Clinical Reasoning on an Assignment: Perceptions of Third Year Baccalaureate Nursing Students

Saturday, 7 November 2015

Karen Lynn Oostra, BN, BSc, RN
Faculty of Graduate Studies, Trinity Western University, Langely, BC, Canada
Barbara Astle, PhD, RN
School of Nursing, School of Graduate Studies and Centre for Equity and Global Engagement, Trinity Western University, Langley, BC, Canada
Heather Meyerhoff, MSN, RN
School of Nursing, Trinity Western University, Langley, BC, Canada


                Nursing students must develop strong clinical reasoning skills during their undergraduate program in order to be able to make sound clinical judgments regarding patient care.  How students understand the evolution and application of their own critical thinking/clinical reasoning skills is of interest to nurse educators as they seek to support and enhance these skills through educational interventions and assessments.         


            Both critical thinking and clinical reasoning exist as terms in the literature.  Critical thinking can be defined as “purposeful, self-regulatory judgement, that results in interpretation, analysis, evaluation and inference” (Facione, 1990, p.2).  Clinical reasoning may be defined as the process of generating alternatives, weighing them against the available evidence and choosing the best alternative (Tanner, 2006).  Both terms are used to represent the problem-solving skills used by nurses.  Nurses require these problem-solving skills to function in a complex and changing health care environment (Lee & Brysiewicz, 2009; Marchigiano, Eduljee, & Harvey, 2011; Chabeli, 2007).  Nursing education must strive to teach and to facilitate the development of this type of thinking (Marchigiano et al., 2011).  Various educational interventions have been studied in order to improve the critical thinking of students or new graduates, but have not shown more than modest success (Thompson & Stapley, 2011).  Several studies have focused on critical thinking dispositions in an attempt to find out, using quantitative methodologies, the skills and traits possessed by students that may facilitate critical thinking (Profetto-McGrath, 2003; Paans, Sermeus, Nieweg, & Van Der Schans, 2010).

            Three qualitative studies were found that described students’ or new graduate nurses’ experience of developing or applying critical thinking.  Duchscher (2003) described the development of critical thinking in new graduates in their first six months of practice as moving from no reflection and unable to see beyond the task to critical thinking being woven into the nursing process, keeping an open mind, generating various perspectives and finally to coping with uncertainty.  Di Vito-Thomas (2005) utilized a qualitative approach to explore students’ perspectives on learning to think like a nurse.  Students identified their thinking as a cognitive process developing through experience in practice (Di Vito-Thomas, 2005).  Ellermann, Kataoka-Yahiro, & Wong, (2006) also collected qualitative data and asked students how they made decisions about care in the clinical setting.  Content themes such as identifying priorities, assessing causes and solutions, logical thinking and using the nursing process were identified.        

            In comparison to the published quantitative research on this topic, there were very few qualitative studies that sought to describe the student experience of critical thinking either in practice or through assignments.  Marchigiano et al. (2011) reflected that “little information is available regarding how students perceive their abilities to think and process information related to their delivery of patient care” (p. 145).  Marchigiano et al. (2011) also state that the use of qualitative methods may “provide information about how an assignment affected thinking skills within a nursing process framework” (p. 150).  This project seeks to address this gap in the literature and provide qualitative data with respect to student thinking on an assignment.

Purpose and Methods

            The purpose of this study was to explore the clinical reasoning skills of students who, during their third year of their Baccalaureate nursing program, applied the nursing process to complete a Clinical Judgment Exercise (CJE) assignment.  Eight third year students were interviewed regarding their understanding of the development of their critical thinking skills and the application of these skills as they worked through the CJE assignment.  A qualitative research method was employed using Interpretive Description to analyze the data from the transcribed interviews.

Preliminary Findings

            During data analysis, one overarching theme emerged from the data:  Over Time.  During the interviews, students reflected on how they had come to understand the development of their critical thinking over their time in the nursing program.  Emerging from this overarching theme was Theme One:  “understanding of critical thinking.”  Students also described how they approached and moved through the CJE assignment over time, from the initial phase of figuring out what to do with the data through to the completion of the assignment.  The second theme to emerge was Theme Two:  “making sense of the assignment expectations.”

            Theme One was identified as “understanding critical thinking” and refers to the student perceptions that their critical thinking/clinical reasoning abilities progressed from not knowing in year one, coming to know in years two and three, able to know at the end of year three and valuing the knowing in terms of preparing for independent practice at the onset of year four.  Theme Two emerging from the data, was “making sense of assignment expectations.” As in the first theme, a progression of knowing over time was evident in the data.  Students moved from a place of not knowing in the initial phase of the assignment, coming to know as steps were taken to understand and engage with the assignment, application of knowing as experience and prior knowledge were applied to the assignment and finally valuing the need to know as students prepared to move the nursing process into practice. 

Data analysis is currently ongoing and conclusions forthcoming.


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Di Vito-Thomas, P. (2005). Nursing student stories on learning how to think like a nurse. Nurse Educator , 3, 133-136.

Duchscher, J. (2003). Critical thinking: Perceptions of newly graduated female baccalaureate nurses. Journal of Nursing Education , 42 (1), 14-27.

Ellermann, C., Kataoka-Yahiro, M., & Wong, L. (2006). Logic models used to enhance critical thinking. 45 (6), 220-227.

Facione, P. (1990). Critical thinking: A statement of expert consensus for purposes of educational assessment and instruction. Research findings and recommendations. Newark: American Philosophical Association.

Lee, M., & Brysiewicz, P. (2009). Enhancing problem solving and nursing diagnosis in year III Bachelor of Nursing students. Nurse Education Today , 29, 389-397.


Marchigiano, G., Eduljee, N., & Harvey, K. (2011). Developing critical thinking skills from clinical assignments: A pilot study on nursing students' self-reported perceptions. Journal of Nursing Management , 19, 143-152.

Paans, W., Sermeus, W., Nieweg, R., & Van Der Schans, C. (2010). Determinants of the accuracy of nursing diagnoses: Influence of ready knowledge, knowledge sources, dispostion toward critical thinking, and reasoning skills. Journal of Professional Nursing , 26 (4), 232-241.

Profetto-McGrath, J. (2003). The relationship of critical thinking skills and critical thinking dispositions of baccalaureate nursing students. Journal of Advanced Nursing , 43 (6), 569-577.

Thompson, C., & Stapley, S. (2011). Do educational interventions improve nurses' clinical decision making and judgement? A systematic review. International Journal of Nursing Studies , 48, 881-893.