Students’ Perceptions of Clinical Reasoning Development Rebecca Jensen, PhD, RN

Clinical Reasoning Necessary for safe patient care Definition: mental process during which nurses assess and evaluate various patient cues to determine possible actions to take in regards to a patient concern Synonyms: clinical judgment, critical thinking, clinical decision- making Process of making a clinical judgment as portrayed in Tanner’s (2006) Clinical Judgment Model

Clinical Judgment Model (Tanner, 2006)

Measuring & Assessing Clinical Reasoning Few instruments available (Simmons, 2010) Jenkins’ Clinical Decision Making in Nursing Scale (CDMNS) (2005) Documented use in a few studies Findings Poor discrimination among program levels No clear factors were identified Small relationship scores were found in comparison to the CCTST Did not demonstrate increases in scores over time as students progressed in their nursing programs

Clinical Reasoning Instruments Lasater developed 2 instruments A rubric that can be used to assess students’ clinical reasoning behaviors – Lasater Clinical Judgment Rubric A self-assessment survey of clinical reasoning behaviors used during patient care – Lasater Clinical Judgment in Practice Survey (LCJPS)

LCJPS Developed from critical thinking habits of the mind and skills that were proposed by Scheffer and Rubenfeld’s Delphi project (2000) 30-item survey of behaviors used during patient care Participants rank their behaviors on a 4-point scale: strongly disagree (1), somewhat disagree (2), somewhat agree (3), and strongly agree (4)

LCJPS Survey demonstrated Cronbach alpha of.65 (n = 59)when developed and used by Lasater (2005) Initially used to investigate the effects of patient simulation on clinical judgment development in 39 junior and 44 senior level nursing students Findings: Distinguished between junior and senior level nursing students’ clinical judgment Demonstrated increases in scores over time

Current Study 2 groups of students surveyed Students in initial nursing course (Fundamentals in Nursing) – all BS program students Students enrolled in nursing leadership courses in the AS (Manager of Care) and BS (Leadership) programs 2 surveys Demographic data LCJPS

Sample (n = 178) Ages: 19 – 53 with a mean of 26 (SD = 8.2) Caucasian (84%) Female (92%) Previous healthcare experience (56%) Previous College degree (86%) Programs RN to BS program (N = 10, 6%) AS programs (N = 57, 32%) 4-year generic BS programs (N = 111, 62%)

Findings Cronbach alpha =.72 (n=178) No significant differences in LCJPS scores based on demographic categories Comparing beginning students (N = 75, M = 95.85, SD = 6.4) to those completing the program (N = 102, M = 98.44, SD = 6.4), significant differences between LCJPS scores (t (175) = -2.66, p=.009) with a small to moderate effect size, r =.20

Findings Significant differences were found among program types (F (2,175) = 7.349; p =.001). AS (M = 99.27, SD = 6.1) and RN to BS (M = 101.4, SD = 5.9) programs had significantly higher mean LCJPS scores than 4-year generic (M = 96, SD = 6.4) program students

Findings In further analysis, the 10 RN-BS students were removed from the data Significant differences among the three groups of beginning and end of program students were found (F (2, 165) = 5.05, p =.007): Fundamentals in Nursing students (SD = 6.4) Manager of Care – AS students (SD = 6.1) Leadership – BS students (SD = 6.4) Post hoc analysis: students in the AS program had significantly higher LCJPS mean scores than both beginning (p =.002) and end of program (p =.031) BS students

Findings To determine if clinical reasoning scores increased across the program: 52 students were surveyed at the beginning and end of their first nursing course with a hospital clinical experience & at the end of their respective programs, AS or BS Scores increased significantly at each measurement (F (1,51) = 11,425, p <.0005, partial eta squared =.996) Beginning of the nursing course with the first hospital clinical experience mean 87.4 (SD = 7.9) End of nursing course mean 96.5 (SD = 6.5) End of the program mean 99.0 (SD = 7.1).

Discussion Lasater also found higher LCJPS scores as students progressed from junior to senior level The significantly higher AS student vs BS student scores near the end of the program may be due to a lack of metacognition on the part of the AS students

Discussion BS students may have felt “the burden of what is at stake” (Day, Benner, Sutphen, & Leonard, 2009, p. 78) in nursing practice more than AS program students AS students experienced Fewer clinical experiences Less diverse clinical experiences

Discussion AS and BS students describe different types of stressors with clinical experiences AS nursing - instructor oversight BS students - patient care & working with nursing staff (Oermann, 1998) May indicate AS nursing students Not fully grasp the intricacies of patient-centered care, concentrating instead on instructor-provided direction and feedback Unable to critically evaluate their self-perception of the use of clinical reasoning skills Resulting in inflated LCJPS scores.

Limitations Single sample Single nursing school Non-experimental design

Implications for Nursing Education What can we do with this information? BS students may perceive a difference in their abilities to use clinical reasoning in practice, because they have had more opportunities to use clinical reasoning skills and can critically examine and identify weaknesses in their clinical thinking Students may need additional clinical reasoning practice to improve perceptions of clinical reasoning abilities

Implications continued Students’ perceptions of clinical reasoning can be assessed as they progress through their nursing programs to identify gaps Evaluate various pedagogies for impact on students’ perceptions of their clinical reasoning behaviors

References Day, L., Benner, P., Sutphen, M., & Leonard, V. (2009). Reflections on clinical education: Insight from the Carnegie Study. In N. Ard & T. Valiga (Eds.), Clinical nursing education: Current reflections (pp ). New York, NY: National League for Nursing. Jenkins, H. (1985). A research tool for measuring perceptions of clinical decision making. Journal of Professional Nursing, 1(4), Jenkins, H. (2001). Clinical decision making in nursing scale. In C. Waltz & L. Jenkins (Eds.), Measurement of nursing outcomes (Vol. 1, 2 nd ed.) (pp ). New York, NY: Springer. Lasater, K. (2005). The impact of high fidelity simulation on the development of clinical judgment in nursing students: An exploratory study. Dissertation Abstracts International, 66(03), 1936B. (UMI No ). Oermann, M. (1998). Differences in clinical experiences of ADN and BSN students. Journal of Nursing Education, 37(5), Scheffer, B., & Rubenfeld, M. (2000). A consensus statement on critical thinking in nursing. Journal of Nursing Education, 39(8), Simmons, B. (2010). Clinical reasoning: Concept analysis. Journal of Advanced Nursing, 66(5), Tanner, C. (2007). Nursing education: Current themes, puzzles and paradoxes. Communicating Nursing Research, 40(15), 3-14.