Objective: Today, most nursing graduate students are pursuing study as nurse practitioners (NPs) and they are entering their programs much earlier in their career trajectory. One of the most important and challenging skills a student NP must learn is how to weigh evidence and make decisions about treatment based on a chief complaint that is frequently vague in nature. Faculty continue to rely heavily on community preceptors to mentor students; however,patient load constraints limit the time and motivation for preceptors to assess students and support their skill development. A system of health care that is continually changing forces all of us, as nurses, to frequently examine what we do and how we do it. The same should hold true in education, in this case, re-evaluating how to mentor today's graduate student given the resources available to support them. The purpose of this study was twofold: 1. To evaluate the usefulness of a computer software program, DxR, to assess the diagnostic reasoning process used by newly graduated NPs, and 2. An assessment of relationships between contextual factors such as: prior RN experience, type of previous RN experience, critical thinking dispositions, decision style, and academic performance (GPA).
Design: Descriptive correlational
Sample: Recent graduates (N=70) from master’s level NP programs. Subjects were recruited from five universities in Central and Southern California and all had less than one year of NP experience (m=3.5 mos). More than half of the subjects had at least five years RN experience prior to their NP programs, most commonly, in acute care settings.
Theoretical Framework: A diagnostic reasoning framework was developed using constructs from Elstein’s (1978) model of hypothetico-deductive diagnostic reasoning, decision style theory (Rowe & Mason, 1986), and the critical thinking literature.
Methods: Three questionnaires were completed (Decision Style Inventory- DSI; California Critical Thinking Dispositions Inventory- CCTDI; and a Demographic Instrument developed by the researcher)as well as an internet-based DxR case. This included (some degree of) simultaneous communication with the researcher for technical assistance while the subject was signed on to the URL. The DxR software provides a case scenario that initially only offers a patient’s chief complaint. From a large database of history questions, physical examination techniques, and laboratory tests the “virtual” patient is evaluated. The reasoning process, as it unfolded, was tracked and recorded by the DxR program for each subject in this study.
Findings: NPs in this sample demonstrated novice diagnostic reasoning skills marked by extensive searching for data seemingly in an effort “to not miss something.” Previous RN experience correlated with DxR performance scores (r=.28; p=.02) and NPs with five or more years of RN experience had significantly higher mean scores (t=2.19;p=.03). A multiple regression analysis similarly identified RN experience to be a predictor of diagnostic reasoning performance as did GPA and NP experience. NPs with at least five years RN experience also had significantly higher CCTDI scores (t=2.23; p=.03). No significant correlation was found between type of RN experience and DxR scores; however, mean DxR scores among NPs with limited direct patient care RN experience were the lowest despite higher CCTDI scores. NPs with analytical decision styles (30%) had higher CCTDI scores (m=328), were more likely to have extensive RN experience and have higher DxR scores (m=68.9).
Conclusions: The results suggest that RN experience (5 or more years) and early NP practice were beneficial factors shaping diagnostic reasoning performance. The DxR software program offered a comprehensive method to assess the cognitive activities of the diagnostic reasoning process. Over two thirds (n=53) had satisfactory DxR performances while 17 subjects failed to identify the correct diagnosis. Common patterns among the latter group included: inadequate search for relevant data, inappropriate selection of data given the patient’s chief complaint, and data not synthesized in a way that allowed recognition of important relationships.
Implications: Gaining more experience in the RN role, particularly direct patient care, should be encouraged prior to beginning an NP program. Based on the differences of only a few months of NP practice, more clinical time should be considered in most programs. Using a computer software program such as DxR to evaluate diagnostic reasoning has considerable potential to simulate direct observation of NP students in the clinical setting. Improved evaluation of students by faculty and prompt communication of concerns to clinical preceptors should facilitate the kind of guidance and supervision necessary to improve diagnostic reasoning skills.
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