TEACHING FOR PRACTICE

Fostering Clinical Reasoning in Nursing Students How can instructors in practice settings impart this essential skill? This article is one in a series on the roles of adjunct clinical faculty and preceptors, who teach nursing students to apply knowledge in clinical settings. This article describes why it’s important that nursing students develop clinical reasoning skills and how clinical nursing instructors can help them learn these skills.

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romoting the development of clinical reasoning is the crux of nursing education. A nurse who is adept at clinical reasoning will be able to make timely and effective patient-centered decisions. Sound clinical reasoning is essential for preserving the standards of the nursing profession and promoting good patient outcomes. Clinical reasoning involves applying ideas to experience in order to arrive at a valid conclusion and is the term most widely used to describe the way a health care professional analyzes and understands a patient’s situation and forms conclusions. (While the terms clinical thinking and clinical judgment are often used synonymously, in this article we prefer to use the term clinical reasoning.) In nursing literature, definitions of clinical reasoning center on both the formal and informal processes involved in making sound professional judgments. Levett-Jones and colleagues, drawing upon Hoffman’s initial findings, have described eight steps in the clinical reasoning process: looking, collecting, processing, deciding, planning, acting, evaluating, and reflecting.1, 2 Both experienced and inexperienced nurses move through these phases—which, in the clinical environment, can overlap and will not always occur sequentially—to make judgments about the nursing care of patients. Along the way, the nurse uses cognition, metacognition, and discipline-specific knowledge to quickly review and analyze patient information, evaluate the significance of the information to the clinical situation, and formulate appropriate actions.

CLINICAL REASONING AND THE ‘EXPERT NURSE’

The decisions nurses make about a patient’s health care needs are supported by reasoning but also by intuition and knowledge gained from professional 58

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experience. The way the nurse applies the processes of clinical reasoning differs according to experience; Patricia Benner’s novice-to-expert model provides a useful framework for describing this process as it evolves.3 The novice. As Benner describes it, a nursing student starts at the elementary level, owing in part to her or his lack of experience or confidence. This lack of experience and self-assurance impedes the novice nurse’s ability to appropriately identify information that should be collected, accurately analyze this information, and correctly evaluate its significance to the clinical situation, especially when it is complex. Or, as Simmons puts it, “While novices readily retrieve patient data, important cues are often overlooked as the degree of uncertainty or decision complexity increases.”4 At this level, the nursing student follows rules and applies them to all situations, regardless of the context of the situation: with no experience to draw from, she or he cannot perceive important aspects of the situation. The expert. If a nursing student sees all information about a patient as equally important, an experienced nurse is able to distinguish between important and less important information and move through the phases of clinical reasoning in a way that is efficient and precise.3 Drawing on previous experience, the expert nurse uses patient-centered “prototypes” (or cognitive shortcuts) during the thinking process.5, 6 Prototypes are formed from previously acquired knowledge and skills obtained through experiential learning.6 To manage patient care, the experienced nurse applies a stored composite prototype to the current situation and initiates the clinical reasoning process. The experienced nurse’s grasp of the clinical situation allows her or him to develop and implement ajnonline.com

Photo by Greg Sorber / Albuquerque Journal / ZUMAPRESS.com.

By Linda Koharchik, DNP, MSN, RN, CNE, Linda Caputi, EdD, MSN, RN, CNE, ANEF, Meigan Robb, PhD, MS, AAS, RN, and Alicia L. Culleiton, DNP, MSN, RN, CNE

appropriate actions. Clinical reasoning, therefore, can be seen as a learned process that requires the melding of analysis and reflection. Simmons notes, however, that while an experienced nurse may analyze a situation more quickly than a novice nurse, she or he may also reach erroneous conclusions if data are overlooked or dismissed.4 To arrive at more accurate conclusions, nurses should recognize, understand, and work through each phase of clinical reasoning rather than make assumptions about patient problems and initiate interventions that have not been adequately considered.2

TEACHING THINKING

In a 2006 review of the research to date on how nurses arrive at clinical decisions, Tanner proposed four steps in the process7: • noticing • interpreting • responding • reflecting Noticing refers to how a nurse expects a situation to unfold and how she or he understands it during a first encounter. Interpreting involves defining the meaning of collected data and determining the appropriate course of action. Responding entails applying thinking strategies and anticipating outcomes. Reflecting, according to Schön, occurs in two ways: “reflection-in-action” and “reflection-on-action.”8 [email protected]



Tanner describes reflection-in-action as the nurse’s ability to interpret the patient’s response to an intervention, while reflection-on-action refers to the nurse’s subsequent thinking about the situation and what she or he has learned from it. This framework can also guide nursing instructors in helping students develop clinical reasoning. A student may ask the following questions, as described in a recent conference paper by one of us (LC).9 1. What did you observe? The clinical instructor must first focus the student’s perceptual awareness. The student will report signs, symptoms, and clinical data. 2. What do you make of what you saw? The instructor can help students see the clinical data that is of significance. From the student’s perspective, everything is important, and the student must learn what level of ambiguity is acceptable. For example, students learn that normal blood pressure is 120/80 mmHg, but they are unlikely to know when a blood pressure of 90/60 mmHg is a cause for concern. (In such instances, the context usually determines the data’s significance, as the following analogy illustrates: While the speed limit suggests that driving at 55 miles per hour is safe, on some highways 65 miles per hour may be safer, and in icy road conditions, 40 miles per hour might be more judicious.) Students may be given the following exercise to develop clinical reasoning in the presence of ambiguity: First collect all patients’ vital signs, then examine the AJN ▼ January 2015



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TEACHING FOR PRACTICE

patients’ histories, medications, and other clinical data to explain any variations in the vital signs. Students can present their findings and conclusions in a postclinical conference, explaining both the acceptable and unacceptable vital sign ranges for each patient and why. 3. What course of action will you take? The clinical instructor must help the student determine how to respond in a particular situation. For example, the student might be instructed to investigate a critical event experienced by a hospitalized patient in the previous 24 hours. The student would be told to review the patient’s medical record, looking for signs of deterioration in anything the patient reported during the period leading up to the problem, and then to discuss any potentially important observations with the nurses ­involved in the patient’s care. The student might then complete an identification–situation–background– assessment–recommendation (ISBAR) form. (When the nurses initially assessed the situation for the attending physician, they would have used the ISBAR system, and later they would have documented the problem using that same format.) The clinical educator should explain that the following information must be included in a completed form10:

Clinical reasoning is a learned process that requires the melding of analysis and reflection. • Identification. Who are you? What is your role in caring for the patient? To what unit do you belong? • Situation. Who is the patient? What is the patient’s room number? What is the immediate concern or clinical situation? Is it urgent? • Background. When was the patient admitted? What was the admitting diagnosis? What is the patient’s medical history? Are there any pertinent data? Does the patient have any allergies? What is the patient’s code status? • Assessment. What are the patient findings? Is there a significant change in the patient’s status compared with previous assessment findings? What do you think the problem is? Include the following assessments, as indicated: neurologic, respiratory (oxygen therapy, respiratory effort), cardiovascular, musculoskeletal, and skin. Vital signs (including any patient reports of pain) should also be noted, as well as blood glucose level, any interventions needed, abnormal laboratory results, 60

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radiology results, fluid balance, and results of psychological and social examinations. • Recommendations. What do you want the person you have contacted to do? What are your recommendations? Include patient care goals, as indicated (identifying any changes; new orders since start of shift; consults completed, scheduled, or that need to be ordered; tests and treatments completed, scheduled, or that need to be ordered; and discharge needs). A hypothetical case. Consider the following scenario: A senior-level nursing student is assigned the care of a 65-year-old male patient who was admitted to the progressive care unit four days earlier. His diagnosis on admission was spontaneous pneumothorax secondary to a ruptured bleb, requiring the placement of a small-bore, left-sided chest tube. He has a medical history of severe chronic obstructive pulmonary disease (COPD), has no known allergies, and is a “full code.” His chest tube was removed on his second day in the hospital. A change-of-shift report describes him as resting comfortably and tentatively scheduled for discharge this morning. But during the morning assessment, the nursing student finds that the patient has a heart rate of 125 beats per minute, a respiratory rate of 32 breaths per minute, and blood pressure of 110/60 mmHg. He is sitting upright in bed and reports shortness of breath and chest pain on inspiration as a 9 on a scale of 1 to 10. The student recognizes that the patient is in acute distress and immediately seeks out the nursing instructor and nursing staff for assistance and guidance. The ISBAR in this case might look like this: • I: Senior nursing student Jane Smith. Progressive care unit. • S: John Jones. Room 312. Hemodynamic instability. Situation is urgent. Condition C has been called. (Condition C means a respiratory or cardiovascular crisis, or both.) • B: Admitted four days ago. Spontaneous pneumothorax due to ruptured bleb. COPD. No known drug allergies. Full code. Chest tube removed hospital day 2. • A: Patient stable at 6 am assessment. Current: Patient alert and oriented ×3. Heart rate: 125 beats per minute. Respirations: 32 breaths per minute. Blood pressure: 110/60 mmHg. Patient reports shortness of breath and chest pain with inspiration at a level of 9. Faint or absent left-sided breath sounds. O2 applied 100% via face mask. Respiratory distress. Possible recollapse of lung. • R: Request attending physician at bedside. STAT ABG. Portable chest X-ray. Maintain high-flow oxygen support. Prepare for reinsertion of chest tube. Crash cart at patient bedside. ajnonline.com

During the postclinical conference, the student would identify the most important data from the ISBAR to communicate to the health care provider, explaining her or his rationale and discussing anticipated patient outcomes.

LEARNING THROUGH REFLECTION

It is imperative that the nurse educator explore activities that require the student to use reflection-in-action and reflection-on-action practices. For reflection-inaction, educators must give students a chance to reflect immediately on the clinical activity and patient interaction, learn from it, correct their thinking if necessary, and use what they have learned in the next situation. Students should be encouraged to become “reflective practitioners.”8 Reflection-on-action promotes the student’s development of clinical knowledge and judgment.7 A learning activity that may be used to enhance the student’s ability is reflective writing, in which the student explores, examines, dissects, and explains a specific patient situation or encounter. As an exercise, students can be told to revisit a clinical situation and construct a short essay that answers the questions provided by Gibbs in Learning by Doing: A Guide to Teaching and Learning Methods11: Description. Explain the patient situation. What happened? Feelings. How do you feel about what happened? What were you thinking and feeling? Evaluation. Evaluate the situation. How did you react? How did others react? What problems did you encounter? What challenged you? Describe the positives and negatives of the experience. Analysis. Explore the details. What was really going on? Why did you encounter problems? What else could you have done? Have you been in a similar situation before? What facts did you base your judgments and actions on? Conclusion. Make a decision about what happened. What could you have done differently? What did you do well? How could you have improved the situation or avoided any negative outcomes? Action plan. Make a plan. If this situation arose again, what would you do? What needs to be done to improve things in the future? What additional knowledge or training do you need?

CONCLUSION

The nursing instructor must set out to foster nursing students’ clinical reasoning. By developing a systematic, formalized method to teach effective clinical thinking across the curriculum, along with evaluation methods to measure gains in learning, the instructor prepares students to graduate with essential [email protected]



tools for practice. It is also extremely important that new graduate orientation programs build on the thinking learned in nursing school. Preceptors who are assigned to orient new graduate nurses to their jobs can use these exercises to reinforce the fundamental competencies students learn during their prelicensure training.

Expertise in clinical reasoning requires lifelong learning. Expertise in clinical reasoning requires lifelong learning. As new nurses face critical situations with patients, taking the time to reflect will promote the development of clinical reasoning. They will gradually find that they are becoming experienced, competent nurses with reliable and tested decision-making skills. ▼ Linda Koharchik is a clinical assistant professor and director of adjunct faculty and clinical affairs at Duquesne University School of Nursing, Pittsburgh, PA, where Alicia L. Culleiton is also a clinical assistant professor. Linda Caputi is professor emerita at College of DuPage, Glen Ellyn, IL, and Meigan Robb is assistant professor of nursing at Chatham University, Pittsburgh, PA. Contact author: Linda Koharchik, [email protected]. The authors have disclosed no potential conflicts of interest, financial or otherwise.

REFERENCES 1. Hoffman K. A comparison of decision-making by ‘‘expert” and ‘‘novice” nurses in the clinical setting, monitoring patient haemodynamic status post abdominal aortic aneurysm surgery [dissertation]. Sydney, NSW, Australia: University of Technology; 2007. 2. Levett-Jones T, et al. The ‘five rights’ of clinical reasoning: an educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients. Nurse Educ Today 2010;30(6):515-20. 3. Benner P. From novice to expert. Am J Nurs 1982;82(3):402-7. 4. Simmons B. Clinical reasoning: concept analysis. J Adv Nurs 2010;66(5):1151-8. 5. Banning M. Clinical reasoning and its application to nursing: concepts and research studies. Nurse Educ Pract 2008;8(3): 177-83. 6. Ferrario CG. Developing clinical reasoning strategies: cognitive shortcuts. J Nurses Staff Dev 2004;20(5):229-35. 7. Tanner CA. Thinking like a nurse: a research-based model of clinical judgment in nursing. J Nurs Educ 2006;45(6):204-11. 8. Schön DA. The reflective practitioner: how professionals think in action. New York: Basic Books, Inc.; 1983. 9. Caputi L. Teaching thinking: we do it but where’s the evidence? Presented at the Elsevier Faculty Development Conference symposium. Las Vegas, NV; 2014 Jan. 10. Enlow M, et al. Incorporating interprofessional communication skills (ISBARR) into an undergraduate nursing curriculum. Nurse Educ 2010;35(4):176-80. 11. Gibbs G. Learning by doing: a guide to teaching and learning methods. Oxford, UK: Further Education Unit, Oxford Brookes University; 1988.

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Fostering clinical reasoning in nursing students.

This article is one in a series on the roles of adjunct clinical faculty and preceptors, who teach nursing students to apply knowledge in clinical set...
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