Journal of Nursing Education

Educational Innovations 

Clinical Reasoning: Adapting Teaching Methods During the COVID-19 Pandemic to Meet Student Learning Outcomes

Terri Wyatt, MSN, RN, CNE; Valerie A. Baich, MSN, RN; Charlotte A. Buoni, MSN, RN, CNE; Alison E. Watson, EdD, RN, CNE; Victoria E. Yurisic, BSN, RN

Abstract

Background:

The COVID-19 pandemic impacted all aspects of health care, including nursing education. Senior nursing students saw the elimination of in-person clinical opportunities in the final months prior to graduation as health care facilities restricted access to essential personnel in an effort to minimize transmission of the virus and conserve personal protective equipment.

Method:

To fulfill course requirements, faculty created a COVID-19 assignment that implored students to research the most current infection control recommendations for COVID-19 and to describe the impacts of the virus on nursing care, patients, families, interdisciplinary collaboration, and public safety.

Results:

The COVID-19 assignment fostered clinical reasoning and encouraged personal reflection with application to practice. Students reported that the assignment greatly enhanced knowledge and awareness of COVID-19.

Conclusion:

This assignment was beneficial for transition to practice in the midst of a pandemic, and it can be easily replicated for any future emerging health care topic that may affect nursing education. [J Nurs Educ. 2021;60(1):48–51.]

Abstract

Background:

The COVID-19 pandemic impacted all aspects of health care, including nursing education. Senior nursing students saw the elimination of in-person clinical opportunities in the final months prior to graduation as health care facilities restricted access to essential personnel in an effort to minimize transmission of the virus and conserve personal protective equipment.

Method:

To fulfill course requirements, faculty created a COVID-19 assignment that implored students to research the most current infection control recommendations for COVID-19 and to describe the impacts of the virus on nursing care, patients, families, interdisciplinary collaboration, and public safety.

Results:

The COVID-19 assignment fostered clinical reasoning and encouraged personal reflection with application to practice. Students reported that the assignment greatly enhanced knowledge and awareness of COVID-19.

Conclusion:

This assignment was beneficial for transition to practice in the midst of a pandemic, and it can be easily replicated for any future emerging health care topic that may affect nursing education. [J Nurs Educ. 2021;60(1):48–51.]

The COVID-19 pandemic created unprecedented challenges in global health care and had tremendous effects on nursing education. Nursing programs were forced to suspend traditional classroom education due to social distancing restrictions, as well as discontinue in-person clinical experiences to help control the spread of the virus and conserve personal protective equipment (PPE) (Organization for Associate Degree Nursing, 2020). Alternative clinical platforms, such as virtual and simulated patient scenarios, were used to minimize disruptions to curriculum, fulfill course requirements, and ensure continued progress to degree completion (Jackson et al., 2020). However, the clinical restrictions prevented nursing students from actually participating in the care of COVID-19 patients. Nevertheless, students graduating in spring 2020 faced the prospect of joining the frontlines immediately after passing their licensure examination to care for this unique population.

Nurse educators should “examine educational practices for relevancy to prepare entry-level graduates to enter the current health care environment” (Hatzenbuhler & Klein, 2019, p. 96). The COVID-19 crisis presented a unique opportunity for nursing programs to adapt curriculum content to reflect the present health care landscape and prepare graduating seniors for the challenge of combatting the virus. Faculty at a diploma program in the Mid-Atlantic region of the United States developed a unique written assignment titled “COVID-19” that required senior nursing students to access the most current information available on COVID-19 from the Centers for Disease Control and Prevention (CDC). The assignment reinforced the importance of infection prevention and asked students to describe the impact of COVID-19 on nursing care, patient and family member well-being, interdisciplinary collaboration, and public and personal safety. The assignment satisfied recommendations from the American Association of Colleges of Nursing (2020) for nursing programs to expand infection control and prevention curriculum content, including surveillance, detection, isolation, containment, hand washing, appropriate use of PPE, and standard, contact, and airborne precautions. The recommendation also came from the National League for Nursing (personal communication “Message to the Educational Community,” March 10, 2020), instructing schools of nursing to review and expand the amount of content related to infection control and prevention within their curriculum.

When in-person clinical experience was no longer possible, the COVID-19 assignment created a practice-oriented scenario to develop higher level clinical reasoning, which Hatzenbuhler and Klein (2019) stated is essential for successful transition to professional nursing. Jessee (2018) summarized the construct of clinical reasoning from multiple sources, concluding that clinical reasoning “encompasses the cognitive processes through which nurses combine patient data, knowledge, experience, professional values, and reflection-in-action to make nursing decisions” (p. 8). In planning the COVID-19 assignment, the design required students to draw on research and their existing knowledge base, reflect on patient experiences and professional values affected by alterations in the environment, analyze person-to-person interactions affected by COVID-19, and take into account safety and interdisciplinary collaboration to make nursing decisions. The reflection component would summarize key points, knowledge gained, and incorporation of what was learned into personal practice.

Design

Student learning outcomes (SLOs) are the cornerstone of the school of nursing's curriculum. Eight SLOs are introduced to the students in the first year of nursing school and are threaded throughout the curriculum. The expectation is that senior students master each of the SLOs by the end of the final semester. Before designing the COVID-19 assignment, the SLOs were reviewed, and two were chosen as the framework:

  • Integrate knowledge gained from the related sciences and nursing courses to provide comprehensive, culturally competent care to individuals of all ages, levels of wellness, and in a variety of health care settings.
  • Evaluate critical thinking skills, the nursing process, and evidence-based practice/best practice standards when providing patient care in all health care settings.

When first planning the assignment, the faculty started by determining objectives. The first objective was for students to use prior knowledge and apply critical thinking skills when researching best practices regarding COVID-19 and infection prevention. The goal then was for students to examine key concepts, recommendations, and ongoing changes set forth by the CDC. The final objective was for students to analyze infection prevention recommendations for COVID-19 as presented on the CDC website and correlate findings with the policies implemented by the governing health care organization associated with the school of nursing. The assignment was designed for the senior-level nursing student to recognize the current impact of COVID-19 on nursing practice, patients, families, and the community. The student was required to research the pathophysiology of COVID-19 and transmission precautions. Students then were led to identify members of the care team and analyze the influence of interdisciplinary collaboration. The last portion of the assignment was designed for the student to reflect on the assignment, compare research to practice, and critically think about improvements to personal practice. Prior to submission of this article, informed consent was obtained from students for use of reflective comments.

Implementation

The COVID-19 assignment was given to 29 prelicensure senior nursing students in March 2020. Students were provided with written and verbal instructions, an evaluation rubric, and a template to complete the assignment. Students were required to review the following CDC recommendations (CDC, 2020):

  1. Adhere to standard and transmission-based precautions.

  2. Manage visitor access and movement within the facility.

The PPE and COVID-19 visitor policies from the governing health care organization were reviewed and provided to students. The students researched evidence-based practice on the CDC's website and compared findings with the health care organization's policies and with personal practice. Using critical thinking, the students documented how the CDC recommendations affected nursing care, patients, and visitors.

The assignment also included sections on COVID-19 pathophysiology, nursing process, and a reflective narrative. Students were instructed to develop two specific nursing diagnoses and four expected outcomes for a patient who is positive for COVID-19. This exercise enhanced critical thinking and analysis of concurrent application to practice. The narrative allowed students to summarize their research, discuss how the assignment enhanced their knowledge of COVID-19, and reflect on how personal practice can influence the spread of the virus.

Evaluation

Faculty graded the assignment using an evaluation rubric that was designed specifically for the assignment. Seven sections and 29 specific criteria were included on the rubric. One point was awarded for successfully meeting the criteria for each section. At least six points were required for the assignment to be satisfactory. The narrative section was a mandatory satisfactory area, and if unsatisfactory, the student was given one additional opportunity to successfully complete the section. Senior faculty met to discuss the rubric components to maintain evaluation consistency.

Results

All students satisfactorily completed the assignment with evidence of research, analysis, and professional growth. After reviewing the student reflective responses in the narrative component, three recurring themes were identified. The first theme was an enhanced understanding of COVID-19 transmission and PPE use. The following student comments demonstrate how their knowledge was enhanced as a result of completing this assignment:

  • One positive thing I can take away from it all is the mindfulness I now have to prevent the spread of infection. Hand hygiene has been stressed from day one of nursing school, but the COVID-19 pandemic has shown just why it is so important.
  • This assignment has opened my eyes on how simple it is transmitting a pathogen and the significance of proper infection control measures. The one simple task of washing your hands properly can be the number one thing that decreases the spread of COVID-19. I gained knowledge on correct procedure of donning and doffing PPE when caring for a COVID-19 patient.
  • This assignment has given me a better understanding of why the CDC has put into place all the guidelines and necessary measures to prevent the spread of infection.
  • Since this all began, supplemented with my further understanding after performing this research project, I ensure that all my PPE is donned appropriately prior to entering any patient room, no matter the circumstance. This is to decrease the transmission risk not only to other patients that I may encounter, but also to decrease the potential of transmission to myself.

The second theme identified from student reflections was an enhanced understanding of pathophysiology of COVID-19:

  • I wasn't completely familiar with the pathophysiology of COVID-19, but after completion of this assignment I am able to speak to how COVID-19 manifests in the human body, and what it does to the individual it infects.
  • I personally have acquired a lot of knowledge from this assignment. Once understanding how the virus impacted the human body, then I was able to gain a better understanding of all the precautionary measures put into place to decrease the spread.
  • My personal knowledge of COVID-19 has increased as well. I did not know about all of the possible complications that could occur that are not even related to the respiratory system even though this is a virus that primarily affects the lungs.
  • This research assignment has thoroughly improved my knowledge on COVID-19. It has allowed me to really dive into the pathophysiology and understand why the clinical manifestations occur as they do. I understand the progression of the disease from start to finish now.

The third theme on which the students reflected was the impact on personal practice and future delivery of nursing care:

  • I recognize that throughout my time in school there have been many instances in which I unknowingly contaminated myself. Actions that at the time seemed minor to me, such as adjusting my surgical mask without washing my hands prior or removing my PPE out of order, put me at risk for exposure. Moving forward in my nursing career I now understand how vital it is to educate myself on and adhere to infection control practices, not just for my protection but also those around me.
  • An area I can definitely improve upon is clustering my care. Clustering care is more important than ever now, because I would be limiting my exposure to the client and decreasing my risk just by implementing that practice.
  • Upon reflection on this project, it has become increasingly clear to me that strict self-discipline is required when dealing with infectious diseases like COVID-19.
  • This is a unique and challenging time for the field of health care, and I think this assignment has made me better prepared to enter the field as a nurse.
  • As a soon to be graduate nurse, I believe this assignment truly gave me insight on what my near future nursing will be like. I believe I will have an advantage on how to appropriately provide care to patients who are diagnosed with COVID-19.
  • We must stay up to date on guidelines because we are moving directly into a crisis upon graduation. As the nurse, it is my responsibility to be competent in all areas that were covered in this assignment. We ultimately are responsible for our actions; small mistakes can have detrimental consequences.

The student reflections demonstrate an increased knowledge of COVID-19 and enhanced awareness of infection control measures and the effects on future practice. Student reflections also confirmed that the design of the assignment met the desired objectives, enabling students to meet the SLOs of integration of knowledge gained from the related sciences and nursing courses, and evaluation of critical thinking skills, the nursing process, and evidence-based practice/best practice standards.

In the COVID-19 assignment, not only was the SLO of evaluating critical thinking skills met, but the project took it a step further by enhancing clinical reasoning skills through research, analysis, and reflection on application to practice involving a patient situation. Critical thinking is an analysis of knowledge gained and is a necessary component of clinical reasoning. Clinical reasoning requires not only background knowledge but also the process of applying it to a patient or caregiving situation (Victor-Chmil, 2013). According to Koharchik et al. (2015), clinical reasoning is a result of “melding of analysis and reflection” (p. 59) in that clinical reasoning “involves applying ideas to experience in order to arrive at a valid conclusion” (p. 58). Defining attributes of clinical reasoning are identified by Simmons (2010) as “data analysis (interpreting information), deliberation (rumination), heuristics (informal thinking), inference (speculation), metacognition (reflective thinking), logic (argument), cognition (perception or awareness), information processing (organizing data), and intuition (insight independent of reasoning)” (p. 1155). All the above components are evident in the student reflections, thus supporting development of clinical reasoning skills by the completion of the COVID-19 assignment. Faculty believe the assignment was timely and extremely beneficial to the senior students who would soon be entering the work force.

Implications for Nursing Education

This assignment can be easily replicated for any unforeseen health condition or emerging hot topic in medicine that may present in the future. A surprising finding for faculty was that although news outlets, social media, and general conversations abounded concerning the COVID-19 epidemic, students were largely unaware about the specifics of the disease. Nursing students are largely consumed by the intensity of their educational demands and home responsibilities, with little time left to ponder or research current events. As such, although students were familiar with COVID-19, their main concerns were how it was going to affect the outcome of their final semester of school and risk to self and families, rather than on the actual pathophysiology and differential treatment. As seen in the student experience section, they were amazed at the learning that took place through completion of the assignment. Following completion, students were able to correlate and have a deeper understanding of the treatment protocols that were initiated to minimize the transmission and spread of the illness. This assignment supports the importance of addressing current health events in nursing education and of not assuming knowledge is gained by informal educational sources or independent research by the student. Nursing education is all-consuming, especially in the final semester, and limits the student's time and attention to matters outside of the educational arena.

Other nursing education programs could apply the principles from this assignment to any current events in health care that are not included in the standard curriculum and that would be beneficial for transition to professional practice. This assignment reinforced to students that health care is always changing, that nurses must be flexible and adaptable, and that it is important to seek and incorporate the latest knowledge, research, and evidence-based practice into nursing care.

Conclusion

This assignment encouraged students to learn more about COVID-19, including pathophysiology, symptoms, transmission, prevention, and nursing care. Students learned about the disease progression of COVID-19, what treatments are effective, how care is modified for safety and social distancing restrictions, how nursing interventions affect patients and visitors, and how each health care professional on the collaborative care team plays a role in recovery. Finally, students were asked to reflect on their professional growth and behaviors in the clinical setting. After completing the assignment, students expressed that they felt more informed about the disease, developed a greater understanding of the need for social distancing and PPE, and were more aware of how their own personal practice can help reduce the spread of the virus. The COVID-19 crisis has presented unique challenges to all health care professionals, including nursing students. This assignment effectively prepared students for graduate nursing practice by allowing them to acquire the knowledge and clinical reasoning necessary to help combat COVID-19, which is arguably the greatest challenge in health care today.

References

  • American Association of Colleges of Nursing. (2020). Considerations for COVID-19 preparedness and response in U.S. schools of nursing. https://www.aacnnursing.org/Portals/42/AcademicNursing/pdf/Considerations-for-COVID19-Nursing-Schools.pdf
  • Centers for Disease Control and Prevention. (2020). Interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (COVID-19) in healthcare settings. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html
  • Hatzenbuhler, N. J. & Klein, J. E. (2019). Educational preparation for clinical practice: Reflections of newly graduate RNs. Nurse Educator, 44(2), 93–97 doi:10.1097/NNE.0000000000000550 [CrossRef] PMID:29794883
  • Jackson, D., Bradbury-Jones, C., Baptiste, D., Gelling, L., Morin, K., Neville, S. & Smith, G. D. (2020). Life in the pandemic: Some reflections on nursing in the context of COVID-19. Journal of Clinical Nursing, 29, 2041–2043 doi:10.1111/jocn.15257 [CrossRef] PMID:32281185
  • Jessee, M. A. (2018). Pursuing improvement in clinical reasoning: The integrated clinical education theory. Journal of Nursing Education, 57(1), 7–13 doi:10.3928/01484834-20180102-03 [CrossRef] PMID:29381154
  • Koharchik, L., Caputi, L., Robb, M. & Culleiton, A. L. (2015). Fostering clinical reasoning in nursing students. American Journal of Nursing, 115(1), 58–61 doi:10.1097/01.NAJ.0000459638.68657.9b [CrossRef] PMID:25545533
  • Organization for Associate Degree Nursing. (2020). Innovations in nursing education: Recommendations in response to the COVID-19 pandemic. https://oadn.org/images/pdf/COVID-19/Nursing%20Education%20and%20COVID%20Pandemic%20March%2030%202020%20FINAL.pdf
  • Simmons, B. (2010). Clinical reasoning: Concept analysis. Journal of Advanced Nursing, 66(5), 1151–1158 doi:10.1111/j.1365-2648.2010.05262.x [CrossRef] PMID:20337790
  • Victor-Chmil, J. (2013). Critical thinking versus clinical reasoning versus clinical judgment: Differential diagnosis. Nurse Educator, 38(1), 34–36 doi:10.1097/NNE.0b013e318276dfbe [CrossRef] PMID:23222632
Authors

Ms. Wyatt is Simulation and Technology Coordinator, and Ms. Baich, Ms. Buoni, Dr. Watson, and Ms. Yurisic are Faculty, Beebe Healthcare, Margaret H. Rollins School of Nursing, Lewes, Delaware.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Terri Wyatt, MSN, RN, CNE, Simulation and Technology Coordinator, Beebe Healthcare, Margaret H. Rollins School of Nursing, 424 Savannah Road, Lewes, DE 19958; email: twyatt@beebehealthcare.org.

Received: July 01, 2020
Accepted: September 23, 2020

10.3928/01484834-20201217-11

Sign up to receive

Journal E-contents