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Pedagogical research in nursing education is essential for improving clinical nursing practice and ultimately patient outcomes (Institute of Medicine [IOM], 2010; National League for Nursing [NLN], n.d.). Current research in nursing education has focused on the development of clinical reasoning and the impact it has on the ability of new graduate nurses to practice safe and effective patient care in complex healthcare environments (Banfield, Fagan, & Janes, 2012; Jensen, 2013; Levett-Jones et al. 2010). Clinical reasoning has been defined as the process whereby nurses use clinical judgment and critical thinking to make decisions based on both knowledge and experience. Benner et al. (2010) discussed clinical reasoning as the ability for which student nurses strive through the course of clinical nursing education and defined it as “the ability to reason as the clinical situation changes, taking into account . . . patients’ trends and trajectories” (p. 85).
Safe and effective provision of patient care is vital to nursing practice and is enhanced when clinical reasoning is used to make nursing patient care decisions (American Association of Colleges of Nursing, 2008). Positive patient care outcomes result from well-educated nurses who have the ability to clinically reason through both emergent and non-emergent patient care situations and make sound clinical judgments (American Association of Colleges of Nursing, 2008; Jensen, 2013). According to Kuiper (2013), the prevention of adverse patient outcomes directly relates to nurses’ use of clinical reasoning and their ability to recognize and treat patient problems in a timely manner. Exploration of methods to promote the development of clinical reasoning in pre-licensure nursing education is essential to ensure graduate nurses are prepared to provide safe and effective patient care. Therefore, the purpose of this qualitative research study was to explore pre-licensure baccalaureate nursing students’ perceptions of their development of clinical reasoning; including the best teaching strategies and best learning environments in which to promote the development of clinical reasoning.
Aims of the Study
The objective of the study was to gather data from pre-licensure baccalaureate nursing students to discern methods and strategies used in nursing education to promote development of clinical reasoning and how clinical reasoning was emphasized in their nursing education. Three teaching environments, classroom, clinical, and simulation, were discussed to determine student perceptions regarding the environment that best enhanced their development of clinical reasoning. Students’ lived experiences with learning clinical reasoning during their pre-licensure education were explored to better understand the most effective methods of preparing new graduate nurses to use clinical reasoning in providing safe and effective patient care.
Methods
In this phenomenological study, individual semi-structured interviews were conducted with eighteen participants who had recently graduated (within the last six months) or were in the final semester of their baccalaureate program. The interviews aimed to gather data related to the participants’ views on their development of clinical reasoning, the importance of clinical reasoning in nursing, and the best environment in which to learn clinical reasoning. Students’ words were transcribed verbatim and analyzed using Giorgi’s (1985) qualitative data analysis methods. Themes in the data were identified and the data was categorized for further review. Five main themes were identified: (1) instructor characteristics, (2) learning environment, (3) progression of learning, (4) importance of clinical reasoning, and (5) best place to learn clinical reasoning. The themes were then organized into subthemes, which when analyzed further, provided support for researcher conclusions regarding the participants’ views on their experiences with clinical reasoning.
Results
Results of the study indicated that new graduate nurses were best prepared for practice when learner-centered teaching strategies and methods were used to introduce, promote, and enhance the development of clinical reasoning in nursing education. Participants indicated that the clinical environment provided the best opportunities to develop clinical reasoning, followed closely by the simulation environment. Overall, the participants’ views on the importance of clinical reasoning in nursing and their development of clinical reasoning while in nursing school supported the need for continued emphasis on the development of clinical reasoning in undergraduate nursing programs.
Many participants viewed the development of clinical reasoning as a process that became more clear as they entered the final semesters of their nursing program. Nursing students begin with a minimal base of knowledge and skill and work toward meeting the goal of becoming a competent provider of safe patient care (Banfield, et al., 2012; Benner, 1984/2010; Kuiper, 2013). The participants voiced their views that emphasis on clinical reasoning should have begun earlier in their nursing education in order to better prepare them for the practice arena.
Participants believed their learning was directly affected by the attitude, competency, approachability, and level of trust with their instructors. Comfort and trust with nursing instructors as well as staff nurses in the clinical environment benefitted student learning. Chuan and Barnett (2012) noted that a good relationship with staff nurses positively impacts student learning. When asked about their learning and the end result, every participant indicated that the ability to use clinical reasoning in practice was the goal of their nursing program. Each participant realized this goal at a different time in their progression through the program, however it was unanimously offered as the most important part of their education.
Discussion and Implications
Findings from this study support prior research findings that have demonstrated the role that clinical reasoning has in enhancing safe and effective clinical practice. Data also indicated that the clinical arena is the most beneficial environment in which to learn clinical reasoning. Analysis of the participants’ words led to the discernment of implications for nursing education; most pointedly that clinical reasoning should be promoted and facilitated by nursing faculty throughout nursing programs from the first semester to the last with an emphasis on use of learner-centered teaching strategies. Participants overwhelmingly indicated that use of learner-centered methods were more successful in promoting the development of confidence and motivation to succeed in delivering safe and effective patient care.
In order to prepare new graduates for practice in the current complex healthcare environment, teaching and learning strategies must be reviewed and reconstructed to provide new nurses with the tools necessary to create positive patient care outcomes (Kuiper, 2013). The IOM (2010) has called for transformation in nursing education to prepare the next generation of nurses to be lifelong, active learners able to adjust and change with the ever-changing healthcare environment. The findings of this study contribute knowledge on methods and settings for developing clinical reasoning in pre-licensure nursing students. Continued exploration of nursing students’ development of clinical reasoning is recommended to further enhance pre-licensure nursing students’ preparation for practice.
References
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