for teaching these clinical reasoning concepts, then novice students seeking to become competent, confident practitioners may wonder what it means to think like a nurse. Without clear guidance in clinical reasoning, how will students know when they achieve sound clinical judgment?

Given that there are many facets to thinking like a nurse, skills such as clinical reasoning may also be imparted with transparency and intention across curriculum. As nurse educators continue to revise curriculum that prioritize clinical reasoning, they answer the call for radical transformation. In reviewing the literature, this project offers a method that could serve as the next logical step for clinical instruction and research. Educators are in a vital role to deepen students' insight into their clinical thinking, facilitate their clinical reasoning skill development, and prepare future nurses to think-in-action. Teaching and unpacking clinical reasoning concepts, perhaps, is an essential first step.

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Aspects and Dimensions from the CJM and LCJR

Aspect of CJM (Tanner, 2006)LCJR Dimension (Lasater, 2007)
Effective noticingFocused observation
Recognizing deviations from expected patterns
Information seeking
Effective interpretingPrioritizing data
Making sense of data
Effective respondingCalm or confident manner
Clear communication
Well-planned interventions; flexibility
Being skillful
Effective reflectingEvaluation and self-analysis
Commitment to improvement
Transfer of learning

Clinical Reasoning Daily Themes by Week

ThemeTopic
Week 1: Flow of the shiftHow to organize a shift and use a report sheet
Week 2: DocumentationEssentials of documentation (e.g., progress notes)
Week 3: The focused assessmentWhat to pay close attention to and further assess
Week 4: Data to diagnosisConnection between assessment and nursing diagnosis
Week 5: Priority diagnosisDeveloping their nursing instincts and judgment
Week 6: CommunicationPractice verbalizing their judgment and making recommendations
Week 7: InterventionsImplement clinical judgment to meet patient's needs
Week 8: PrioritizationDegrees of patient stability; what to do first
Week 9: Putting it all togetherUsing clinical reasoning in real time competently
Week 10: ReflectionWhat we have accomplished this semester and moving forward

Examples of Clinical Reasoning Concepts Threaded With Daily Theme, Warm-up Activity, Lesson, and Learning Activity

Daily ThemeWarm-UpLesson/Midshift ConferenceLearning Activity
Week 3: The focused assessment What to pay close attention to and further assess CJM phase: Noticing LCJR dimension: Focused observationPreconference question:

What is the difference between a head-to-toe assessment and focused assessment?

Warm-up activity:

Instructor introduces the concept of noticing and prompts students to pay attention to what they notice when walking in the patient's room.

Instructor guidance:

What did you notice when walking in the patient's room?

What did you notice about the patient?

Identify a focused assessment and discuss why/how you chose that?

Lesson:

Role of the focused assessment in recognizing deviations from expected pattern or identifying unstable patients.

Frequency of focused assessment versus a complete head-to-toe assessment.

Examples of focused assessments and their purpose (ETOH withdrawal, NIH stroke scale).

Reflective moment:

Students share or ask questions about noticing and/or their focused assessment.

During shift:

Students are broken into two groups. Each group creates a skit using one of the focused assessments discussed during the seventh inning stretch, ETOH withdrawal, NIH stroke scale, or suicide risk assessment.

Postconference:

One group performs the skit while the other group completes the appropriate focused assessment.

Students and instructor reflect on the theme for the day.

Week 4: Data to diagnosis connection between assessment and nursing diagnosis CJM phase: Interpreting LCJR dimension: Making sense of dataPreconference question:

What do we do with all the data we collected?

Warm-up activity:

Instructor introduces the concept of making sense of data and asks students pay attention to abnormal assessment findings today.

Instructor guidance:

What abnormal assessment findings did you notice and what is the significance?

Based on the data, what issues are starting to emerge, and what nursing diagnoses are becoming evident?

What information connects with which issue?

Lesson:

Making connections between the data.

Instructor goes through a concept-mapping activity to show how concept mapping can help you see the connections between data.

Checking accuracy of your connections between the data by explaining the connection. Does it make sense?

Reflective moment:

Students share or ask questions about the meaning or connections between their patients' data.

During shift:

Student creates a concept map that reflects collected data and includes sentences explaining each connection.

Postconference:

Students share the connections made in their concept map activity.

Students share a nursing diagnosis with supporting assessment data; fellow students listen and offer feedback.

Students and instructor reflect on the theme for the day.

Week 6: Communication verbalize judgments and recommendations CJM phase: Responding LCJR dimension: Clear communicationPreconference question:

What types of communication occur in the health care setting?

What situations might arise that need prompt communication?

Warm-up activity:

Instructor introduces the concept of communication in the hospital setting and guides students to consider situations that arise today that may need communicating to patient, family, or members of the health care team.

Instructor guidance:

What assessment findings, situation, or nursing diagnosis may require follow up using Situation, Background, Assessment, Recommendation (SBAR).

Help formulate SBAR to communicate with the health care team member (e.g., doctor).

Lesson:

Situations requiring clear, concise communication.

Discuss SBAR communication sheet.

Share Ticket to Ride transport communication sheet.

Reflective moment:

Students share or ask questions about any situations that may need communication or recommendations they may need to communicate to members of the health care team.

During shift:

Student complete communication case study.

Complete SBAR sheet if needing to communicate with health care member (e.g., call the doctor) and then they follow through with instructor guidance.

Rounding activity:

Students practice verbalizing clinical judgments and recommendations.

Postconference:

Discuss answers to case study.

Students share SBAR activity and their experience. Did they call the doctor? How did it go?

Students and instructor reflect on the theme for the day.

Authors

Ms. Gonzalez is Associate Professor, Health Sciences Division, College of Southern Maryland, La Plata, Maryland.

The author has disclosed no potential conflicts of interest, financial or otherwise.

The author thanks Jesse Gonzalez, Ann Nielsen, and Kathie Lasater for the encouragement and editorial support. The author also thanks Vivian Vasquez and Kimberly Donnelly for sharing their wisdom and guidance throughout this journey.

Address correspondence to Lisa Gonzalez, MSN, RN, CNE, CCRN-K, Associate Professor, Health Sciences Division, College of Southern Maryland, 8730 Mitchell Road, PO Box 910, La Plata, MD 20646-0910; e-mail: lgonzalez@csmd.edu.

Received: January 02, 2018
Accepted: July 27, 2018

10.3928/01484834-20181119-05

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