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.
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
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
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.